Dietitians Guide to Eating Disorders (#112704)

Transcription

1 Dietitians Guide to Eating Disorders (#112704) (Florida CE Provider #: ) Vantage Professional Education P.O. Box Tampa, FL (813) Visit our Web-Site Dietitians -2 CPEU s $21 ($10.50 per CPEU) These reports can be used to satisfy Continuing Education requirements. Place a copy in your office for other dietetic professionals to use.

2 About the Author: Ellen M. Griffiths, RD, LDN, MPH Ellen M. Griffiths is a registered and licensed dietitian who has worked in the Washington, DC area for the past 27 years. She received her Master of Public Health degree from the University of Michigan. She has worked in mental health for the past 14 years. Since 1998 she has been the Clinical Dietitian at the Saint Luke Institute, a rehab facility, where she works in the care of clients with depression, addictions, and eating disorders. She also has a private practice of nutrition counseling. Copyright 2013 Vantage Professional Education This publication is designed for educational purposes only. Vantage Professional Education is not engaged in rendering medical advice or professional services. Any medical or other decisions should be made in consultation with your doctors. Vantage Professional Education will not be liable for any complications, injuries or other medical accidents arising from or in connection with the use of the subject matter covered. Page ii.

3 Preface Vantage Professional Education has a mission to serve as an information resource to enhance the knowledge and personal development of healthcare professionals. These reports can be used to satisfy continuing education requirements. Place a copy of this report in your office for other healthcare professionals to use. Tests can also be taken online or download free copies of our reports: Continuing Education Accreditation and Credits Dietitians: RD, CDE, LDN, DTR This activity is approved for 2 Continuing Professional Education Units as a Level I Activity, which assumes that the participant has little or no prior knowledge of the area(s) covered. Activity Expiration Date: 12/21/2016. How to Obtain Your Continuing Education Credits Complete the answer sheet found in Section VII. Make a copy of the answer sheet. This will keep the entire course intact so that other healthcare providers can use this course to satisfy their continuing education requirements. 1. Mail the completed answer sheet to: Ms. Angela Turton, Registrar Vantage Professional Education P.O. Box Tampa, FL (813) We will mail you a Certificate of Completion for your Activity Log for the CDR. You must have a passing grade of 70% or better to document your successful mastery of the course content. If you do not receive a passing grade, a letter notifying you of your nonpassing status will be sent to you along with a new answer sheet to use with the same test questions. Important Notice: Payment must be submitted before a Certificate of Completion can be issued. Accreditation Vantage Professional Education (Provider Number VA002) is a Continuing Education Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Florida CE Provider #: Guarantee We guarantee our Continuing Education Certificates. If for any reason your state does not accept our Continuing Education Credits, we will refund the amount paid by the student for the Continuing Education Certificate. Page iii.

4 Table of Contents Section I. Course Objectives Introduction 1 Course Objectives 1 Section II. Types of Eating Disorders Eating Disorders Overview 2 Types of Eating Disorders 2 Anorexia Nervosa 3 Bulimia Nervosa 3 Binge-eating Disorder 3 Section III. Eating Disorders Risk and Prevalence Who Is At Risk 4 Prevalence 5 Eating Disorders Among Children 6 How Males are Affected 7 Section IV. Eating Disorders Causes, Diagnosis, and Symptoms Page Eating Disorder Causes 7 Diagnosis 8 Symptoms 9 Risk Factors 10 Complications 10 Mortality and Eating Disorders 11 Section V. Treatment Eating Disorders Treatment 11 Treating Anorexia Nervosa 12 Treating Bulimia Nervosa 12 Treating Binge-Eating Disorder 13 Teen Eating Disorders Prevention 13 Psychotherapies 13 Family-focused Therapy 16 Section VI. Role of the Registered Dietitian Academy of Nutrition and Dietetics Recommendations 14 Case Studies 16 Summary 18 Section VII. Bibliography and Additional Information Sources 18 Section VIII. Continuing Education Answer Sheet & Test Questions 20 Section IX. Footnotes 21 Page iv.

5 Section I: Course Objectives Introduction Eating disorders were once thought to affect only a narrow portion of the population in the teens and early twenties, but we now know that they affect people of every age, race, gender and socio-economic status. Increasing interest and concern about eating disorders have been demonstrated in both the public and private sectors. Anorexia nervosa and bulimia nervosa have become familiar household words. 1 According to the National Eating Disorders Association, in the United States, 20 million women and 10 million men suffer from a clinically significant eating disorder at some time in their life, including anorexia nervosa, bulimia nervosa, binge eating disorder, or an eating disorder not otherwise specified. For various reasons, many cases are likely not to be reported. Eating Disorders have a biological basis that is modified and influenced by emotional and cultural factors. Without treatment of both emotional and physical symptoms of these disorders, malnutrition, heart problems and, unfortunately, death can result. Recovery is possible and the registered dietitian is an important part of the treatment team. Course Objectives At the conclusion of this program the dietetics professional will be able to: 1. Identify the National Institute of Health criteria for defining eating disorders 2. Describe the three types of eating disorders 3. Identify who is at risk for eating disorders 4. Explain the differences between Bulimia Nervosa and Anorexia Nervosa 5. Discuss the prevalence of eating disorders 6. Discuss the causes and diagnosis of eating disorders 7. Explain the treatment options for eating disorders 8. Discuss the role of the Registered Dietitian in the nutritional care of individuals with eating disorders Page 1.

6 Section II. Types of Eating Disorders Eating Disorders Overview According to the National Institute of Health an eating disorder is an illness that causes serious disturbances to the person s everyday diet, such as eating extremely small amounts of food or severely overeating. A person with an eating disorder may have started out just eating smaller or larger amounts of food, but at some point, the urge to eat less or more spiraled out of control. Severe distress or concern about body weight or shape may also characterize an eating disorder. 2 Eating disorders affect both men and women. It is unknown how many adults and children suffer with other serious, significant eating disorders, including one category of eating disorders called eating disorders not otherwise specified (EDNOS). EDNOS includes eating disorders that do not meet the criteria for anorexia or bulimia nervosa. Binge-eating disorder is a type of eating disorder called EDNOS. EDNOS is the most common diagnosis among people who seek treatment. Eating disorders are real, treatable medical illnesses. They frequently coexist with other illnesses such as depression, substance abuse, or anxiety disorders. People with anorexia nervosa are 18 times more likely to die early compared with people of similar age in the general population. Types of Eating Disorders Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life. The National Institute of Health lists the common eating disorders as: Anorexia nervosa Bulimia nervosa Binge-eating disorder Anorexia Nervosa Anorexia nervosa is characterized by emaciation, a relentless pursuit of thinness, a distortion of body image and intense fear of gaining weight, and extremely disturbed eating behavior. Many people with anorexia see themselves as overweight, even when they are starved or are clearly malnourished. Eating, food, and weight control become obsessions for people with anorexia. 3 Anorexia nervosa is characterized by: 4 Extreme thinness (emaciation) A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight Intense fear of gaining weight Distorted body image, a self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight Lack of menstruation among girls and women Extremely restricted eating People with anorexia nervosa typically weigh themselves repeatedly, portion food carefully, and eat very small quantities of only certain foods. Some people with anorexia nervosa may also engage in bingeeating followed by extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas. Page 2.

7 Some who have anorexia nervosa recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic, or long-lasting, form of anorexia nervosa, in which their health declines as they battle the illness. Other symptoms may develop over time, including: Thinning of the bones (osteopenia or osteoporosis) Brittle hair and nails Dry and yellowish skin Growth of fine hair all over the body (lanugo) Mild anemia and muscle wasting and weakness Severe constipation Low blood pressure, slowed breathing and pulse Damage to the structure and function of the heart Brain damage Multi-organ failure Drop in internal body temperature, causing a person to feel cold all the time Lethargy, sluggishness, or feeling tired all the time Infertility Bulimia Nervosa Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes. This binge-eating is followed by behavior that compensates for the overeating such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors. 5 Unlike anorexia nervosa, people with bulimia nervosa usually maintain what is considered a healthy or normal weight, while some are slightly overweight. But like people with anorexia nervosa, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Usually, bulimic behavior is done secretly because it is often accompanied by feelings of disgust or shame. The binge-eating and purging cycle happens anywhere from several times a week to many times a day. Other symptoms include: Chronically inflamed and sore throat Swollen salivary glands in the neck and jaw area Worn tooth enamel, increasingly sensitive and decaying teeth as a result of exposure to stomach acid Acid reflux disorder and other gastrointestinal problems Intestinal distress and irritation from laxative abuse Severe dehydration from purging of fluids Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium and other minerals) which can lead to heart attack Binge-eating Disorder With binge-eating disorder a person loses control over his or her eating. Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with bingeeating disorder often are over-weight or obese. People with binge-eating disorder who are obese are at Page 3.

8 higher risk for developing cardiovascular disease and high blood pressure. They also experience guilt, shame, and distress about their binge-eating, which can lead to more binge-eating. Section III. Eating Disorders Risk and Prevalence Who Is At Risk Eating disorders were once thought to affect only a narrow portion of the population in the teens and early twenties, but we now know that they affect people of every age, race, gender and socio-economic status. Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life. 6 The Academy of Nutrition and Dietetics reports that the biggest difference between men and women with eating disorders is that women are more likely to seek treatment, says Jessica Setnick, MS, RD, CSSD, CEDRD, director of training and education for Ranch 2300 Eating Disorder Treatment Program. National statistics suggest that about 10 percent of those with eating disorders are male, but Setnick suspects it's much greater. "Because almost all eating disorder statistics are based on who gets treatment, the numbers are skewed toward females," she says. 7 Like females who have eating disorders, males also have a distorted sense of body image. For some, their symptoms are similar to those seen in females. Others may have muscle dysmorphia, a type of disorder marked by an extreme concern with becoming more muscular. Unlike girls with eating disorders, who mostly want to lose weight, some boys with muscle dysmorphia see themselves as smaller than they really are and want to gain weight or bulk up. Men and boys are more likely to use steroids or other dangerous drugs to increase muscle mass. Although males with eating disorders exhibit the same signs and symptoms as females, they are less likely to be diagnosed with what is often considered a female disorder. Additionally, dieting and weight control strategies reflect how dissatisfied an individual is with her or his own body size and shape. Besides being associated with the onset of eating disorders, these behaviors alone can be dangerous to one s health. The National Eating Disorders Association has summarized recent research and found the following trends among teenage girls: 8 42% of 1st-3rd grade girls want to be thinner. In elementary school fewer than 25% of girls diet regularly. Yet those who do know what dieting involves and can talk about calorie restriction and food choices for weight loss fairly effectively. 81% of 10 year olds are afraid of being fat. 46% of 9-11 year-olds are sometimes or very often on diets, and 82% of their families are sometimes or very often on diets. Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives % of adolescent girls engage in crash dieting, fasting, self-induced vomiting, diet pills, or laxatives. Overweight girls are more likely than normal weight girls to engage in such extreme dieting. Even among clearly non-overweight girls, over 1/3 report dieting (Wertheim et al., 2009). Girls who diet frequently are 12 times as likely to binge as girls who don t diet The average American woman is 5 4 tall and weighs 165 pounds. The average Miss America winner is 5 7 and weighs 121 pounds. Page 4.

9 The average BMI of Miss America winners has decreased from around 22 in the 1920s to 16.9 in the 2000s. The World Health Organization classifies a normal BMI as falling between 18.5 and % of all dieters will regain their lost weight in 1-5 years. 35% of normal dieters progress to pathological dieting. Of those, 20-25% progress to partial or full-syndrome eating disorders. Of American, elementary school girls who read magazines, 69% say that the pictures influence their concept of the ideal body shape. 47% say the pictures make them want to lose weight. Prevalence According to the National Eating Disorders Association, in the United States, 20 million women and 10 million men suffer from a clinically significant eating disorder at some time in their life, including anorexia nervosa, bulimia nervosa, binge eating disorder, or an eating disorder not otherwise specified. For various reasons, many cases are likely not to be reported. In addition, many individuals struggle with body dissatisfaction and sub-clinical disordered eating attitudes and behaviors, and the best-known contributor to the development of anorexia nervosa and bulimia nervosa is body dissatisfaction. By age 6, girls especially start to express concerns about their own weight or shape % of elementary school girls (ages 6-12) are concerned about their weight or about becoming too fat. This concern endures through life. 9 The rate of development of new cases of eating disorders has been increasing since There has been a rise in incidence of anorexia in young women in each decade since 1930 The incidence of bulimia in year old women TRIPLED between 1988 and 1993 The prevalence of eating disorders is similar among Non-Hispanic Whites, Hispanics, African- Americans, and Asians in the United States; with the exception that anorexia nervosa is more common among Non-Hispanic Whites The following chart highlights the demographics of the lifetime prevalence rate of eating disorder for males and females: In August of 2010, American Viewpoint (a nationally recognized public opinion research company) conducted a telephone survey of American adults for the National Eating Disorders Association. The national survey shows an increased public awareness of eating disorders and a shift in how eating disorders are viewed. Page 5.

10 The survey polled a nationwide sample of one thousand adults in the United States. Among the findings were the following: 82% percent of respondents believe that eating disorders are a physical or mental illness and should be treated as such, with just 12% believing they are related to vanity 85% of the respondents believe that eating disorders deserve coverage by insurance companies just like any other illness 86% favor schools providing information about eating disorders to students and parents 80% believe conducting more research on the causes and most effective treatments would reduce or prevent eating disorders 70% believe encouraging the media and advertisers to use more average sized people in their advertising campaigns would reduce or prevent eating disorders Eating Disorders Among Children While many people are concerned about what they eat and their body image, eating disorders are marked by extremes. They are present when a person experiences severe disturbances in their eating behavior, such as extreme reduction of food intake or extreme overeating, or feelings of extreme distress or concern about body weight or shape. 10 The following chart shows eating disorder information from the National Comorbidity Survey Adolescent Supplement (NCS-A), and defines an eating disorder broadly as anorexia nervosa, bulimia nervosa, and/or binge eating disorder. It shows key information about eating disorders among 13 to 17 year olds, including an estimate of 2.7 percent for those suffering from an eating disorder and that girls are more than two and a half times as likely as boys to have an eating disorder. Obese teenagers who lose weight are at risk of developing eating disorders such as anorexia nervosa and bulimia nervosa, Mayo Clinic researchers imply in a recent Pediatrics article. Eating disorders among these patients are also not being adequately detected because the weight loss is seen as positive by providers and family members. 11 In the article, Mayo Clinic researchers argue that formerly overweight adolescents tend to have more medical complications from eating disorders and it takes longer to diagnose them than kids who are in a normal weight range. This is problematic because early intervention is the key to a good prognosis, says Leslie Sim, Ph.D., an eating disorders expert in the Mayo Clinic Children's Center and lead author of the study. Page 6.

11 Although not widely known, individuals with a weight history in the overweight (BMI-for-age greater than or equal to the 85th percentile but less than the 95th percentile, as defined by CDC growth chart) or obese (BMI-for-age greater than or equal to the 95th percentile, as defined by the CDC growth chart) range, represent a substantial portion of adolescents presenting for eating disorder treatment, says Dr. Sim. "Given research that suggests early intervention promotes best chance of recovery, it is imperative that these children and adolescents' eating disorder symptoms are identified and intervention is offered before the disease progresses," says Dr. Sim. This report analyzes two examples of eating disorders that developed in the process of obese adolescents' efforts to reduce their weight. Both cases illustrate specific challenges in the identification of eating disorder behaviors in adolescents with this weight history and the corresponding delay such teenagers experience accessing appropriate treatment. In their findings at least 6 percent of adolescents suffer from eating disorders, and more than 55 percent of high school females and 30 percent of males report disordered eating symptoms including engaging in one or more maladaptive behaviors (fasting, diet pills, vomiting, laxatives, binge eating) to induce weight loss. Eating disorders are associated with high relapse rates and significant impairment to daily life, along with a host of medical side effects that can be life-threatening, says Dr. Sim. How Males are Affected Like females who have eating disorders, males also have a distorted sense of body image. For some, their symptoms are similar to those seen in females. Others may have muscle dysmorphia, a type of disorder that is characterized by an extreme concern with becoming more muscular. Unlike girls with eating disorders, who mostly want to lose weight, some boys with muscle dysmorphia see themselves as smaller than they really are and want to gain weight or bulk up. Men and boys are more likely to use steroids or other dangerous drugs to increase muscle mass. 12 Although males with eating disorders exhibit the same signs and symptoms as females, they are less likely to be diagnosed with what is often considered a female disorder. More research is needed to understand the unique features of these disorders among males. Section IV. Eating Disorders Causes, Diagnosis, and Symptoms Eating Disorder Causes Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. But many questions still need answers. Researchers are using the latest in technology and science to better understand eating disorders. 13 One approach involves the study of human genes. Researchers are studying various combinations of genes to determine if any DNA variations are linked to the risk of developing eating disorders. Neuroimaging studies are also providing a better understanding of eating disorders and possible treatments. One study showed different patterns of brain activity between women with bulimia nervosa and healthy women. Using functional magnetic resonance imaging (fmri), researchers were able to see Page 7.

12 the differences in brain activity while the women performed a task that involved self-regulation (a task that requires overcoming an automatic or impulsive response). Psychotherapy interventions are also being studied. One such study of adolescents found that more adolescents with bulimia nervosa recovered after receiving Maudsley model family-based treatment than those receiving supportive psychotherapy that did not specifically address the eating disorder. Researchers are studying questions about behavior, genetics, and brain function to better understand risk factors, identify biological markers, and develop specific psychotherapies and medications that can target areas in the brain that control eating behavior. Neuroimaging and genetic studies may provide clues for how each person may respond to specific treatments for these medical illnesses. For example, the exact cause of anorexia nervosa is unknown. As with many diseases, the Mayo Clinic research indicates that it's probably a combination of biological, psychological and environmental factors. 14 Biological. There may be genetic changes that make some people more vulnerable to developing anorexia. However, it's not clear specifically how your genes could cause anorexia. It may be that some people have a genetic tendency toward perfectionism, sensitivity and perseverance, all traits associated with anorexia. There's also some evidence that serotonin one of the brain chemicals involved in depression may play a role in anorexia. Psychological. Some emotional characteristics may contribute to anorexia. Young women may have obsessive-compulsive personality traits that make it easier to stick to strict diets and forgo food despite being hungry. They may have an extreme drive for perfectionism, which means they may never think they're thin enough. Environmental. Modern Western culture emphasizes thinness. The media are splashed with images of thin models and actors. Success and worth are often equated with being thin. Peer pressure may help fuel the desire to be thin, particularly among young girls. Diagnosis Eating disorders are real, treatable medical illnesses. They frequently coexist with other illnesses such as depression, substance abuse, or anxiety disorders. According to the National Institute of Health some symptoms can become life-threatening if a person does not receive treatment. People with anorexia nervosa are 18 times more likely to die early compared with people of similar age. 15 It may be hard to notice signs and symptoms of anorexia because people with anorexia often go to great lengths to disguise their thinness, eating habits or physical problems. The Mayo Clinic has developed the following list of red flags to be aware of for signs of anorexia: 16 Skipping meals Making excuses for not eating Eating only a few certain "safe" foods, usually those low in fat and calories Adopting rigid meal or eating rituals, such as cutting food into tiny pieces or spitting food out after chewing Cooking elaborate meals for others but refusing to eat Repeated weighing of themselves Frequent checking in the mirror for perceived flaws Complaining about being fat Not wanting to eat in public Page 8.

13 Unfortunately, many people with anorexia don't want treatment, at least initially. Their desire to remain thin overrides concerns about their health. Symptoms Some people with anorexia lose weight mainly through severely restricting the amount of food they eat. They may also try to lose weight by exercising excessively. Others with anorexia binge and purge, similar to bulimia. They control calorie intake by vomiting after eating or by misusing laxatives, diuretics or enemas. 17 No matter how weight loss is achieved, anorexia has a number of physical, emotional and behavioral signs and symptoms. Physical Anorexia Symptoms Physical signs and symptoms of anorexia include: Extreme weight loss Thin appearance Abnormal blood counts Fatigue Insomnia Dizziness or fainting A bluish discoloration of the fingers Hair that thins, breaks or falls out Soft, downy hair covering the body Absence of menstruation Constipation Dry skin Intolerance of cold Irregular heart rhythms Low blood pressure Dehydration Osteoporosis Swelling of arms or legs Emotional and Behavioral Anorexia Symptoms Emotional and behavioral characteristics associated with anorexia include: Refusal to eat Denial of hunger Afraid of gaining weight Lying about how much food has been eaten Excessive exercise Flat mood (lack of emotion) Social withdrawal Irritability Preoccupation with food Reduced interest in sex Page 9.

14 Depressed mood Possible use of laxatives, diet aids or herbal products Risk Factors According to the Mayo Clinic certain risk factors increase the risk of anorexia, including: 18 Being female. Anorexia is more common in girls and women. However, boys and men have been increasingly developing eating disorders, perhaps because of growing social pressures. A young age. Anorexia is more common among teenagers. Still, people of any age can develop this eating disorder, though it's rare in people older than 40. Teenagers may be more susceptible because of all of the changes their bodies go through during puberty. They also may face increased peer pressure and may be more sensitive to criticism or even casual comments about weight or body shape. Genetics. Changes in certain genes may make people more susceptible to anorexia nervosa. Family history. Those with a first-degree relative a parent, sibling or child who had the disease have a much higher risk of anorexia nervosa. Weight changes. When people lose or gain weight on purpose or unintentionally those changes may be reinforced by positive comments from others if weight was lost, or by negative comments if there was a weight gain. Such changes and comments may trigger someone to start dieting to an extreme. Transitions. Whether it's a new school, home or job, a relationship breakup, or the death or illness of a loved one, change can bring emotional stress and increase the risk of anorexia nervosa. Sports, work and artistic activities. Athletes, actors and television personalities, dancers, and models are at higher risk of anorexia. For some, such as ballerinas, ultrathinness may even be a professional requirement. Sports associated with anorexia include running, wrestling, figure skating and gymnastics. Professional men and women may believe they'll improve their upward mobility by losing weight, and then take it to an extreme. Coaches and parents may inadvertently raise the risk by suggesting that young athletes lose weight. Media and society. The media, such as television and fashion magazines, frequently feature a parade of skinny models and actors. But whether the media merely reflect social values or actually drive them isn't clear-cut. In any case, these images may seem to equate thinness with success and popularity. Complications Anorexia can have numerous complications. At its most severe, it can be fatal. Death may occur suddenly even when someone is not severely underweight. This may result from abnormal heart rhythms (arrhythmias) or an imbalance of electrolytes minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body. Complications of anorexia include: Death Anemia Heart problems, such as mitral valve prolapse, abnormal heart rhythms and heart failure Bone loss, increasing risk of fractures later in life In females, absence of a period In males, decreased testosterone Gastrointestinal problems, such as constipation, bloating or nausea Electrolyte abnormalities, such as low blood potassium, sodium and chloride Page 10.

15 Kidney problems If a person with anorexia becomes severely malnourished, every organ in the body can be damaged, including the brain, heart and kidneys. This damage may not be fully reversible, even when the anorexia is under control. In addition to the host of physical complications, people with anorexia also commonly have other mental disorders as well. They may include: Depression Anxiety disorders Personality disorders Obsessive-compulsive disorders Drug abuse Mortality and Eating Disorders While it is well known that anorexia nervosa is a deadly disorder, the death rate varies considerably between studies. This variation may be due to length of follow-up, or ability to find people years later, or other reasons. In addition, it has not been certain whether other subtypes of eating disorders also have high mortality. Several recent papers have shed new light on these questions by using large samples followed up over many years. Most importantly, they get around the problem of tracking people over time by using national registries which report when people die. A paper by Papadopoulos studied more than 6000 individuals with AN over 30 years using Swedish registries. Overall people with anorexia nervosa had a six fold increase in mortality compared to the general population. Reasons for death include starvation, substance abuse, and suicide. Importantly the authors also found an increase rate of death from natural causes, such as cancer. 19 It has not been certain whether mortality rates are high for other eating disorders, such as bulimia nervosa and eating disorder not otherwise specified, the latter of which is the most common eating disorder diagnosis. Another research report studied 1,885 individuals with anorexia nervosa (N=177), bulimia nervosa (N=906), or eating disorder not otherwise specified (N=802) over 8 to 25 years. The investigators used computerized record linkage to the National Death Index, which provides vital status information for the entire United States, including cause of death extracted from death certificates. Crow and colleagues found that crude mortality rates were 4.0% for anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for eating disorder not otherwise specified. They also found a high suicide rate in bulimia nervosa. The elevated mortality risks for bulimia nervosa and eating disorder not otherwise specified were similar to those for anorexia nervosa. Section V. Treatment Eating Disorders Treatment Adequate nutrition, reducing excessive exercise, and stopping purging behaviors are the foundations of treatment. The National Institute of Health recommends that specific forms of psychotherapy, or talk therapy, and medication are also effective for many eating disorders. However, in more chronic cases, specific treatments have not yet been identified. Treatment plans often are tailored to individual needs and may include one or more of the following: 20 Individual, group, and/or family psychotherapy Page 11.

16 Medical care and monitoring Nutritional counseling Medications Some patients may also need to be hospitalized to treat problems caused by mal-nutrition or to ensure they eat enough if they are very underweight. Treating Anorexia Nervosa Treating anorexia nervosa involves three components: 21 Restoring the person to a healthy weight Treating the psychological issues related to the eating disorder Reducing or eliminating behaviors or thoughts that lead to insufficient eating and preventing relapse Some research suggests that the use of medications, such as antidepressants, antipsychotics, or mood stabilizers, may be modestly effective in treating patients with anorexia nervosa. These medications may help resolve mood and anxiety symptoms that often occur along with anorexia nervosa. It is not clear whether antidepressants can prevent some weight-restored patients with anorexia nervosa from relapsing. Although research is still ongoing, no medication yet has shown to be effective in helping someone gain weight to reach a normal level. Different forms of psychotherapy, including individual, group, and family-based, can help address the psychological reasons for the illness. In a therapy called the Maudsley approach, parents of adolescents with anorexia nervosa assume responsibility for feeding their child. This approach appears to be very effective in helping people gain weight and improve eating habits and moods. Shown to be effective in case studies and clinical trials, the Maudsley approach is discussed in some guidelines and studies for treating eating disorders in younger, non-chronic patients. Other research has found that a combined approach of medical attention and supportive psychotherapy designed specifically for anorexia nervosa patients is more effective than psychotherapy alone. The effectiveness of a treatment depends on the person involved and his or her situation. Unfortunately, no specific psychotherapy appears to be consistently effective for treating adults with anorexia nervosa. However, research into new treatment and prevention approaches is showing some promise. One study suggests that an online intervention program may prevent some at-risk women from developing an eating disorder. Also, specialized treatment of anorexia nervosa may help reduce the risk of death. Treating Bulimia Nervosa As with anorexia nervosa, treatment for bulimia nervosa often involves a combination of options and depends upon the needs of the individual. The National Institute of Health recommends that to reduce or eliminate binge-eating and purging behaviors, a patient may undergo nutritional counseling and psychotherapy, especially Cognitive Behavioral Therapy (CBT), or be prescribed medication. CBT helps a person focus on his or her current problems and how to solve them. The therapist helps the patient learn how to identify distorted or unhelpful thinking patterns, recognize, and change inaccurate beliefs, relate to others in more positive ways, and change behaviors accordingly. CBT that is tailored to treat bulimia nervosa is effective in changing binge-eating and purging behaviors and eating attitudes. Therapy may be individual or group-based. Page 12.

17 Some antidepressants, such as fluoxetine (Prozac), which is the only medication approved by the U.S. Food and Drug Administration (FDA) for treating bulimia nervosa, may help patients who also have depression or anxiety. Fluoxetine also appears to help reduce binge-eating and purging behaviors, reduce the chance of relapse, and improve eating attitudes. Treating Binge-Eating Disorder Treatment options for binge-eating disorder are similar to those used to treat bulimia nervosa. Psychotherapy, especially CBT that is tailored to the individual, has been shown to be effective. Again, this type of therapy can be offered in an individual or group environment. Fluoxetine and other antidepressants may reduce binge-eating episodes and help lessen depression in some patients. Teen Eating Disorders Prevention To help prevent teen eating disorders, talk to your teen about eating habits and body image. It might not be easy, but it's important. The Mayo Clinic recommends that following steps to get started: 22 Encourage reasonable eating habits Discuss media messages Promote a healthy body image Foster self-esteem Share the dangers of dieting and emotional eating Use food for nourishment not as a reward or consequence Psychotherapies Psychotherapy, or "talk therapy", is a way to treat people with a mental disorder by helping them understand their illness. It teaches people strategies and gives them tools to deal with stress and unhealthy thoughts and behaviors. Psychotherapy helps patients manage their symptoms better and function at their best in everyday life. 23 Sometimes psychotherapy alone may be the best treatment for a person, depending on the illness and its severity. Other times, psychotherapy is combined with medications. Therapists work with an individual or families to devise an appropriate treatment plan. Types of Psychotherapy Many kinds of psychotherapy exist. There is no "one-size-fits-all" approach. In addition, some therapies have been scientifically tested more than others. Some people may have a treatment plan that includes only one type of psychotherapy. Others receive treatment that includes elements of several different types. The kind of psychotherapy a person receives depends on his or her needs. This section explains several of the most commonly used psychotherapies. However, it does not cover every detail about psychotherapy. Patients should talk to their doctor or a psychotherapist about planning treatment that meets their needs. CBT for Eating Disorders Page 13.

18 Eating disorders can be very difficult to treat. However, some small studies have found that CBT can help reduce the risk of relapse in adults with anorexia who have restored their weight. CBT may also reduce some symptoms of bulimia, and it may also help some people reduce binge-eating behavior. CBT for Depression Many studies have shown that CBT is a particularly effective treatment for depression, especially minor or moderate depression. Some people with depression may be successfully treated with CBT only. Others may need both CBT and medication. CBT helps people with depression restructure negative thought patterns. Doing so helps people interpret their environment and interactions with others in a positive and realistic way. It may also help a person recognize things that may be contributing to the depression and help him or her change behaviors that may be making the depression worse. Family-focused Therapy Family-focused therapy (FFT) was developed by David Miklowitz, Ph.D., and Michael Goldstein, Ph.D., for treating bipolar disorder. It was designed with the assumption that a patient's relationship with his or her family is vital to the success of managing the illness. FFT includes family members in therapy sessions to improve family relationships, which may support better treatment results. Family-based therapy may also be used to treat adolescents with eating disorders. One type is called the Maudsley approach, named after the Maudsley Hospital in London, where the approach was developed. This type of outpatient family therapy is used to treat anorexia nervosa in adolescents. It considers the active participation of parents to be essential in the recovery of their teen. The Maudsley approach proceeds through three phases: Weight restoration. Parents become fully responsible for ensuring that their teen eats. A therapist helps parents better understand their teen's disease. Parents learn how to avoid criticizing their teen, but they also learn to make sure that their teen eats. Returning control over eating to the teen. Once the teen accepts the control parents have over his or her eating habits, parents may begin giving up that control. Parents are encouraged to help their teen take more control over eating again. Establishing healthy adolescent identity. When the teen has reached and maintained a healthy weight, the therapist helps him or her begin developing a healthy sense of identity and autonomy. Several studies have found the Maudsley approach to be successful in treating teens with anorexia. Currently a large-scale, NIMH-funded study on the approach is under way. Section VI. Role of the Registered Dietitian Academy of Nutrition and Dietetics Recommendations The Academy of Nutrition and Dietetics (AND) recommends that the Registered Dietitian assess the nutritional status, knowledge base, motivation, and current eating and behavioral status of the patient, develops the nutrition section of the treatment plan and supports the patient throughout the course of treatment. The registered dietitian s role in the nutritional care of individuals with eating disorders is supported by the American Psychological Association, the Academy for Eating Disorders and the American Academy of Pediatrics. 24 Page 14.

19 The registered dietitian addresses the food and nutrition issues, the behavior associated with these issues, and assist the medical team with monitoring lab values, vital signs, and physical symptoms associated with malnutrition. The psychotherapeutic issues are the focus of the psychotherapist or mental health worker. 25 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. Because of the complex bio psychosocial aspects of eating disorders, the Academy of Nutrition and Dietetics recommends that the optimal assessment and ongoing management of these conditions appears to be with an interdisciplinary team consisting of professionals from medical, nursing, nutritional and mental health disciplines. Medical Nutrition Therapy (NMT) provided by a registered dietitian trained in the area of eating disorders plays a significant role in the treatment and management of eating disorders. The registered dietitian, however, must understand the complexities of eating disorders such as comorbid illness, medical and psychological complications, and boundary issues. The registered dietitian needs to be aware of the specific populations at risk for eating disorders and the special considerations when dealing with these individuals. The American Psychiatric Association guidelines recommend nutritional rehabilitation as a first goal in the treatment of anorexia and bulimia. For patients diagnosed with an eating disorder there are two phases of the nutritional aspect of treatment. 1. The education phases, in which nutrition information is provided in a factual manner with little or no emphasis on the emotional issues 2. The experimental phase, where the registered dietitian works in conjunction with other members of a treatment team and builds a long-term, relationship-based counseling When working with eating disordered individuals, a treatment team is important because the psychological issues involved in the patient s eating and exercise patterns are so intertwined. The registered dietitian needs therapeutic backup and must be in regular contact with the therapist and other members of the team. The American Psychiatric Association recommends psychotherapy to help individuals with eating disorders to understand the thoughts, emotions and behaviors that trigger these disorders. In addition, some medications have also proven to be effective in the treatment process. Because of the serious physical problems caused by these illnesses, it is important that any treatment plan for a person with anorexia nervosa, bulimia nervosa, or binge eating disorder include general medical care, nutritional management and nutritional counseling. These measures begin to rebuild physical well-being and healthy eating practices. 26 In 2011, the Academy of Nutrition and Dietetics produced its first practice paper on eating disorders, providing up-to-date information for registered dietitians on current research and controversies in the field; offers guidance on diagnostic criteria, symptoms, assessment and treatment of eating disorders; and delineates concrete ideas about the role of RDs. Academy of Nutrition and Dietetics position paper is designed to: Increase awareness of the types of disordered eating and Eating Disorders (ED) Page 15.

20 Detail emerging issues including associations between binge eating disorder and overweight and obesity Focus on special populations such as athletes, adolescents and those considering bariatric surgery Address other challenging issues encountered in treatment of eating disorders such as insurance coverage. The complexities of EDs, such as epidemiologic factors, treatment guidelines, special populations and emerging trends highlight the nature of EDs, which require a collaborative approach by an interdisciplinary team of mental health, nutrition and medical specialists, the authors of Academy of Nutrition and Dietetics position paper write. RDs are integral members of treatment teams and are uniquely qualified to provide medical nutrition therapy for the normalization of eating patterns and nutritional status. However, this role requires understanding of the psychologic and neurobiologic aspects of EDs. Advanced training is needed to work effectively with this population. Further efforts with evidence-based research must continue for improved treatment outcomes related to EDs, along with identification of effective primary and secondary interventions. Dietitians should involve the patient in a discussion of the following topics: What kind and how much food the client's body needs Symptoms of starvation and of refeeding (the process of beginning to eat normally after a period of starvation) Effects of fat and protein deficiency Effects of laxative and diuretic abuse Metabolic rate and the effect of restricting, bingeing, purging, and yo-yo dieting Food facts and fallacies How restricting, bingeing, and taking laxatives or diuretics influence hydration (water) shifts in the body and thus body weight on the scale The relationship between diet and exercise The relationship of diet to osteoporosis and other medical conditions The extra nutritional needs during certain conditions such as pregnancy or illness The difference between "physical" and "emotional" hunger Hunger and fullness signals How to maintain weight Establishing a goal weight range How to feel comfortable eating in social settings How to shop and cook for self and/or significant others Nutritional supplement requirements Case Studies 1. Gina is a 14 year-old 9 th grade student in a large suburban high school. When she started there 6 months ago, she had come from a small school where she had spent the previous 8 years. It has been a major challenge for her and she has had a hard time figuring out how to fit in. The few people she knew before starting there are not in any of her classes. The classroom work is also challenging and although she is generally keeping up, she has to work hard. She comes home every evening and spends most of the time in her bedroom, choosing to focus on her grades until she feels confident enough to try an extracurricular activity. Though she was quiet before, she seems to have become withdrawn as the year has progressed. Page 16.

21 Her mother became very concerned about Gina s behavior when she noticed she was always napping during the dinner hour and she observed her eating only a few grapes for breakfast, cutting them in half with a knife before eating them. Gina s favorite clothes were looking baggy on her. When she went to her pediatrician, she found Gina had lost 20 pounds in the past year, had not changed in height, and Gina admitted her periods had stopped. Gina was given a diagnosis of anorexia. Because her weight was 90% of a healthy body weight, the doctor recommended outpatient care including weekly visits with a psychotherapist and a registered dietitian who collaborate with the doctor to help Gina understand effective ways to deal with the dynamic changes often experienced in this phase of adolescence. Gina met with the dietitian weekly to understand her nutritional needs and how to eat to meet these needs. Establishing a trusting relationship between the professionals and Gina was key. Once this occurred, she talked easily with the dietitian. The dietitian worked with her to increase calories to an appropriate level for weight maintenance and gain, described the variety and portions of foods needed, helped her understand the symptoms of starvation and nutritional deficiencies, helped her to understand fluid shifts. They worked on dispelling food myths and misinformation, did role play for eating meals out and meal preparation at home. Gina s meal plan consisted of 3 meals and 2 snacks daily; she was not to vary from the plan. Her family was also intimately involved in her therapy and observing for accountability with the meal plan. Deviations with the meal plan observed by the family were handled by the dietitian to reduce conflict at mealtimes in the home. Gina eventually regained the weight she had lost and grew in stature though the process was long term with relapses. 2. Sheila is a 22-year-old overweight (BMI=29), recent college graduate working as a preschool teacher. She excelled in college earning honors in her program and great letters of recommendation from professors. She has a boyfriend who is very enamored of her, anticipating her needs, driving her from place to place. She is soft-spoken and very well liked by most who encounter her. She asked her primary care doctor for a referral to see a registered dietitian because she wanted to lose weight. When she met with the dietitian, just before the initial interview was finished, she asked to share something very private. She admitted that she had been bingeing and purging by vomiting for the past 3 years. The dietitian worked with her to inform her of the benefit of letting the primary care doctor know about this. The dietitian gave her a meal plan with 3 meals and 3 snacks at an appropriate level for weight maintenance. The dietitian shared with her the observation that nutrition counseling and physician care is not usually enough for maximum patient benefit. Sheila did not keep her third scheduled appointment, did not return a phone call, and did not come back for care. 3. Janet is a 55-year-old, obese (BMI=35), female with type 2 diabetes, hypertension, and hyperlipidemia, all of which are poorly controlled. She has lived with her elderly, infirmed parents for the past 5 years since a divorce. She works the night shift as a nurse s aide in a nursing home. Her days are spent taking care of her parents. She feels like her work never ends because her life at home is so similar to her job. Janet knows she is gaining weight but she ignores this fact. She has much pride in behavior she changed ten years before when she attended Alcoholics Anonymous and overcame her alcohol dependence. She knows she struggles with eating but it sometimes seems to be the only activity that gives her pleasure. Her parents do not help the situation by continually making derogatory remarks about her weight and size, the kind they have made throughout her life. She cooks and eats with her parents, being careful to Page 17.

22 have small meals. When she eats at work however and other times when she is alone, she eats large quantities of food. A few times a week she goes to 3 or 4 drive thru restaurants for the inexpensive breakfast foods, which she eats quickly but then feels terrible about after she finishes. After these fast food binges, she goes to a ladies room and brushes her teeth and washes her hands before heading home to prepare and eat breakfast with her parents. Janet knows her eating is out of control but she is not sure how to stop. An incident of blurred vision secondary to a high blood sugar level got her attention and caused her to see her physician, who adjusted her diabetes medication and suggested she work with a therapist and a registered dietitian. Janet s dietitian realized from her assessment that Janet had binge eating disorder (Total calories on a binge day-3500 with 2000 from fast food bingeing), confirming this with the therapist. She worked to stabilize Janet s weight, blood sugar, blood pressure and cholesterol levels. She gave Janet a meal plan at a realistic calorie level given her medications and activities. She encouraged Janet to believe that all foods can fit into a healthful eating plan so that stigmas about good and bad foods could be dispelled. She encouraged Janet to pay attention to her hunger and fullness before and after meals. Janet identified activities she enjoyed that she could do for pleasure other than eating which included some walking for exercise. Janet s episodes of binges diminished substantially, her physical health improved as did her mood. Summary The more that is learned about eating disorders the more it is realized that there are certain individuals predisposed to develop them. There are far more people with eating or body image problems than those with full-blown eating disorders. The registered dietitian must be aware of specific populations at risk for eating disorders and specific considerations when treating these patients. The registered dietitian plays a significant role in the treatment and management of eating disorders. Section VII. Bibliography and Additional Information Sources National Organizations For general information on National Support Organizations for eating disorders. Academy for Eating Disorders (AED) 6728 Old McLean Dr. McLean, VA (703) Promotes effective treatments and prevention initiatives; stimulates research. Sponsors international conferences. Academy of Nutrition and Dietetics (AND) 216 W. Jackson Blvd. Chicago, IL (312) Promotes sound information about nutrition to the public. Sponsors publications, national events, and media/marketing programs. Eating Disorders Coalition for Research, Policy & Action 611 Pennsylvania Avenue SE #423 Washington, DC (202) Active on Capitol Hill since 2000, the Eating Disorders Coalition for Research, Policy & Action (EDC) is a group of professional and advocacybased organizations. The EDC is committed to Page 18.

23 raising national awareness of eating disorders, improving access to care, and promoting prevention strategies, parity and research. Mayo Clinic 200 First Street SW Rochester, MN Mayo Clinic, is the largest integrated medical center in the world, providing comprehensive diagnosis and treatment in virtually all medical and surgical specialties. More than 350,000 patients from all walks of life seek answers at Mayo Clinic each year. National Association of Anorexia Nervosa and Associated Disorders (ANAD) Box 7 Highland Park, IL (847) Distributes listing of therapists, hospitals, and informative materials; sponsors support groups, conferences, advocacy, campaigns, research, and a crisis hotline. National Eating Disorders Association 603 Stewart St., Suite 803 Seattle, WA (206) National nonprofit organization. Provides prevention and outreach programs, educational materials and a toll-free information and treatment referral hotline. National Institute of Mental Health (NIMH) 6001 Executive Blvd. Rm MSC 9663 Bethesda, MD (301) NIMH is a government agency helping people to better understand mental health and mental disorders. NIMH Eating Disorder Fact Sheets provide helpful general information for families and loved ones. Overeaters Anonymous (OA) P.O. Box Rio Rancho, NM (505) Addresses issues of compulsive overeating. Free local meetings. Page 19.

24 Section VIII. Continuing Education Answer Sheet & Test Questions Dietitians: RD, CDE, LDN, DTR. Approved for 2 CPE credits. VPE (Provider Number VA002) is a CPE Accredited Provider with the CDR. We will mail you a Certificate of Completion for your Activity Log for the CDR reporting. Course Expiration Date: 12/21/2016. (#112704) Dietitians Guide to Eating Disorders Guarantee: We guarantee our Continuing Education Certificates. If for any reason your state does not accept our Continuing Education Credits, we will refund the amount paid by the student for the Certificate. A grade of 70% or better is required to pass this test. Payment Total Mail Answer Sheet & Payment: Credits Per Credit Ms. Angela Turton, Registrar 2 x $10.50 $ Vantage Professional Education Make Check Payable to: VPE P.O. Box Tampa, FL Print Name Address City State Zip Name of Employer Phone Day ( ) - AND/CDR Lic# (Required) State # Dietitian: O RD O DTR O LDN Other Time Required to Complete this Course? How did you hear about our course? Content Evaluation Disagree Agree 1. Relationship of objectives appropriate to meet the goals of activity? Effective as a learning resource? Extended my knowledge on the topic? Was consistant with the objectives? Was related to my job? Course Objectives Evaluation: Did the course content meet the stated objectives? Disagree Agree 1. Identify the National Institute of Health criteria for defining eating disorders Describe the three types of eating disorders Identify who is at risk for eating disorders Explain the differences between Bulimia Nervosa and Anorexia Nervosa Discuss the prevalence of eating disorders Discuss the causes and diagnosis of eating disorders Explain the treatment options for eating disorders Discuss the role of the Registered Dietitian in the nutritional care of individuals with eating disorders...., Page 20.

25 Dietitians Guide to Eating Disorders (#112704) 16 Test Questions: Please use the Answer Sheet Dietitians: RD, CDE, LD/LCN, DTR. This offering is approved for 2 Continuing Professional Education Credits by the Commission on Dietetic Registration (CDR). 1. Which of the following illnesses may co-exist with eating disorders? a) Depression b) Substance abuse c) Anxiety disorders d) All of the above 2. How do many people with Anorexia Nervosa perceive their body weight? a) Overweight b) Starved c) Malnutrition d) Healthy body weight 3. What differentiates Bulimia Nervosa from Binge-eating Disorder? a) Binge-eaters are always obese b) Binge-eaters weigh themselves constantly c) Binge-eating is not followed by purging, excessive exercise, or fasting d) They both usually maintain a healthy body weight 4. According to the Academy of Nutrition and Dietetics, what is the biggest difference between men and women with eating disorders? a) Women are more likely to seek treatment b) Men are more likely to seek treatment c) Eating disorders only appear in teen years for men d) Men want to lose weight 5. According to recent research from the NEDA, what percentage of 1 st through 3 rd grade girls want to be thinner? a) 61% b) 42% c) 30% d) 5% 6. The prevalence of Anorexia Nervosa is higher in which of the following groups? a) Non-Hispanic Whites b) Hispanics c) African Americans d) Asians 7. Why does the Mayo Clinic believe obese teenagers that lose weight are at risk of developing eating disorders? a) Eating disorder symptoms are not identical b) Former overweight adolescents tend to have more medical complications c) Weight loss is seen as positive by providers and family d) All of the above 8. People diagnosed with Anorexia Nervosa are how many more times likely to die early compared with people of a similar age? a) 2 b) 10 c) 18 d) According to research from the Mayo Clinic, how does family history increase the risk factors of developing Anorexia Nervosa? a) There was no effect from family history b) Those with first-degree relative a parent, sibling, or child have a much higher risk c) Inherited from mothers side of the family d) Siblings was key factor 10. What are the foundations for treating eating disorders? a) Adequate nutrition b) Reducing excessive exercise Page 21.

26 c) Stopping purging behavior d) All of the above 11. What is the only medication approved by the U.S. Food and Drug Administration for treating Bulimia Nervosa? a) Anti-depressant such as Prozac b) Lipitor c) Steroids d) Ambien 12. According to the American Psychiatric Association, a treatment plan for an eating disorder should include which of the following activates? a) General medical cure b) Nutritional management c) Nutritional counseling d) All of the above d) No conclusive research findings 15. Which of the following best describes Cognitive Behavioral Therapy? a) Helps a person focus on their current problems and how to solve them b) Combination therapy of dieting and exercise c) Nutritional counseling d) Psychiatric counseling 16. Which of the following is called Eating Disorders not Otherwise Specified (EDNOS)? a) Anorexia Nervosa b) Binge-eating c) Bulimia Nervosa d) All of the above 13. What characteristic separates some males with eating disorders from females? a) Males generally want to lose weight b) Distorted sense of body image c) Males may have muscle dysmorphia d) There is no difference 14. What is the relapse rate for people with eating disorders? a) Very low b) Very high c) Usually no relapse after adolescence Page 22.

27 Section IX: Footnotes 1 National Eating Disorders Association, Types & Symptoms of Eating Disorders (Website) Accessed November 12, National Institute of Health, What are eating disorders? (Website) Accessed November 12, National Institute of Health, Eating Disorders Among Adults - Anorexia (Website) Accessed November 12, Nervosahttp:// 4 National Institute of Health, What are eating disorders? (Website) Accessed November 12, National Institute of Health, What are eating disorders? (Website) Accessed November 12, National Institute of Health, What are eating disorders? (Website) Accessed November 12, Academy of Nutrition and Dietetics, Problem also Affects Boys and Men (Website) Accessed November 15, National Eating Disorders Association, What Are Eating Disorders? (Website) Accessed November 12, National Eating Disorders Association, What Are Eating Disorders? (Website) Accessed November 12, National Institute of Health, Eating Disorders Among Children (Website) Accessed November 12, Mayo Clinic, Obese Teenagers Who Lose Weight at Risk for Developing Eating Disorders (Website) Accessed November 16, National Institute of Health, What are eating disorders? (Website) Accessed November 12, National Institute of Health, Eating Disorder Causes (Website) Accessed November 12, Mayo Clinic, Anorexia nervosa (Website) Accessed November 16, National Institute of Health, Eating Disorder Causes (Website) Accessed November 12, Mayo Clinic, Anorexia nervosa (Website) Accessed November 16, Mayo Clinic, Anorexia nervosa (Website) Accessed November 16, Mayo Clinic, Anorexia nervosa (Website) Accessed November 16, National Eating Disorders Association, Mortality and Eating Disorders (Website) Accessed November 13, National Institute of Health, What are eating disorders? (Website) Accessed November 12, National Institute of Health, What are eating disorders? (Website) Accessed November 12, Mayo Clinic, Teen eating disorders: Tips to protect your teen (Website) Accessed November 17, National Institute of Health, Psychotherapies (Website) Accessed November 18, Academy of Nutrition and Dietetics, Registered Dietitians Are Essential for Successful Treatment of Eating Disorders (Website) Accessed November 18, Academy of Nutrition and Dietetics, Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS) (Website) Accessed November 17, American Psychiatric Association, Eating disorders (Website) Accessed November 19, Page 23.