Academy Position Paper

Position of the American Dietetic Association:

Nutrition Intervention in the Treatment of Eating Disorders
Written by Amy D. Ozier, PhD, RD, LDN and Beverly W. Henry, PhD, RD, LDN and
provided in the Journal of the American Dietetic Association

Kortney Richardson
NFS 4950: Senior Seminar
February 22, 2016

It is the position of the American Dietetic Association that nutrition intervention,

including nutrition counseling by a registered dietitian, is an essential component of the
team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating
disorders during assessment and treatment across the continuum of care. This position
was in effect until December 31, 2014. The authors of this position are Amy D. Ozier,
PhD, RD, LDN and Beverly W. Henry, PhD, RD, LDN.
Eating disorders affect many individuals including adolescents and adults. There
are many different types of eating disorders including anorexia nervosa, bulimia nervosa,
and binge eating disorders. Eating disorders can be defined as psychiatric disorders that
are characterized by the psychological and physiological condition of the body and the
individuals behavior patterns. No one case of an eating disorder is the same; there are
several different types of eating disorders and each case will vary in its severity. The
Diagnostic and Statistical Manual of Mental Disorder is a tool to help identify eating
disorders and gives information on the different methods of treatment.
Registered dietitians play a major part in treating individuals with eating
disorders, and nutrition interventions play a major role in preventing eating disorders
from occurring. A registered dietitian is typically the first person in a health care team
that will notice that an eating disorder exists. They may also have an easier time
recognizing the symptoms that are associated with an eating disorder. Registered
dietitians use the nutrition care process when diagnosing and treating a patient. Nutrition
interventions implemented by the registered dietitian need to take into account several
factors. The nutritional requirements of the patient are based on their age, individualized
treatment options, and methods of returning the patients eating habits back to normal.

These are all integral factors that need to be considered by the dietitian when planning the
patients plan of care. There are several components that make up the assessment stage of
the nutrition care process when working with a patient who is suffering from an eating
disorder. Assessing their food history offers much insist to the dietitian. It allows them to
see dietary intake patterns and eating habits over a longer period of time; this also helps
the dietitian to recognize any nutrient deficiencies that may exist. If an intervention is to
work the patient needs to want to see change; if they are not willing to put in the work
then change is not going to happen and the interventions may not work. To assess the
patients willingness to change, the registered dietitian can do a motivational interview.
This is a client-centered and goal-oriented style of counseling that will help enforce
readiness to change and encourage the client to make behavior changes. Low weight
status is commonly seen in clients who are unwilling to change their behaviors or eating
habits. When treating a patient with anorexia nervosa, it is important to assess their
weight gain regularly. This is a major indicator of what the patients outcome will be.
Treating patients with eating disorders is a collaborative effort; many members of the
health care team are needed when caring for these individuals.
Although eating disorders are quite common, many cases may actually go
unnoticed, undiagnosed, or untreated. There are many risk factors that may preface an
eating disorder diagnosis. These factors include sex, ethnicity, early childhood eating,
gastrointestinal issues, weight gain, concerns about body shape, negative self-evaluation,
sexual abuse, trauma, and psychiatric disorders. There are also several risk factors that
may cause an individual to develop symptoms of an eating disorder. These include
perceived pressure to be thin, thin-ideal internalization, body dissatisfaction, dietary

restraint expressed by the patient, negative thoughts about themselves, and substance
abuse. Two factors that predispose an individual to develop symptoms of an eating
disorder include genetics and neurobiological vulnerabilities.
Although eating disorders are more prevalent in adolescent women, they can also
occur in men and in the general adult population. Statistical results related to the
prevalence that an individual will develop an eating disorder sometime in their life are as
follows: Anorexia nervosa at 0.3% in men and 0.9% in women; bulimia nervosa at 0.5%
in men and 1.5% in women; and binge eating disorders at 2% in men and 3.5% in
women. Anorexia nervosa and bulimia nervosa most commonly affects the adolescent
population. Binge eating disorders on the other hand seem to affect individuals during
adulthood. The adolescent girl population is the most vulnerable to developing eating
disorders. About 12% of girls between the ages of twelve and fifteen will experience an
eating disorder. In order to prevent an eating disorder from occurring, early detection of
changes in eating patterns and altered body image is key.
There are several conditions that are commonly present in individuals with an
eating disorder. These conditions can be divided into two categories, Axis I and Axis II.
Axis I represents psychiatric disorders. Some common psychiatric disorders associated
with an eating disorder includes anxiety, depression, body dysmorphic disorders, and
chemical dependency. Axis II represents personality disorders. Any condition that is
associated with an eating disorder makes treating the disorder more challenging.
Treating eating disorders involves many different members of the health care
team including mental health specialists, registered dietitians, and medical specialists.
Registered dietitians play a major role in the care of a patient with an eating disorder.

They are influential in the treatment of the diagnosis, the recovery period, and in
preventing a relapse from occurring. It is important that any treatments or interventions
are individualized in order for the treatment to be most effective.
There are two main types of therapy that is targeted towards treating eating
disorders. The first type of therapy is called cognitive behavioral therapy or CBT.
Cognitive behavioral therapy focuses on psychotherapy to help recognize any irrational
beliefs, thoughts, or behaviors. For treating bulimia nervosa, cognitive behavioral therapy
is the treatment of choice. Patients who are suffering from binge eating disorders also
respond well to cognitive behavioral therapy. Cognitive behavioral therapy aims at
decreasing binge eating episodes and promoting weight loss. Patients suffering from
binge eating disorders tend to express several behaviors. For example they tend to have
chaotic eating patterns; they may be overweight or obese; and they do not control their
diets or watch what foods they eat. To determine if this intervention worked for a patient
with binge eating disorders, reassessment is necessary. The registered dietitian needs to
measure how often the patient is binge eating and measure the severity of their binge
eating; body image, depression, and self-esteem should also be assessed. The patient
should show improvement in all these areas. On the other hand, cognitive behavioral
therapy has not been as effective in treating anorexia nervosa. This is because it can
interfere with neurotransmitter secretions and functions; this in turn decreases the
patients response to the treatment.
The second type of therapy to treat eating disorders is called dialectical behavior
therapy. This type of therapy looks at poor emotional responses and considers this to be a
major contributor to many eating disorders. It also considers symptoms of an eating

disorder to be irrational coping skill. This method of treatment focuses on changing these
behaviors and coping skills and teaching them new coping skills. Helping the patients to
minimize behaviors that could potentially harm them is the main focus of this treatment
method. This method also helps patients build a sense of respect for themselves, and
helps them to understand that what they are doing is harming their bodies. Dialectical
behavior therapy has been successful in treating binge-eating symptoms. There are also
several other treatments that can be used to treat adults with eating disorders. Some of
these include interpersonal therapy, psychodynamic therapy, family or group therapy,
self-esteem enhancement, and assertiveness training.
One population that needs special consideration is athletes. When looking at
athletes, before an eating disorder is diagnosed extreme dieting is normally seen. This is
because many athletes restrict their diet in an effort to keep their body weight low. In
female athletes with eating disorders, common symptoms associated with low body
weight include amenorrhea, restrictive dietary intake, and osteoporosis. Another
population that needs special consideration is adolescents. This population continues to
be the most vulnerable for developing symptoms of an eating disorder. Influence from
peers plays a major role in the development of symptoms in adolescents. An adolescents
own thoughts about what is acceptable from social can also trigger an eating disorder to
develop. Family-based therapy has shown to be effective in treating adolescents with
anorexia nervosa. Cognitive behavioral therapy and dialectical behavior therapy are also
used to decrease symptoms in adolescents.
There are many alternative therapies that can be used to treat eating disorders.
One example is the Community Outreach Partnership Program. This program provides

other options for treating eating disorders when other methods were not effective. This
program helps decrease eating disorder symptoms as well as psychiatric symptoms in
about four months. Other examples of alternative therapy interventions include yoga,
stress management, spirituality, and religion. These interventions can help improve
behaviors related inappropriate dietary intake and can reduce anxiety related to eating.
Currently there are not any medications on the market that have been approved by
the FDA to treat anorexia nervosa. Medications that are commonly prescribed for treating
patients with anorexia nervosa typically only treat anxiety and reduce symptoms affecting
mood. Serotonin reuptake inhibitors have also been used during the maintenance phase of
eating disorder treatments. Pharmacotherapy has also shown some success in improving
eating disorder behaviors and mood especially when used with cognitive behavioral
therapy. Only one drug, called fluoxetine, has been approved by the FDA for treating
bulimia nervosa.
In order to help individuals with an eating disorder, it is recommended that
registered dietitians focus on promoting health-centered behaviors instead of focusing on
weight-centered dieting. It is the responsibility of the registered dietitian to research new
evidence-based interventions in order to improve treatment outcomes for eating
disorders. It is also the responsibility of the registered dietitian to stop the progression of
an eating disorder, treat an existing eating disorder, and prevent an eating disorder from
occurring.
I agree with the Academys position for treating eating disorders. The Academy
recommends that registered dietitians be apart of the health care team when treating a
patient who is suffering from an eating disorder. I agree that a registered dietitian is

essential when it comes to recognizing that an eating disorder exists, and that they are the
most qualified for treating them. Many of the treatments that the Academy recommends
focuses on changing the thought pattern and behaviors of the patients, which I believe is
the most important step for treating eating disorders. Most individuals with an eating
disorder express irrational thoughts and fears about being fat or overweight when they are
actually a normal weight or underweight. Helping the patient realize that what they are
doing is harming their body is necessary in order for the patient to be willing to change
their thought patterns and behaviors. In addition to psychiatric counseling, I also agree
that the registered dietitian should perform nutrition counseling. These individuals need
to learn how to properly take care of their bodies; they need to learn what nutrients are
necessary in their diet and the importance of consuming enough kcalories. Being
someone who has struggled with body image and irrational thoughts of being overweight,
I think it is important for dietitians to focus on prevention especially with the female
adolescent population. Registered dietitians need to be aware of the pressures society puts
on these young women. Society has its own idea of what is considered pretty and what is
considered acceptable, and that being thin is the only way to be pretty. When dietitians
are aware of these pressures, they have a better chance of recognizing risk factors before
an eating disorder progresses too far.

References
1. Henry BW, Ozier AD. Position of the American Dietetic Association: Nutrition
Intervention in the Treatment of Eating Disorders. Journal of the American Dietetic
Association. 2011;111:1236-1241