Nutritional interventions for individuals with bulimia nervosa

The complexity of the interaction between binge-eating and attention

OBJECTIVE

To investigate whether binge-eating in patients with eating disorders (EDs) is associated with attentional deficits.

METHODS

We studied ED patients with binge-eating (n = 51), no binge-eating (n = 59) and controls (n = 58). ED patients were assessed following the stabilization of weight and ED pathology. Attention assessment included evaluation of attention deficit hyperactivity disorder (ADHD) diagnosis, the Adult ADHD Self-Report (ASRS) and ADHD Rating Scale-IV-Home Version (ADHD-RS) questionnaires, and attention functioning assessed with neuropsychological tools. The severity of eating-related pathology, depression, anxiety and obsessionality was also monitored.

RESULTS

Patients with binge-eating showed more ADHD symptomatology on the ADHD-RS compared with non-binge-eating patients. No differences were found between binge-eating and non-binge-eating patients in ADHD diagnosis and neuropsychological functioning. Among the specific ED subtypes, patients with anorexia nervosa binge/purge type (AN-B/P) showed the highest rates of ADHD symptomatology on the ADHD-RS, and were characterized with sustained attention deficits.

CONCLUSION

Binge-eating is not associated with attention deficits as measured by objective neuropsychological tools. Nonetheless, it is associated with attentional difficulties as measured with the self-reported ADHD-RS. AN-B/P patients are the only ED category showing objective sustained attention deficits.

The use of enteral nutrition in the treatment of eating disorders: a systematic review

PURPOSE

Enteral nutrition (EN) is frequently used in the treatment of anorexia nervosa (AN), and less commonly, bulimia nervosa (BN); yet, no standardized guidelines for treatment exist at this time. The aim of this review is to investigate the efficacy of EN in the treatment of eating disorders and make recommendations for clinical practice and future research.

METHODS

An exhaustive literature search of 7 databases was completed. The search strategy combined key terms anorexia nervosa, bulimia, and eating disorders with terms associated with EN. There were no restrictions on publication date or language. Studies that assessed the effect of EN on weight restoration, refeeding syndrome, and binge/purge behaviors in the treatment of AN and BN were included.

RESULTS

Of 73 full-text articles reviewed, 22 met inclusion criteria. Nineteen studies reported that significant short-term weight gain was achieved when EN was used for refeeding malnourished AN patients; however, results varied for the six studies reporting on long-term weight gain, maintenance, and recovery. In studies with a comparator, no significant differences were found between the EN and oral refeeding cohorts regarding gastrointestinal disturbance, refeeding syndrome, or electrolyte abnormalities. Five studies examined the effect of EN on binge/purge behaviors, suggesting that temporary exclusive EN decreases the frequency and severity of binge/purge episodes.

CONCLUSION

Although EN is an essential life-saving treatment in severe cases of AN, it does not guarantee long-term success or recovery. The results of this systematic review highlight the need for prospective controlled trials with adequate sample sizes to make comparisons between specific feeding methods, formulations, and defined short and long-term outcomes. Evidence-based standards for clinical practice are needed with specific guidelines for best results for AN and BN treatment.

LEVEL OF EVIDENCE

I, systematic review.

Development of the "Recovery from Eating Disorders for Life" Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder

BACKGROUND

There is limited evidence to inform nutrition and dietetic interventions for individuals with eating disorders even though it is recommended as an essential part of multidisciplinary management. There is minimal guidance, an absence of standardised nutrition educational material, and no research on how best to educate patients on healthy eating and how to achieve nutrition adequacy. Therefore the REAL Food Guide was developed.

METHODS

The REAL Food Guide is a pyramid with four layers and key nutrition messages beside each layer that was conceived to address gaps in nutrition education and intervention for individuals with eating disorders. Written and verbal consumer feedback was obtained from consumers receiving treatment regarding the acceptability and usefulness of the REAL Food Guide. A unique database was developed to reflect the types of foods and realistic portion sizes that patients are likely to select. This database was used for nutrition modelling to assess the nutrition adequacy of three meal patterns (meat containing, vegetarian and semi-vegan) for both weight maintenance and weight regain. Each meal pattern was compared to the Nutrient Reference Values for Australia and New Zealand.

RESULTS

Nutritional analysis demonstrated nutritional adequacy of meal patterns for energy, macronutrients and most micronutrients when the recommended number of serves from the REAL Food Guide were assessed. All meal patterns were adequate in micronutrients except for the semi-vegan meal pattern that was inadequate in vitamin D. Feedback from individuals with eating disorders demonstrates the nutrition education tool was acceptable to them as they felt it was more helpful for their recovery than general nutrition guidelines.

CONCLUSION

The REAL Food Guide is a comprehensive and user-friendly guide that clinicians can use to educate patients about components of a balanced and healthy diet. The guide can educate all eating disorder clinicians, including those who are new to the field, about the basics of nutrition. Clinicians using the guide can be confident that, if followed, patient's energy and nutritional requirements will be met and important nutrition education messages are reinforced, that are tailored to the beliefs and concerns of individuals with eating disorders.

Temperamental differences between adolescents and young adults with or without an eating disorder

OBJECTIVE

There is an increasing interest into the role of temperament, and more specifically the traits Sensitivity to Punishment (SP) and Sensitivity to Reward (SR), in the occurrence of eating disorder (ED) symptoms. However, the results on this topic are inconsistent, different instruments are used to measure SP and SR and there is a lack of research on adolescents and young adults, although they form a group at risk to develop an ED. Therefore, the present objective was to study personality profiles co-occurring with specific EDs in adolescents and young adults.

METHOD

The present study examined the levels of SP and SR for different ED-diagnoses, namely Anorexia Nervosa of the Restricting type (AN-R; n=41), Anorexia Nervosa of the Binge/Purge type (AN-B/P; n=20) and Bulimia Nervosa (BN; n=30), and compared these with a Healthy Control group (HC; n=292). SP and SR were measured by three different temperament questionnaires in order to rule out instrument-specific findings. Only female participants between the age of 14 and 25 years were included.

RESULTS

SP was transdiagnostically increased compared to HCs, whereas SR was lower in AN-R patients compared to BN patients. These results were independent of the questionnaire being used.

DISCUSSION

Further research is necessary to explain how these traits may influence specific ED-symptoms.

A 3-month at-home tube feeding in 118 bulimia nervosa patients: a one-year prospective survey in adult patients

BACKGROUND & AIMS

To study the 1-yr follow-up of 118 bulimia nervosa (BN) patients after a 3-month at-home tube feeding (TF) in a prospective study.

METHODS

At-home TF lasted 3 months, including one month of exclusive TF (no food). All patients fulfilled 4 questionnaires (score of binge/purging episodes (BP), eating disorder inventory, anxiety, depression), before, at the 3-month TF point, and 6 and 12 months latter.

RESULTS

The score of BP episodes dramatically decreased from 28.8 ± 15 (before TF) to 7.3 ± 5.4 at 3 months, as well as at 1 yr (15.1 ± 6.2). We also obtained a 50% decrease in Beck score (depression) and Hamilton score (anxiety). Curiously, there was no difference between the BP scores of the patients following psychotherapy and those who did not, despite lower scores for anxiety and depression.

CONCLUSION

In conclusion, in bulimia nervosa patients having normal BMI and purging behavior, home-TF allow to obtain total withdrawal from bingeing/purging in at least 75% of the cases at short term (3 months) and in 25% of the patients at one year, whatever the patients have or have not psychotherapy.

Efficacy of tube feeding in binge-eating/vomiting patients: a 2-month randomized trial with 1-year follow-up

BACKGROUND

In many binge-eating/vomiting patients, abstinence could not be obtained from classical treatments. Since the authors showed that tube feeding (TF) reduced such episodes in anorexia nervosa (AN)-hospitalized patients, they carried out a randomized trial on the efficacy of TF plus cognitive behavioral therapy (CBT) vs CBT alone in AN and bulimia nervosa adult outpatients.

METHODS

The authors randomly assigned 103 ambulatory patients to receive 16 sessions of CBT alone (n = 51) or CBT plus 2 months of TF (n = 52). The main goal was abstinence of binge-eating/vomiting episodes. Other criteria were gains in fat-free mass and muscle mass improvements in nutrition markers, and quality of life (SF-36 Health Survey), depression (Beck Depression Inventory), and anxiety (Hamilton Anxiety Rating Scale) scores. Evaluations were performed at 1, 2 (end of treatment), 5, 8, and 14 months (analysis of variance).

RESULTS

TF patients were rapidly and more frequently abstinent at the end of treatment (2 months) than the CBT patients: 81% vs 29% (P < .001). Fat-free mass, biological markers, depressive state (-58% vs -26%), anxiety (-48% vs -15%), and quality of life (+42% vs +13%) were more improved in the TF group than in the CBT group (P < .05). One year later, more TF patients remained abstinent (68% vs 27%, P = .02); they were less anxious, were less depressed, and had better quality of life than the CBT patients (P < .05).

CONCLUSION

TF combined with CBT offered better results than CBT alone.

Tratamento nutricional da bulimia nervosa

A bulimia nervosa é um transtorno alimentar caracterizado por compulsões alimentares e métodos compen-satórios recorrentes. Os pacientes apresentam ingestão alimentar inadequada e comportamentos alimentares disfuncionais. O adequado tratamento do transtorno requer uma equipe multiprofissional e terapia nutricional especializada. Compreender as características desse transtorno, os padrões de consumo e o comportamento alimentar, bem como atentar para as atitudes alimentares dos pacientes, é fundamental para o planejamento e para a adequada condução da abordagem nutricional. A terapia nutricional para esse transtorno é diferenciada, exigindo do nutricionista maiores habilidades de aconselhamento nutricional. Educação nutricional e acon-selhamento nutricional, com ênfase na abordagem de atitudes alimentares e insatisfação corporal, são o foco da terapia nutricional. Para o atendimento eficaz desses pacientes e o sucesso no tratamento nutricional, é importante que o profissional se mantenha atualizado sobre nutrição e transtornos alimentares e procure especialização e experiência nessa área do conhecimento.

Alterations in QT dispersion in the surface electrocardiogram of female adolescent inpatients diagnosed with bulimia nervosa

Increased QT dispersion (QTd) reflects cardiac autonomic imbalance and indicates elevated risk for cardiac arrhythmias. In the present study, we assessed heart rate, QT and corrected QT intervals, and QTd in 20 acutely ill bulimia nervosa adolescent inpatients on admission and discharge. A significant decrease in QTd was found between admission and discharge (67 +/- 13 milliseconds vs 55 +/- 12 milliseconds, respectively; P = .0005). The decrease in QTd values correlated significantly with the decrease in the frequency of bingeing/purging behaviors (r = 0.51, P = .022). No significant correlations were found between the electrocardiographic indices and other clinical and laboratory measures. The elevated QTd in malnourished bulimia nervosa patients might indicate a cardiac autonomic imbalance that is most likely corrected after symptomatic improvement.

Sensitivity to reward and punishment in eating disorders

The aim of this review was to collate and summarise the self-report data regarding anomalies in sensitivity to reward and punishment in eating disorders (ED) with use of a meta-analysis where possible. Electronic databases were searched to December 2008. Studies were required to have a non-eating disorder healthy control group and include at least one self-report measure of sensitivity to reward or punishment in an eating disorder population. Findings were very heterogeneous and inconsistencies between studies and measures were highlighted. In general, patients with anorexia nervosa (restricting type) were less sensitive to reward than healthy controls, whereas patients with bulimia nervosa and anorexia nervosa (binge/purge) type were more sensitive. All ED groups report higher sensitivity to punishment than healthy controls. Individuals with eating disorders differ from healthy controls in measures of reward and punishment sensitivity as measured using the Temperament and Character Inventory, Tridimensional Personality Questionnaire and BIS/BAS scales, but further work is required as there is some heterogeneity in the data. Generating more research using behavioural measures may increase understanding of the findings.

Evaluation of integrative medicine supplements for mitigation of chronic insomnia and constipation in an inpatient eating disorders setting

OBJECTIVE

The aim of this study was to determine whether patients with eating disorders used fewer conventional sleep and constipation medications when given integrative medicine interventions.

DESIGN

Retrospective data from two cohorts were compared; the eating disorder group (ED) received only conventional treatments for insomnia and constipation and the integrative medicine eating disorders group (IMED) received integrative medicine and conventional treatments if needed. Patient reports of insomnia and constipation as well as medication use for these conditions were collected and compared.

RESULTS

Patient demographics were similar in the two groups. Although reports of sleeping well were similar, use of conventional sleep medications was significantly lower for the IMED group. Reports of constipation and use of conventional constipation medications were also lower for IMED versus ED, but these differences were not all statistically significant.

CONCLUSION

Integrative medicine interventions for insomnia and constipation appear to benefit patients with eating disorders and may allow these patients more focus for the work of recovery.