M39 Treatment of Eating Disorders
Section 1: Introduction
What Are Eating Disorders?
Eating disorders are complex medical and psychiatric illnesses that affect physical and mental health, involving intense emotions and disordered food-related behaviours.
They are serious illnesses and can be fatal if left untreated.
Types include: anorexia nervosa, avoidant/restrictive food intake disorder (ARFID), bulimia nervosa, binge eating disorder, and other specified feeding and eating disorders (OSFED).
Anorexia nervosa (AN): significant weight loss or failure to gain weight, distorted body image, and restriction of food intake. Fear of gaining weight even if underweight. Often starts in early adolescence (11–13) or late adolescence (17–18), but can occur at any age. Binge/purge may or may not occur.
ARFID: restricting intake of food or food groups without a fear of weight gain, leading to weight loss, poor growth, or nutritional deficiencies. Usually onset in early adolescence (average 12–13). Lacks significant body image concerns.
Bulimia nervosa (BN): cycles of binge eating followed by purging (vomiting, laxatives, enemas, diuretics) or excessive exercise to compensate.
Binge eating disorder (BED): episodes of unusually large food intake with a sense of loss of control; no purging afterward.
OSFED: combinations of symptoms from other disorders that do not meet full criteria for any single disorder.
Disordered eating: patterns that don’t meet full criteria but put someone at risk (e.g., extreme dieting, orthorexia).
Prevalence and overlap: symptoms may overlap across disorders; difficult to diagnose by appearance alone.
MYTH: Only girls and women have eating disorders. TRUTH: Males are affected too; risk is higher in male athletes in weight-class sports and those seeking muscle gain.
Causes of Eating Disorders
Multifactored etiology: rarely a single cause; biological, psychological, and environmental factors interact.
Biological: mood disorders, anxiety, depression; familial predisposition; temperament traits.
Psychological: OCD-like features, trauma (physical, emotional, sexual), need for control.
Environmental: societal emphasis on thinness and dieting; media influences and diet culture; sports with weight/class pressures (dancing, gymnastics, rowing, wrestling, track).
Stressors: school, work, sports, peer or family pressures; cultural attitudes about appearance.
Interaction with family history and personal traits (perfectionism, excessive drive to succeed, impulsivity).
Warning Signs & Symptoms
Warning signs are not definitive but are red flags suggesting risk or presence of a disorder.
Examples: skipping meals or hiding meals; over-exercising or prioritizing exercise; restricting food groups or adopting restrictive diets (vegans, paleo, ketogenic); odd food behaviors (cutting food, rearranging food, obsessively reading nutrition info, counting calories);
Body monitoring: constant weighing, body checking; chewing gum, caffeine or calorie-free drinks; bathroom use after meals; eating unusually large amounts; loss of control around food; scars/calluses on hands from purging; secretive eating; dieting with diet foods.
MYTH: Everyone with an eating disorder is underweight. TRUTH: BN, BED, and OSFED individuals can be normal weight or overweight; some wear baggy clothes to hide changes.
Health Consequences of Eating Disorders
Eating disorders affect multiple body systems and can be severe or life-threatening.
General mechanism: strict food restriction can slow down the body to conserve energy; purging disrupts electrolytes and organ function; binge eating can raise blood pressure, cholesterol, and risk for diabetes.
Systems affected (examples by category):
SKIN, HAIR, TEETH: dry skin, brittle nails, hair loss, lanugo (fine downy hair), cold intolerance, tooth decay (BN).
GENERAL: weight changes, weakness, dehydration, electrolyte disturbances, poor concentration, irritability.
PSYCHOSOCIAL: depression, anxiety, low self-esteem, weight/shape overvaluation, shame, withdrawal.
ENDOCRINE: delayed growth/puberty, menstrual disturbances, abnormal thyroid (sick euthyroid).
CARDIOVASCULAR: low pulse, dizziness, low blood pressure; possible hypertension in BN/BED; arrhythmias.
GASTROESOPHAGEAL: abdominal pain/bloating, constipation, reflux.
MUSCULOSKELETAL: low bone density (osteopenia/osteoporosis), stress fractures, decreased muscle mass.
Abbreviations: AN = Anorexia Nervosa, ARFID = Avoidant/Restrictive Food Intake Disorder, BN = Bulimia Nervosa, BED = Binge Eating Disorder.
Figure 1.1: The effects of an eating disorder on the body.
Section 2: Eating Disorder Treatment
The Treatment Team
Eating disorders require medical and psychological care; team-based approach includes:
Medical Provider: monitors physical health (height, weight, blood pressure, pulse, temperature); orders labs, urinalysis; may order EKG and bone density tests (DXA); advises on supplements, medications, and treatment options; determines medical stability for different care levels.
Therapist: improves self-esteem and body image; involves family in meals; teaches coping skills; addresses related emotional problems (depression, anxiety, OCD, substance use); provides private space to discuss needs and feelings; identifies distorted thoughts; assists in healthy coping and recovery.
Family-Based Therapist (FBT): guides family in re-feeding and meal management; teaches families how to handle mealtime conflicts; empowers parents to restore weight and support recovery; part of a distinct approach focusing on weight restoration.
Registered Dietitian (RD): creates safe, healthy eating plans with the family; answers nutrition questions; advises on healthy eating, weight stabilization, supplements, and exercise; dispels myths about food and dieting.
Treatment Options for Eating Disorders
Outpatient: majority of cases; medically stable individuals maintaining daily activities.
Multi-disciplinary outpatient: regular visits with medical provider, therapist, and RD; weight checks, vitals, labs; structured meal plans or general guidelines; therapy targets avoidance of restriction or purging.
Family-Based Treatment (FBT): families manage recovery, meals, and weight restoration with professional guidance; focus on weight restoration and behavioral change; once weight is restored, address developmental issues.
Suitability of FBT: best for AN diagnosed individuals living at home, illness duration <3 years.
FBT structure: three phases over 6–12 months; weekly sessions initially; then biweekly.
Intensive Outpatient Program (IOP): for transition from residential or when not ready for higher levels; 3–5 days/week, ~3 hours per day; includes at least one supervised meal/snack; may include outpatient team support.
Partial Hospitalization (Day Program): 6–8 hours/day; 2–3 supervised meals/snacks; group/individual therapy; nutrition education; additional modalities (yoga, art therapy).
In-Patient: for medically unstable or failures at lower levels; 24-hour hospital care; structured meals, therapy, and groups; transition to higher levels after stability.
Residential: 24-hour therapeutic living environment for medically stable individuals; frequent team meetings; post-residential transition to outpatient or IOP.
Transitioning: support during transition from inpatient/residential to outpatient; set up outpatient team; ensure access to ED specialists; plan and coordinate with insurance; recognize meals can be challenging; presuppose ongoing team support.
Group Support Meetings: weekly groups for patients and separate groups for family members; provide encouragement and shared coping strategies; located at health centres, community agencies, or schools.
Common Myths vs Truths (in treatment context):
MYTH: People with anorexia don't eat anything. TRUTH: They may severely restrict foods/types/portions but still eat some foods.
Therapy for Eating Disorders
Rationale: EDs are medical and psychological; therapy is a core component.
Advantages of therapy: safe space to share feelings; address related emotional problems; understand causal factors and cognitive distortions; develop healthy coping skills; build self-esteem and positive body image.
Types of mental health therapies:
Cognitive Behavioural Therapy (CBT): identifies and changes unhealthy thoughts and behaviours; short-term; helps manage anxiety.
Dialectical Behavioural Therapy (DBT): builds coping skills to manage emotions and reduce harmful behaviours; primarily group-based with weekly individual therapy; emphasizes problem solving.
Family-Based Therapy (FBT): empowers families to help restore weight; often called the Maudsley method; therapist coaches family to support re-feeding; goal is weight restoration and normal functioning.
Group therapy: peers with similar struggles share experiences and goals under a therapist.
Family therapy: involves the patient and family members to discuss relationships and support recovery.
Helpful tips to maximize therapy:
Acknowledge initial discomfort; normal to be shy or upset; honesty with therapists improves outcomes.
Ensure compatibility with the therapist; if not a good fit, seek another therapist.
MYTH: It's almost impossible to recover from an eating disorder. TRUTH: Complete recovery is possible but can take months to years and requires a multidisciplinary team.
What is Healthy Eating?
Healthy Eating Defined: nutritionally balanced meals and snacks; RD-guided plan; goal is nourishment, energy, and strength; not a strict diet; flexible and individualized; includes regular meals, snacks, and occasional treats; foods from all groups.
Food Groups and Roles:
Carbohydrates: energy for brain and muscles; needed for physical activity.
Dairy: calcium/vitamin D for bone health; protein helps fullness.
Fruits/Vegetables: vitamins, minerals, fiber.
Protein: supports hair/skin, repair and growth of muscles.
Fats: heart health, hormone production, energy; from oils, nuts, fish.
Meal Plans and Exchanges:
Meal plans use exchanges: portions from food groups; plan tailored to nutritional needs; not always used in Family-Based Therapy (FBT).
Snacks:
Provide energy between meals; should include two or more food groups; examples include combinations of fruit, dairy, grains, fats, and proteins.
Grocery Shopping and Cooking:
Involve the person in grocery shopping with RD guidance; create lists; planning ahead reduces stress; RD assists with meal planning.
Cooking strategies to reduce meal-time stress; plan ahead with RD; discuss best support around meals/snacks.
Hunger and Fullness Cues:
Learning to eat when hungry and stop when full; cues take time to understand; RD can help with a hunger/fullness scale.
Hunger and Fullness Scale:
0 STARVED, FEELING FAINT AND WEAK WITH HUNGER
1 EXTREMELY HUNGRY
2 VERY HUNGRY
3 HUNGRY, STRONG DESIRE TO EAT
4 SOMEWHAT HUNGRY
5 NOT HUNGRY NOR FULL
6 SOMEWHAT FULL
7 FULL, DON'T NEED TO EAT MORE
8 VERY FULL
9 UNCOMFORTABLY FULL
10 STUFFED, PAINFULLY FULL
Sample Snack List: various combinations across food groups (fruit/protein/fat, fruit/dairy/fat, dairy/fruit, etc.).
Grocery Shopping and Cooking Details: guidance on involving the patient; planning and exploration of foods; cooking helps reduce meal-time stress.
Hunger/Fulness Concept Emphasis: listening to body cues; goal to balance energy needs; scale to guide intake (e.g., eat at a 3 and stop at a 7).
Example statements and activities around hunger cues help integrate eating behaviors with recovery.
MYTH: Eating disorders are just extreme dieting. TRUTH: They are psychological problems that may function as coping mechanisms for trauma, loss of control, or abuse.
Exercise, Yoga, and Mindfulness in Treatment
Healthy Exercise:
Benefits: improves heart/lung function, insulin sensitivity, endorphin production, motor and social skills in youth; reduces risks for heart disease, obesity, diabetes.
General adult guidance: CDC recommends 150 minutes of moderate or 75 minutes of vigorous activity weekly, or an equivalent combination.
Concern indicators: exercise should not become a primary path to weight loss or affect sleep, social life, or work.
When to be concerned: exercise to improve sport performance or physician-recommended activity is reassuring; excessive exercise for weight loss or weight-control at healthy/underweight levels is concerning.
Worrisome habits include: exercising to the point of interfering with sleep/social/work; over-fixation on appearance; exercising when sick or underweight; secretive exercise; exercising without increasing caloric intake; continuing exercise despite medical advice against it due to low weight or injuries; distress if unable to exercise; exercising around meals to burn calories.
Additional signs: menstrual irregularities, dizziness, lightheadedness, fatigue, chest pain, injury, excessive weight loss in youth.
Female Athlete Triad: lack of period, disordered eating/nutrition deficits, and low bone density with risk of stress fractures.
Guidance for discussing exercise: open conversation with health care provider’s input; emphasize health and safety; model healthy behavior; avoid implying exercise earns food.
Yoga:
Evidence: yoga can reduce ED symptoms and serve as an adjunct to standard treatment due to improved relaxation and body awareness.
What is Yoga: combination of physical poses, breathing, and instructor guidance; non-competitive, self-paced practice.
Styles for ED populations:
Ananda: gentle movements, meditation, breathing; not aerobic.
Iyengar: precise alignment; may tempt perfectionism; emphasize practice over perfection.
Integral: mind-body-spirit integration with focus on purpose.
Kripalu: three stages—posture learning, meditation with posture, spontaneous/meditative motion; welcoming for beginners.
Sculpt Yoga: cardio/resistance; not recommended for ED due to emphasis on sculpting and calorie burning.
Vinyasa (Flow): slower, meditative flow preferred for ED; avoid hot yoga due to dehydration risk and weight-loss triggers.
Yin Yoga: restorative, long-held floor poses (3–5 minutes) for stress management.
Breathing and meditation: awareness of breath is foundational; longer-term practice improves focus and regulation; yoga and meditation can be combined but are not mandatory.
Practical pre-class considerations: consult with primary care provider; communicate limitations to instructors; ensure hydration and rest; modify poses as needed.
THREE IMPORTANT POINTS ABOUT YOGA:
1) Yoga should never hurt; back off if uncomfortable; seek modifications.
2) Poses vary; practice is about progress, not perfection; avoid comparison with others.
3) Comfortable clothes are fine; no need for special apparel.MYTH: You can never eat too healthfully. TRUTH: Obsessive focus on only “pure/natural” foods (orthorexia) can cause malnutrition.
Body Image and Self-Esteem
Media influence and societal pressures contribute to poor body image and low self-esteem; impact across age groups and genders.
Boys/men: rising recognition; risk linked to sports that emphasize lean or muscular ideals; interest in muscle mass rather than weight loss.
Sexual orientation: higher rates of binge/purging in LGBTQ+ populations compared to heterosexual peers.
Athlete risk: wrestling, lightweight rowing, gymnastics, dance, skating; endurance sports also pose risk due to “race weight” pressures; coaches may lack ED knowledge, potentially triggering comments about size/shape.
Body distortion: misperception of body shape/size; focus on perceived flaws.
Counselor strategies to support body image:
Encourage comfortable clothing and non-triggering clothing choices.
Suggest relaxing activities (music, yoga, games, singing, meditation).
Normalize diverse body shapes; promote time with positive social circles.
Writing exercises and journaling to build self-esteem; list accomplishments; identify body parts liked; critique media; write to companies about harmful ads; practice positive self-talk.
Do's and Don'ts for Family Members
Do:
Eat together and maintain regular meals/snacks.
Keep meals positive; discuss interests and events; keep table conversation natural.
Reduce mealtime stress and food-talk; provide mealtime structure.
Plan ahead for meals and structure.
Don't:
Talk about food, calories, fat, or portion sizes at meals.
Discuss doctor appointments or progress unless invited.
Use food as a reward/punishment.
Label foods as “good” or “bad”; avoid moral judgments on eating.
Treat the patient differently than before diagnosis; avoid overemphasizing the patient’s status.
Additional Tips for Family and Caregivers
Learn about eating disorders and listen to the patient’s experiences.
Be understanding, patient, and avoid judgmental language.
Model healthy eating and exercise behavior; avoid shaming or guilt.
Encourage journaling and new interests to replace disordered behaviours.
Continue long-term therapy and coordinate with licensed professionals for ongoing support.
Avoid health/fashion magazines; avoid dieting products or self-critique; avoid comments about appearance.
Avoid dictating how or when to exercise; do not confuse activity with weight loss goals.
Avoid pressuring the patient to “lose weight”; support health and wellbeing instead.
Eating Disorder Studies (Section 2: Studies and Evidence base)
EDs are among the most lethal psychiatric illnesses; high mortality rate.
Socioeconomic impact: 2012 Australian Butterfly Report estimated over AUD 69 billion (approx. USD 48 billion) annually in Australia.
Treatment outcomes (typical evidence): BN abstinence ~30% after treatment; anorexia nervosa remission rates in adolescents around one-third by end of treatment, with about one-third maintaining remission long-term; adult AN remission ranges from 0% to 25% in some studies.
BED and OSFED outcomes show more favorable response rates (18–86% abstinence from binge episodes by end of treatment in some studies) but with wide variance.
Recent calls for multi-dimensional outcome indices: behavioural, biological, and cognitive dimensions; importance of distinguishing weight-based and cognitive symptom outcomes.
Access and uptake of treatment:
Only about 26% of those with EDs receive any consultation; 20% of female and 13% of male ED patients engage in treatment in Australian studies.
Barriers include fear of change, fear of losing control, low motivation; congruence between patient and family perceptions of severity increases uptake.
Higher levels of care and treatment translation:
FBT adapted to partial hospital settings shows promising gains, with weight restoration and symptom improvement.
Mood symptoms (depression, anxiety) predict outcomes; social anxiety can predict poorer residential outcomes; body image flexibility relates to better outcomes; acceptance-based therapies show promise across care settings.
Section 3: Glossary (Key terms and definitions)
Amenorrhea: Absence of menstrual periods; may indicate very low weight or hormonal dysfunction.
ANOREXIA NERVOSA: Severe restriction of intake with intense fear of weight gain and distorted body image.
ARFID: Avoidant/Restrictive Food Intake Disorder; significant nutritional deficiencies or interference with functioning without fear of weight gain.
BINGE EATING DISORDER: Recurrent binge eating with a sense of loss of control; no purging; distress and guilt; not due to compensatory behaviours.
BMI: Body Mass Index;
ext{BMI} = rac{Weight ext{ (kg)}}{[Height ext{ (m)}]^2}BONE DENSITY: Bone mineral density, typically measured by a DXA scan.
BULIMIA NERVOSA: Recurrent binge eating with compensatory behaviours to avoid weight gain.
COGNITIVE BEHAVIOURAL THERAPY (CBT): Therapy focusing on recognizing and changing unhealthy thoughts and behaviours; short-term.
CHALLENGE or FEAR FOODS: Foods avoided due to beliefs about health, weight gain, or triggering binges.
DIALECTICAL BEHAVIOURAL THERAPY (DBT): Skills-based therapy for emotion regulation and reducing risk behaviours; group + individual components.
DXA SCAN: Dual-energy X-ray absorptiometry; measures bone density and fracture risk.
EATING DISORDER BEHAVIOURS: Behaviours like purging, counting calories, excessive exercise, binge eating, extreme dieting, etc.
EKG: Electrocardiogram; records heart activity.
ELECTROLYTES: Important minerals (e.g., sodium, potassium, chloride, bicarbonate) that can be disrupted by EDs.
EXCHANGES: Meal-plan portions by food group in an exchange system.
FAMILY-BASED THERAPY (FBT): Parent-led refeeding approach; Maudsley method; aims for weight restoration; family actively involved during meals.
FAMILY THERAPY: Therapy with patient and multiple family members to discuss relationships.
GOAL WEIGHT RANGE: Target healthy weight range for recovery; tailored to prior weight, age, and developmental status; menstrual status affects target.
GROUP THERAPY: Therapy in groups with peers; shared experiences and goals.
HIGHER LEVEL OF CARE: Any care level above outpatient (IOP, PHP, residential, inpatient).
INSULIN RESISTANCE: High insulin levels with decreased tissue sensitivity; related to Type 2 diabetes risk.
MEAL PLAN: Dietitian-designed plan detailing amounts and types of foods; based on nutritional needs.
OSFED: Other Specified Feeding or Eating Disorder; subthreshold presentations with overlapping symptoms.
PERCENT MEDIAN BMI: Age- and sex-adjusted BMI percentile metric used for treatment planning and monitoring.
PURGING: Behaviours to eliminate calories (vomiting, laxatives, excessive exercise, diet pills).
SAFE FOODS: Foods that ED individuals are comfortable eating; varies per person.
TRIGGER: Anything that prompts disordered eating thoughts or behaviours.
VITAL SIGNS: Temperature, blood pressure, pulse, respiration; menstrual status may also be considered a vital sign in girls.
Notes on Figures and Examples
Figure 1.1 documents the systemic effects of EDs on the body; Figure 1.2 shows a Sample Hunger and Fullness Scale.
The content emphasizes real-world applications, such as meal planning, grocery shopping, and family involvement in care.