Binge eating disorder: a review of the literature after publication of DSM-IV

The Impact of Binge-Like Palatable Food Intake on the Endogenous Glucagon-Like Peptide-1 System in Female Rats

Binge eating involves consumption of large amounts of food and a loss of control over the amount consumed. The incidence of binge eating disorder is higher in females than males, hinting at important sex differences in binge eating behavior, but the neural underpinnings of binge eating still remain unresolved. Recent work in male rats has shown that a history of binge-like palatable food intake suppresses hindbrain expression of preproglucagon (PPG), the precursor for glucagon-like peptide-1 (GLP-1). Given the roles of GLP-1 in reducing feeding and food reward, this could be a mechanism underlying binge-like eating in rodents. However, whether similar effects occur in female rats is unknown. Here, we tested the hypothesis that a history of binge-like palatable food intake in female rats would reduce PPG expression in the nucleus tractus solitarius (NTS), a key central site of GLP-1 production. Female rats given access to vegetable shortening every fourth day (4D) engaged in binge-like feeding, demonstrated by consuming significantly more shortening during the first hour of fat access compared to counterparts with ad libitum (AL) fat access. After several weeks of fat access under these schedules, PPG and GLP-1 receptor (GLP-1R) expression were measured in the NTS and ileum. Surprisingly, and in contrast to previous findings in male rats, there were no significant differences in expression of PPG or GLP-1R in either site in 4D versus AL rats, nor were there effects on plasma GLP-1 levels. These findings highlight key differences in the effects of binge-like intake on the central GLP-1 system in female compared to male rats.

A New Dental Approach for Reducing Food Intake

OBJECTIVE

A behavioral recommendation for weight loss is reduction of size of bites of food. This "proof of concept" study tested the efficacy of a new, patented, dental approach, the DDS System, for reducing food intake. This removable tool is inserted into the upper palate of the mouth, reducing the size of the oral cavity, thereby potentially reducing bite size.

RESEARCH METHODS AND PROCEDURES

Thirty-two adults (18 to 65 years) with BMI between 27 and 40 were randomly assigned to the control or experimental conditions. Participants ate all meals and stayed between meals at a research center. Day 1 served as baseline for both groups. On Day 2, experimental participants utilized the tool during meals. Changes in subjective ratings of hunger and satiety were measured using visual analog scales before and after each meal.

RESULTS

Food intake difference scores were calculated for each participant (Day 2 - Day 1). Analysis of covariance on difference scores, using baseline as a covariate, showed that the experimental group ate significantly less (p < 0.05) on the second day (M = -659.2 kcal/d) compared with the control group (M = -125.9 kcal/d). Analysis of covariance, with ratings on Day 1 as a covariate, revealed that the experimental and control group did not differ on visual analog scale difference scores (premeal - postmeal) from Day 1 to Day 2.

DISCUSSION

These findings suggest that use of this tool during meals significantly reduced food intake. This reduction of food intake was not associated with changes in ratings of hunger or satiety.

Does Binge Eating Disorder Impact Weight-Related Quality of Life?

OBJECTIVES

To determine whether binge eating disorder (BED) impacts weight-related quality of life in obese individuals seeking weight loss treatment and to investigate the role of psychological symptoms, BMI, and demographic variables in the relationship between BED and weight-related quality of life.

RESEARCH METHODS AND PROCEDURES

Three hundred seventeen women (BMI = 37.6) and 213 men (BMI = 41.3) completed questionnaires on admission into an intensive residential lifestyle modification program. Weight-related quality of life was assessed using the Impact of Weight on Quality of Life-Lite (IWQOL-Lite). The presence of BED was determined using the Questionnaire on Eating and Weight Patterns-Revised. Psychological symptoms were assessed using the Beck Depression Inventory and the global severity index of the Symptom Checklist 90-R.

RESULTS

BED prevalence in this sample was 17.9%. Participants with BED, in comparison with those without BED, were more likely to be women (75.8% vs. 56.3%, p < 0.001), younger (45.0 vs. 49.7 years, p = 0.003), white (98.9% vs. 91.7%), heavier (BMI = 42.0 vs. 38.5, p = 0.002), psychologically distressed, and more impaired on total IWQOL-Lite (51.5 vs. 65.3, p < 0.001) and all IWQOL-Lite subscales. However, after controlling for demographic variables, BMI, and psychological symptoms, BED was not independently associated with weight-related quality of life.

DISCUSSION

The association between BED and impairment in quality of life that has been previously reported in the literature may largely be accounted for by differences between those with and without BED on demographic variables, BMI, and psychological symptoms. BED does not seem to independently impact weight-related quality of life.

Affective style and eating disorders: a field study

Eating disorders (ED) are a heterogeneous group of problems related to restraint and/or overeating. It is proposed that individual differences in affective reactivity and moods (affective style) might be related to these behaviours. Variations in affective style are expressed by differing levels of sensitivity to the motivation systems of approach and avoidance. The present study tested whether a relation exists between ED and variations in the sensitivity of motivational systems as well as mood dispositions. A total of 2020 undergraduate students completed the Eating Disorder Diagnostic Scale (EDDS), the Behavioural Inhibition System and Behavioural Activation System Scales (BIS/BAS), and the Positive and Negative Affect Schedule (PANAS). The results showed a significant within- subject interaction of Alimentary group x Motivation (F=4.056; p<0.007). It was also observed that the Overeating group had lower levels of motivation asymmetry than the Normal (p<0.01) and Restrictive (p<0.005) groups and marginally lower levels than the Purgative group (p<0.07). The study results suggest mainly that the avoidance/inhibition motivational system is related to eating problems connected with overeating, including chronic alimentary restraint (chronic dieters). The theoretical and clinical implications of these findings are discussed.

Caloric restriction in humans: impact on physiological, psychological, and behavioral outcomes

The current societal environment is marked by overabundant accessibility of food coupled with a strong trend of reduced physical activity, both leading to the development of a constellation of disorders, including central obesity, insulin resistance, dyslipidemia, and hypertension (metabolic syndrome). Prolonged calorie restriction (CR) has been shown to extend both the median and maximal lifespan in a variety of lower species such as yeast, worms, fish, rats, and mice. Mechanisms of this CR-mediated lifespan extension are not fully elucidated, but possibly involve significant alterations in energy metabolism, oxidative damage, insulin sensitivity, inflammation, and functional changes in both the neuroendocrine and sympathetic nervous systems. Here we review some of the major physiological, psychological, and behavioral changes after 6 months of CR in overweight otherwise healthy volunteers. Special emphasis is given to the first completed clinical studies that have investigated the effects of controlled, high-quality energy-restricted diets on both biomarkers of longevity and on the development of chronic diseases related to age in humans. With the incremental expansion of research endeavors in the area of energy or caloric restriction, data on the effects of CR in animal models and human subjects are becoming more accessible.

Mindfulness-Action Based Cognitive Behavioral Therapy for concurrent Binge Eating Disorder and Substance Use Disorders

Individuals with Binge Eating Disorder (BED) often evidence comorbid Substance Use Disorders (SUD), resulting in poor outcome. This study is the first to examine treatment outcome for this concurrent disordered population. In this pilot study, 38 individuals diagnosed with BED and SUD participated in a 16-week group Mindfulness-Action Based Cognitive Behavioral Therapy (MACBT). Participants significantly improved on measures of objective binge eating episodes; disordered eating attitudes; alcohol and drug addiction severity; and depression. Taken together, MACBT appears to hold promise in treating individuals with co-existing BED-SUD.

Prevalence of binge eating and associated factors in a Brazilian probability sample of midlife women

OBJECTIVE

To estimate the prevalence of binge eating (BE) and inappropriate behaviors of weight control in a population sample of Brazilian midlife adult women and to correlate the prevalence of BE with self-rated health (SRH).

METHOD

A household sample of 1,298 females aged 35 years or older answered a face-to-face interview including questions on eating behaviors and had their weight and height measured.

RESULTS

The prevalence of regular BE (twice or more episodes by week) and inappropriate methods of weight control was 11.5 and 10.2%, respectively. BE episodes were positively correlated with BMI and negatively correlated with age and SRH. These correlations persisted when mutually adjusted by BMI, age, and SRH.

CONCLUSION

These findings show the relevance of BE on the overall health of women of this age group and emphasize the need for expanding research on eating disorders to beyond the populations more frequently assessed of teenagers and young adults.

Effect of caloric restriction in non-obese humans on physiological, psychological and behavioral outcomes

The focus of this review is on current research involving long-term calorie restriction (CR) and the resulting changes observed in physiological and behavioral outcomes in humans. Special emphasis will be given to the first completed clinical studies which are currently investigating the effects of controlled, high-quality energy-restricted diets on both biomarkers of longevity and on the development of chronic diseases related to age in humans. Prolonged CR has been shown to extend both the median and maximal lifespans in a variety of lower species such as yeast, worms, fish, rats, and mice. Mechanisms of this CR-mediated lifespan extension are not fully elucidated, but possibly involve significant alterations in energy metabolism, oxidative damage, insulin sensitivity, and functional changes in both the neuroendocrine and sympathetic nervous systems. In this brief report, we review some of the major physiological, psychological and behavioral changes after 6 months of CR in overweight otherwise healthy volunteers. Ongoing studies of prolonged CR in humans are now making it possible to analyze changes in "biomarkers of longevity" to unravel some of the mechanisms of its anti-aging phenomenon. With the incremental expansion of research endeavors in the area of energy or calorie restriction, data on the effects of CR in animal models and human subjects are becoming more accessible. Detailed analyses from controlled human trials involving long-term CR will allow investigators to link observed alterations from body composition down to changes in molecular pathways and gene expression, with their possible effects on the biomarkers of aging.

The assessment of binge eating disorder in obese women: a comparison of the binge eating scale with the structured clinical interview for the DSM-IV

The purpose of the present study was to evaluate the clinical usefulness of the Portuguese version of the Binge Eating Scale (BES) to assess binge eating disorder (BED) in a clinical sample. The BES is a self-reported instrument developed to identify binge eaters within the obese population. The scale, at the cutoff point of 17, was compared with the Structured Clinical Interview for the DSM-IV-Patient version (SCID-I/P). It was administered to 178 obese Brazilian women, aged 18 to 60 years, seeking treatment for obesity at an outpatient clinic. To assess the test-retest reliability, 121 individuals filled the instrument again 15 days later. The Portuguese version of BES showed a sensitivity of 97.8%, a specificity of 47.7%, a positive predictive value of 66.7% and a negative predictive value of 95.3%. The test-retest reliability, measured by kappa statistics, was 0.66. Cronbach's alpha was 0.89. These results suggest that the BES is valid as a screening instrument for BED in obese Brazilian women seeking treatment for obesity.

Changes in eating behaviour following group therapy for women who binge eat: a pilot study

Survey research is demonstrating that binge eating and compulsive eating may be a significant problem in the obese population. There is higher incidence of binge eating among women, associated with subjective distress and poor prognosis for weight control. Despite attendant health risks, researched clinical responses have not been developed. A before and after uncontrolled pilot study aimed to evaluate the effectiveness of group therapy for women who binge eat and compulsively eat. Participants attended a weekly integrative therapy group for 6 months. Measurements before and after the group intervention were taken using the Binge Eating Scale and Clinical Outcomes in Routine Evaluation inventories. Before and after interviews were thematically analysed for changes in eating behaviour. Following the group intervention, all participants demonstrated changes in eating behaviour measured by the Binge Eating Scale, the overall effect from baseline to 1 year demonstrates statistical significance. Qualitative data revealed four categories that underpinned reduction in binge eating: changes in dichotomous thinking, awareness of eating behaviour, detachment from food and dietary changes. An integrative model of group therapy warrants further research and refinement for this population, a group protocol for nurses working in the field of obesity and eating disorders could be developed.

Eating disorders and disordered eating among patients seeking non-surgical weight-loss treatment in Sweden

The aim of this cross-sectional descriptive study of 194 Swedish men and women seeking non-surgical weight-loss treatment was to investigate the presence of eating disorders and binge eating symptoms and to compare these two groups of patients with a group without eating disorder- or binge eating symptoms. The groups were compared in regard to co-morbid psychopathology, Health Related Quality of Life (HRQL) and anthropometric data. Of the total sample, 9.8% fulfilled criteria for any eating disorder. An additional 7.2% indicated binge eating symptoms without having an eating disorder. The three groups were significantly different in regard to psychopathology scales and most HRQL items. Eating disorders and binge eating symptoms are common among patients seeking non-surgical weight-loss treatments in Sweden and both groups showed elevated levels of co-morbid psychopathology and lower HRQL compared to patients without disordered eating. These findings point to the importance of assessing the full range of eating disorder symptoms and disorders as well as HRQL and co-morbid psychopathology before weight-loss treatment, as these factors might affect treatment outcome.

Microanalysis of eating behavior of three leptin deficient adults treated with leptin therapy

Leptin deficiency has been associated with extreme obesity and hyperphagia in rodents and humans. A rare genetic disorder in humans yields the absence of the hormone leptin, extreme obesity, and a ravenous appetite. Reports on these rare cases have indicated that therapy using leptin injections can yield significant weight loss and changes in appetite. The aim of this report on acute leptin therapy in three leptin deficient adults was to provide a microanalysis of changes in eating behavior and ratings of hunger and satiety. In addition to substantial weight loss, 15 weeks of leptin therapy was associated with approximately 50% reduction in food intake and substantial changes in ratings of hunger and satiety before most meals. After short-term leptin therapy, the three participants ate until ratings indicated they were satiated, which was comparable to the ratings before leptin therapy. These findings suggest that one of the primary effects of acute leptin therapy may be to reduce the ravenous hunger associated with leptin deficiency, resulting in reduced food intake and significant weight loss. These results are discussed in the context of the scientific literature pertaining to leptin and its effects on appetite and obesity.

Behavioral and psychological factors in the assessment and treatment of obesity surgery patients

OBJECTIVE

To provide evidence-based guidelines on the psychological and behavioral screening of weight loss surgery (WLS) candidates and the impact of psychosocial factors on behavior change after gastric bypass surgery.

RESEARCH METHODS AND PROCEDURES

The members of the Behavioral and Psychological subgroup of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS, behavior changes, and mental health, including quality of life (QOL) and behavior modification. Pertinent abstracts and literature were reviewed for references. A total of 198 abstracts were identified; 17 papers were reviewed in detail. Search periods were from 1980 to 2004.

RESULTS

We found a high incidence of depression, negative body image, eating disorders, and low QOL in severely obese patients. Our task subgroup recommended that all WLS candidates be evaluated by a licensed mental health care provider (i.e., psychiatrist, psychologist, or social worker), experienced in the treatment of severely obese patients and working within the context of a multidisciplinary care team. We also recommended development of pre- and postsurgical treatment plans that address psychosocial contraindications for WLS and potential barriers to postoperative success.

DISCUSSION

The psychological consequences of obesity can range from lowered self-esteem to clinical depression. Rates of anxiety and depression are three to four times higher among obese individuals than among their leaner peers. A comprehensive multidisciplinary program that incorporates psychological and behavior change services can be of critical benefit in enhancing compliance, outcome, and QOL in WLS patients.

Towards the pharmacotherapy of eating disorders

The purpose of this review is to discuss pharmacological options for the treatment of patients with eating disorders. Sequentially described are pharmacotherapy studies of anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED). The quantity of drug trials performed with AN patients has been very limited. While the majority of studies have failed to show medication efficacy for the acute treatment of AN, there is data which suggests that fluoxetine hydrochloride may play a role in preventing relapse during maintenance therapy. Atypical antipsychotics, most often olanzapine, have shown promise in a number of uncontrolled studies. BN has been most extensively studied, with the majority of pharmacological trials focusing on antidepressants. Fluoxetine, at a dose of 60 mg/day, is FDA-approved for the treatment of BN. Psychotherapy, particularly cognitive behavioural therapy (CBT) is of well-established utility in BN and data suggests that the combination of an antidepressant plus CBT is superior to either treatment alone. Recently, there has been interest in the 5-HT3 antagonist, ondansetron, and the anticonvulsant, topiramate. BED investigators have focused largely on antidepressants, which may reduce symptoms of depression and augment psychotherapy. While sibutramine and topiramate have both been associated with weight loss in controlled trials, the former appears to be fairly well-tolerated and the latter appears to be responsible for the emergence of significant cognitive and peripheral nervous system side effects in some patients. Further pharmacological research with eating disorder patients is needed, particularly in the areas of AN and BED. Also, pharmacological augmentation strategies for those not responding to primary therapies should be explored.

Topiramate for binge eating disorder

Topiramate is a new anti convulsant agent that acts on the voltage-activated sodium channels and on the glutamate and GABA receptors; it is furthermore able to reduce hunger and therefore contributes to loss of weight. The authors report the case of a patient suffering from binge eating disorder, who was unresponsive to several therapeutic plans but was successfully treated with topiramate.

Weight cycling in treatment-seeking obese persons: data from the QUOVADIS study

OBJECTIVE

To determine parameters of weight history useful for the assessment of weight cycling and their association with psychological distress and binge eating.

DESIGN

Cross-sectional.

SUBJECTS

A total of 1889 treatment-seeking obese subjects, enrolled by 25 Italian centers (78% female subject), aged 20-65 y (median 45); 1691 reported previous efforts to lose weight (median age of first dieting, 30 y).

MEASUREMENTS

The number of yearly attempts to lose weight, weight gain since age 20 y, cumulative weight loss and gain were checked by a predefined structured interview. Psychological distress was tested by means of Symptom Check-List 90 (SCL-90), Binge Eating Scale (BES) and Three Factor Eating Questionnaire (TFEQ).

RESULTS

Differences in anthropometric, clinical and psychological parameters were observed in relation to previous attempts to lose weight. Patients in the upper quartile of parameters of weight history were considered weight cyclers. In multivariate logistic regression analysis, after correction for age, sex and BMI, a high BES score was the only factor systematically associated with a high frequency of dieting (OR, 1.70; 95% confidence interval, 1.22-2.36; P=0.022), with higher cumulative weight loss (1.42; 1.12-1.80; P=0.003) and cumulative weight gain (1.38; 1.06-1.79; P=0.017). However, the sensitivity, specificity and positive predictive value of a high BES score were very low to detect cyclers. Weight cycling did not carry a higher risk of complicating diseases.

CONCLUSIONS

Weight cycling is associated with psychological distress, and binge eating independently increases the risk, but cannot be used to predict cycling. Also, obese patients who do not experience overeating as a loss of control discontinue treatment or regain weight following therapy.

Sleep in eating disorders

Sleep research on eating disorders has addressed two major questions: (1) the effects of chronic starvation in anorexia nervosa and of rapidly fluctuating eating patterns in bulimia nervosa on the sleep regulating processes and (2) the search for a significant neurobiological relationship between eating disorders and major depression. At present, the latter question appears to be resolved, since most of the available evidences clearly underline the notion that eating disorders (such as anorexia and bulimia nervosa) and affective disorders are two distinct entities. Regarding the effects of starvation on sleep regulation, recent research in healthy humans and in animals demonstrates that such a condition results in a fragmentation of sleep and a reduction of slow wave sleep. Although several peptides are supposed to be involved in these regulatory processes (i.e. CCK, orexin, leptin), their mode of action is still poorly understood. In opposite to these experimentally induced sleep disturbances are the findings that the sleep patterns in eating disorder patients per se do not markedly differ from those in healthy subjects. However, when focusing on the so-called restricting anorexics, who maintain their chronic underweight by strictly dieting, the expected effects of malnutrition on sleep can be ascertained. Furthermore, at least partial weight restoration results in a 'deepening' of nocturnal sleep in the anorexic patients. However, our knowledge about the neurobiological systems (as well as their circadian pattern of activity) that transmit the effects of starvation and of weight restoration on sleep is still limited and should be extended to metabolic signals mediating sleep.

Psychopathological differences between morbidly obese binge eaters and non-binge eaters after bariatric surgery

AIMS

To determine the psychological characteristics of a group of morbidly obese patients with binge eating disorders and to investigate whether the psychopathological status of binge eaters is different from that of other morbidly obese patients.

METHODS

We used the Binge Eating Scale, the Three-Factor Eating Questionnaire and the Millon Clinical Multiaxial Inventory-II (MCMI-II) to interview 140 morbidly obese patients 18 months after bariatric surgery (vertical banded gastroplasty), and compared the results obtained in binge eaters (n = 25) and non-binge eaters (n = 115).

RESULTS

The binge eaters had more eating disturbances (more binge eating, less restriction, more disinhibition, more hunger) and psychopathological characteristics (passive-aggressive traits, aggressive-sadistic traits, manic disorders, alcohol dependence and major depression) than the non-binge eaters. They were also younger and achieved a lower percentage of weight loss.

CONCLUSIONS

After bariatric surgery, our obese binge eaters reported significantly more psychiatric symptoms, especially those relating to eating disorders, depression, alcohol dependence and personality disturbances. Their weight loss was less satisfactory, and they sought bariatric surgery at a younger age.

Cognitive behavioural therapy for obesity: one-year follow-up in a clinical setting

Cognitive behavioural therapy (CBT) is the most comprehensive means of medically treating obesity, but only few data have so far been published concerning its long-term effectiveness. We here report our experience of 1068 consecutive patients (868 females) treated with CBT at a university-based obesity centre. The patients were enrolled into three different programmes: a 14-week LEARN programme (672 patients), a 16-week MOB programme for the morbidly obese (259 patients), or a 20-week BINGE programme for subjects affected by binge eating (137 patients). Eighty-five percent of the subjects completed the weekly programmes. The percentage of patients attending the scheduled control visits during the 1-year follow-up gradually decreased, being very low in the BINGE group (10%). The percentage weight loss was an average of 6% during the weekly courses, being higher in the MOB programme; by the end of the weekly sessions, it exceeded 10% of initial body weight in 22% of cases and increased to 36% during the follow-up. The cumulative probability of follow-up was higher among the patients undergoing the MOB and LEARN programmes than among the BINGE patients (p < 0.0001), and decreased with the increasing severity of obesity. Female gender and a weight loss of > 10% i.b.w. increased compliance to follow-up. The study further demonstrates the difficulty of achieving compliance to chronic management of obesity and the critical role of binge eating disorder in the medium-term treatment of obesity. Strategies are needed to improve adherence to a follow-up protocol.

5-HT2A receptor gene polymorphism and eating disorders

Recent studies have reported a genetic association between the -1438 G/A polymorphism within the promoter region of the 5-HT(2A) receptor gene and eating disorders (ED), with conflicting results. To clarify the role of the -1438 G/A polymorphism in different ED categories we have analyzed the genotype and allele frequency distribution in 54 Italian patients with Binge ED (BED) compared to 132 obese non-BED subjects. No significant differences were found between obese BED and obese non-BED individuals, suggesting that this polymorphism does not genetically distinguish these two phenotypes. Moreover, the evaluation of 148 patients with anorexia nervosa and 86 patients with bulimia nervosa revealed an association of the A allele with both these disorders.

Psychosocial variables associated with binge eating in obese males and females

OBJECTIVE

This study tested a psychosocial model of binge eating symptoms in obese men and women. Predictor variables included depression, dietary restraint, self-esteem, weight cycling, history of teasing, body dissatisfaction, and neuroticism.

METHOD

Participants (N = 808) completed a packet of self-report questionnaires.

RESULTS

Weight cycling, teasing about weight and shape, body dissatisfaction, negative affect, and dietary restraint comprised the best fitting models (original and cross-validation) for binge eating in women and men. These variables explained 61-72% of the variance in symptoms of binge eating in the samples of men and 70% of the variance in the samples of women. Although the male and female models were mostly similar, notable differences between them were found.

DISCUSSION

The variables that comprise these etiological models should be considered in the development of prevention programs for obese binge eaters. Longitudinal studies, however, are needed to examine these etiological paths and to test for causal relationships.

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.