Experimental investigation of the effects of naturalistic dieting on bulimic symptoms: moderating effects of depressive symptoms.

Prospective studies suggest that dieting increases risk for bulimic symptoms, but experimental trials indicate dieting reduces bulimic symptoms. However, these experiments may be unrepresentative of real-world weight loss dieting. In addition, the fact that most dieters do not develop eating disorders suggests moderating factors may be important. Accordingly, we randomly assigned 157 female intermittent dieters to either diet as they usually do for weight loss or eat as they normally do when not dieting for 4 weeks. Naturalistic dieting halted the weight gain shown by controls, but did not result in significant weight loss. Although there was no main effect of the dieting manipulation on bulimic symptoms, moderation analyses indicated that naturalistic dieting decreased bulimic symptoms among participants with initially low depressive symptoms. Results suggest that self-initiated weight loss dieting is not particularly effective, which appears to explain several discrepancies in the literature. Additionally, depressive symptoms may be an important determinant of bulimic symptoms that eclipses the effects of naturalistic dieting on this outcome.

Eating disorder nutrition counseling: strategies and education needs of English-speaking dietitians in Canada.

The purpose of this study was to profile nutrition counseling strategies for eating disorders that English-speaking Canadian registered dietitians (RDs) use and to explore their educational needs in this area. A cross-sectional survey consisting of open- and closed-ended questions on nutrition counseling strategies was developed and administered via mail. Types of strategies included assessment, rapport-building, educational, and behavior-change strategies. Sixty-five of the 116 eligible RDs who were members of the Dietitians of Canada Eating Disorder Network responded to the survey. Descriptive statistics, chi(2), and Spearman correlation statistics were used. P values less than 0.05 were considered significant. Canadian RDs used strategies that were familiar and strategies they considered useful. Content-oriented or "doing" strategies were used more often than strategies that involved some process-oriented or "thinking" strategies. Reading and intuition were the most frequently reported learning routes. Seventy-one percent of respondents were dissatisfied with the educational opportunities available to RDs in this area in Canada. In Canada, both generalist RDs and specialist eating disorders RDs work with clients with eating disorders. In the absence of a formal nutrition counseling education program, there seems to be a reliance on informal learning routes such as reading or intuition, which may be suboptimal. To optimize eating disorders nutrition practice in Canada, formal coordinated programming that accounts for the educational needs of specialist RDs as well as generalist RDs is needed.

Chronic food restriction and reduced dietary fat: risk factors for bouts of overeating.

The purpose of this study was to determine the effect of chronic food restriction and reduced dietary fat on feeding behavior and body weight. Young female rats were fed ad lib or food restricted on a low-fat (LF) or a fat-free (FF) diet for 4 weeks. Rats then received 24-h free access to 2 diets, the maintenance diet (LF or FF) plus a novel high-fat (HF) diet (24-h intake test). After the test, all the rats were allowed chronic free access to the HF diet until body weight was stable. During the 24-h test, the restricted groups ate significantly more calories than the ad lib groups, and the FF-restricted rats ate significantly more total food, carbohydrate and protein than the LF-restricted rats; there were no differences between the two ad lib groups. During chronic free access to the HF diet, the formerly restricted rats achieved and defended lower body weights than the formerly non-restricted rats. Throughout the experiment, the ad lib groups had more body fat than the restricted groups independent of the dietary subgroup. Hence, a history of chronic food restriction predisposes to consuming more food in acute feeding situations, particularly when dietary fat is reduced, and lowers the level of body weight maintained and defended. Chronic food restriction accompanied by reduced dietary fat may increase risk for bouts of overeating.

Tratamento nutricional dos transtornos alimentares / Nutritional treatment of eating disorders

Pacientes com transtornos alimentares possuem inadequaçäes profundas no consumo, padrão e comportamento alimentar, além de diversas crenças equivocadas sobre alimentação, o que geralmente acarreta piora do estado nutricional. O tratamento nutricional visa a reverter tais alteraçäes e promover hábitos alimentares saudáveis e melhor relação para com o alimento. Os objetivos e características do tratamento diferem para a anorexia nervosa e a bulimia nervosa, contudo, usualmente, a abordagem é dividida em duas fases: a educacional, cujas principais metas são a regularização do hábito alimentar e o aumento do conhecimento nutricional, e a experimental, que visa a propiciar maior reabilitação nutricional e mudanças mais profundas no comportamento alimentar. As evidências existentes sugerem que o tratamento nutricional promove a melhora de tais parâmetros, porém, alguns comportamentos alimentares, como a sensação de incompetência ao lidar com os alimentos, permanecem. Desta forma, mais estudos são necessários para que se possa de fato avaliar a eficácia da abordagem nutricional.

Relation between dieting and weight change among preadolescents and adolescents.

OBJECTIVE: To assess whether dieting to control weight was associated with weight change among children and adolescents. METHODS: A prospective study was conducted of 8203 girls and 6769 boys who were 9 to 14 years of age in 1996, were in an ongoing cohort study, and completed at least 2 annual questionnaires between 1996 and 1999. Dieting to control weight, binge eating, and dietary intake were assessed annually from 1996 through 1998 with instruments designed specifically for children and adolescents. The outcome measure was age- and sex-specific z score of body mass index (BMI). RESULTS: In 1996, 25.0% of the girls and 13.8% of the boys were infrequent dieters and 4.5% of the girls and 2.2% of the boys were frequent dieters. Among the girls, the percentage of dieters increased over the following 2 years. Binge eating was more common among the girls, but in both sexes, it was associated with dieting to control weight (girls: infrequent dieters, odds ratio [OR]: 5.10; frequent dieters, OR: 12.4; boys: infrequent dieters, OR: 3.49; frequent dieters, OR: 7.30). During 3 years of follow-up, dieters gained more weight than nondieters. Among the girls, frequency of dieting was positively associated with increases in age- and sex-specific z scores of BMI (beta = 0.05 and beta = 0.04 for frequent and infrequent dieters vs nondieters). Among the boys, both frequent and infrequent dieters gained 0.07 z scores of BMI more than nondieters. In addition, boys who engaged in binge eating gained significantly more weight than nondieters. CONCLUSIONS: Although medically supervised weight control may be beneficial for overweight youths, our data suggest that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain.

The use of indirect calorimetry in the clinical management of adolescents with nutritional disorders.

Indirect calorimetry is a noninvasive, inexpensive technique used to determine resting energy expenditure. Its use provides the clinician with objective information that can be used to design, implement, and evaluate efficacy of treatment in the nutritional management of adolescents with anorexia nervosa, bulimia nervosa, chronic dieting behavior, and obesity. This chapter outlines the theoretical framework, interpretation of data, and clinical applications of indirect calorimetry and presents case examples to underscore its utility in adolescents with eating disorders.

Effect of a very low calorie diet on the diagnostic category of individuals with binge eating disorder.

OBJECTIVE: This study examined the factors associated with the diagnostic outcome of obese individuals with and without binge eating disorder (BED) 1 year after completing a very low calorie diet (VLCD) program. METHOD: Participants included 63 individuals with BED, 36 individuals with subthreshold BED, and 29 individuals with no binge eating symptoms. Diagnoses before and after VLCD were obtained using the Structured Clinical Interview for DSM-IV (SCID) interviews. The severity of psychiatric symptoms were assessed using various rating scales. RESULTS: Fifty-six percent (n = 36) of the participants who met criteria for BED at baseline did not meet diagnostic criteria 1 year later. None of the baseline factors were statistically associated with outcome. DISCUSSION: Although the main hypothesis was not supported, absence of a BED diagnosis at 12-month follow-up after a VLCD diet appears to be associated with less weight gain at 1-year follow-up regardless of baseline diagnosis.

Nutritional interventions for individuals with bulimia nervosa.

Many physical and psychological effects of bulimia nervosa are caused by the patient's partial starvation and chaotic nutritional cycle. Attention should thus be initially directed to correcting nutritional deficiencies and abnormal eating patterns, and providing dietary counselling. Nevertheless, very little has been written about the nutritional management of this eating disorder. Nutritional counselling for bulimia patients is reviewed in this paper. Current knowledge about nutritional therapy and its efficacy, goals and objectives is presented, along with recommendations used in treatment programmes. Lastly, the key steps of nutritional management are summarised.

Bulimia nervosa: o que os pacientes nomeiam compulsäo? / Bulimia nervosa: what do patients call binge?

O episódio compulsivo é descrito no critério diagnostico da bulimia nervosa como a ingestäo de grande quantidade de alimento num curto espaço de tempo. Porem do ponto de vista nutricional outras questöes envolvidas no momento da compulsäo alimentar. Objetivos: Analisar os episódios nomeados como compulsivos de 23 pacientes com diagnostico de bulimia nervosa, atendidas no Ambulatório de Bulimia e transtornos alimentares (AMBULIM) do Hospital das Clínicas da USP. A avaliaçäo foi realizada através de metodologia qualitativa, pelo Discurso do Sujeito Coletivo, e os dados de ingestäo alimentar por metodologia quantitativa. Resultados: o valor calórico total mediano dos episódios nomeados como compulsivos foi de 452,6Kcal, sendo que o valor total calórico da dieta das pacientes foi semelhante ao da populaçäo normal. Na análise qualitativa perceberam-se várias peculiaridades no momento do episódio compulsivo, relacionadas a sensaçöes, sentimentos e crenças das pacientes em relaçäo à alimentaçäo. Conclusöes: Alem da ingestäo de alimentos e do tempo, já citados no critério diagnostico, pacientes com bulimia podem chamar de compulsivo o episódio onde ingerirem alimentos que elas consideram proibidos. Alem disso, se existirem sentimentos específicos associados ao momento do episódio, comprometimento social relacionado `a dieta, problemas com comportamento alimentar e pressäo social da família. Com a análise qualitativa, foi possível descrever pontos importantes que näo estäo descritos no critério diagnóstico do DSM-IV

Position of the American Dietetic Association: nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS).

More than 5 million Americans suffer from eating disorders. Five percent of females and 1% of males have anorexia nervosa, bulimia nervosa, or binge eating disorder. It is estimated that 85% of eating disorders have their onset during the adolescent age period. Although Eating Disorders fall under the category of psychiatric diagnoses, there are a number of nutritional and medical problems and issues that require the expertise of a registered dietitian. Because of the complex biopsychosocial aspects of eating disorders, 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 (1). Medical Nutrition Therapy 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.

Bulimia nervosa during pregnancy: a review.

Pregnant women with bulimia nervosa present interesting practice challenges for dietitians and healthcare professionals due to potential complications of bulimia nervosa for both mothers and fetuses. This review summarizes case study reports, case series reports, and retrospective studies of women with bulimia nervosa during pregnancy, and focuses on relationships among bulimic behaviors, pregnancy results, and birth outcomes. Pregnancy and birth outcomes of women with bulimia nervosa varied among individuals and studies. Material outcomes of concern included miscarriages, inappropriate weight gains (excessive or inadequate), complicated deliveries, and resumed and/or continued bulimic behaviors shortly after parturition. Fetal complications included low birth weights, prematurity, malformations, and low Apgar scores. Screening to detect bulimic behaviors is recommended, as is multidisciplinary treatment of pregnant women with bulimia nervosa to emphasize adequate dietary intakes, promote appropriate weight gains, and help achieve healthy infant outcomes in addition to long-term, healthy eating habits for these women. Future research regarding maternal and fetal outcomes of women with bulimia nervosa during pregnancy, conducted by registered dietitians, is needed to provide greater clarity and understanding of the impact of bulimic behaviors, dietary intakes, and nutritional status during pregnancy on maternal and fetal health.

Impulsivity, dietary control and the urge to binge in bulimic syndromes.

OBJECTIVE: Naturalistic studies on sufferers of bulimic syndromes suggest that binge episodes are often precipitated by episodes of dietary restraint. However, evidence also implies that binge eating may, in certain psychopathological contexts, have less direct connection with dietary control factors. Applying an 8- to 22-day experience-sampling procedure in individuals with bulimic syndromes, we explored possible moderating effects of trait impulsivity upon the ongoing association between cognitive dietary control and binge eating. METHOD: Fifty-one women with bulimia spectrum eating disorders provided periodic daily observations on cognitive control over eating, urges to binge, and binge episodes. Impulsivity was assessed by self-report questionnaire. Hierarchical linear modeling techniques were used to assess relationships of interest. RESULTS: Urge to Binge was higher (on average) prior to eating binges than at comparable times on binge-free days, and thus seemed to signal the potential for binge eating. More importantly, scores on Urge to Binge and Dietary Control covaried systematically over time in most participants, but were desynchronous in highly impulsive individuals. CONCLUSIONS: Binge eating is closely linked to dietary control in most bulimic individuals, but this may be less typical of individuals showing marked impulsivity. We discuss factors that may explain the disconnection between Dietary Control and Urge to Binge in impulsive binge eaters as well as the implications of such factors for the management of bulimic patients with marked impulsivity.

The predictive validity of the Diet Readiness Test in a clinical population.

OBJECTIVE: To evaluate the psychometric properties, including the factorial and predictive validity, of the Diet Readiness Test (DRT) in a clinical population. METHOD: The DRT was administered to 132 women who participated in an obesity and binge eating treatment study. RESULTS: The DRT demonstrated adequate internal consistency. The DRT's proposed factor structure was not supported. Neither the DRT subscales nor the derived factors predicted changes in weight, binge eating, or exercise. DISCUSSION: The DRT did not demonstrate factorial or predictive validity in this study. Based on the DRT's cutoff criteria, 100% of the sample was considered not ready to begin a weight loss program, suggesting that the DRT may have limited utility with clinical populations.

Differences in caloric utilization in eating disordered adolescents.

Caloric utilization is an important aspect of the clinical management of eating disorders. Caloric intake and body weight of 32 inpatient bulimic and anorectic girls and 30 normal adolescents were measured. Normal weight bulimics ate fewer calories while anorectics ate more calories per kilogram body weight compared with the control group. Anorectics have greater difficulty to eat sufficient calories to maintain their weight. These findings indicate that treatment should be extended beyond the point of time where normal weight is reached.

Fasting and postprandial cerebrospinal fluid glucose concentrations in healthy women and in an obese binge eater.

OBJECTIVE: We hypothesized that abnormal entry of glucose into the central nervous system (CNS) might exist in some chronic binge eaters of carbohydrates, as either a cause or consequence of binge eating. The purpose of this study was thus to determine fasting and postprandial glucose concentrations in the cerebrospinal fluid (CSF) of healthy women, and to obtain similar data in an obese, irritable woman with chronic binge eating of postpartum onset. METHOD: CSF was sampled continuously at 0.1 ml/min from 1100 hr to 1700 hr from the binge eating patient, who consumed 5,000 to 10,000 calories per day (preferentially binging on refined carbohydrates), and 4 healthy women via an indwelling, flexible spinal canal catheter. CSF aliquots were obtained at 10-min intervals for measurement of glucose concentrations. Simultaneously, blood was withdrawn at 30-min intervals to obtain serum for glucose assay. A glucose-rich mixed liquid meal was consumed by participants at 1300 hr. RESULTS: In striking contrast to the normal women, our bulimic patient showed no postprandial rise whatever in CSF glucose concentrations. Fasting CSF glucose concentrations were slightly lower whereas fasting serum glucose levels were normal in the bulimic patient, compared with the normal women. After eating, serum glucose levels increased in all participants, but less so in our patient. DISCUSSION: This is the first description of a lack of postprandial elevation in CSF glucose concentration in a patient with a binge eating disorder. Defective transport of glucose across the blood-brain barrier might account for the observed abnormality. While considering other possibilities, we conjecture that our patient's binge eating was an attempt to compensate for impaired postprandial entry of glucose into her CNS.

Eating disorders: current nutrition therapy and perceived needs in dietetics education and research.

OBJECTIVE: Research was conducted to obtain a profile of nutrition therapy currently in practice for patients with anorexia nervosa, bulimia nervosa, and anorexia/bulimia (mixed diagnosis) and to identify the areas of dietetics education and research regarding eating disorders that need more attention. DESIGN: A cross-sectional correlational survey was conducted by mailing a questionnaire composed of open- and closed-ended questions to US dietitians who work with patients who have eating disorders. SAMPLE: Of 199 dietitians selected from a list of 495 representing all geographic areas of the United States, 117 responded. The list was obtained from a national referral network for eating disorders. STATISTICAL ANALYSIS: chi 2 Analysis was completed on all closed-ended answers. Pearson's correlation coefficient with a value of P < .05 was considered significant. RESULTS: Nutrition therapy administered varied among dietitians treating inpatients, outpatients, and both. Three community groups were identified as most important to reach for prevention of eating disorders: junior high school students, coaches, and parents. Crucial areas of research were perceived by 94 dietitians to be comparative effectiveness of techniques of medical nutrition therapy (n = 55) and of techniques of prevention (n = 26) and increased understanding of etiology in relation to identification of high-risk groups and prevention (n = 21). Dietitians desired further information on multiple topics related to eating disorders. APPLICATION: Medical nutrition therapy for eating disorders is a specialization that requires education and training beyond the minimum required for dietetic registration. Some of the techniques required are unique to this specialization due, in part, to the psychological nature of the disorders. All dietitians, however, must be able to recognize and refer patients with eating disorders; these skills must be included in basic undergraduate programs and internships. This study supports the need for more research concerning the outcomes of nutrition therapy and the effectiveness of prevention programs.

Psychosocial treatments for eating disorders.

Biological and developmental vulnerabilities, maladaptive learning experiences, and pathological family patterns may all contribute to the appearance and persistence of eating disorder (Bruch 1973, Crisp 1980, Garfinkel and Garner 1982). Psychosocial treatment approaches are currently the most important and effective intervention methods for anorexia nervosa (American Psychiatric Association 1993, Garner 1985) and are at least equivalent to medication approaches for bulimia nervosa as well.