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Eating Disorders during Adolescence:  Nutritional Problems and Interventions

Jane Mitchell Rees, PhD, RD, CD
Departments of Health Services and Pediatrics 
Maternal Child Health and Adolescent Medicine 
University of Washington, Seattle, WA 98195

Eating Disorders 1    2    3

Useful Links

Pregnancy

Puberty

Risky Eating Behaviors

Weight Management

Table  - Nutritional Care Summarized* 

(Unless otherwise stated, all links accessed on March 28, 2012)

(* Schebendach 1999, Schebendach & Nussbaum 1992, Fisher et al. 1995, Golden et al. 1997, Kreipe et al. 1995 [ Society of Adolescent Medicine, Position Paper on Adolescent Eating Disorders ]

Assess and monitor   

• body size - Compare to reference data in percentiles by age and sex :
  
  1) CDC Growth charts (Adobe Acrobat .pdf file):
  

  Girls	Boys
  height-for-age	height-for-age
  weight-for-age	weight-for-age
  BMI-for-age	BMI-for-age
  weight-for-height	weight-for-height

Notes:
 a) Validation studies are needed to determine cut-off points for underweight in BMI-for-age data.
 b) 5th percentile cut-off suggested by WHO was not based on current data
 c) Symptoms of eating disorders are often seen at BMI's above the 5th percentile of current BMI-for-age charts

2)  weight-for-height-for-age and sex table (Cromer et al, 1992), 

• body composition (estimate fat stores and muscle mass)  - Use nomogram to estimate muscle mass from midarm circumference and triceps skinfold measures (Gurney & Jelliffe 1973)
• skin folds (Compare to reference data in percentiles by race, age, sex, (Frisancho 1993))
• muscle mass  (Compare to reference data in percentiles by race, age, sex, (Frisancho 1993))
• fluid retention (edema)  - Assess edema (Seidel, HM et al. 1991)
• weight gain/loss and height gain history (compare to normal for sexual maturity rating, age, sex, and hereditary potential).  At least 25th percentile of reference data should be maintained for lower range of normal healthy weights.  Normality of growth status and progress for pubertal stage requires additional judgment of clinician trained to evaluate pubertal growth
• nutrient intake (adequacy of amount and balance for size, sex, age, energy stores and activity)
• fluid intake and output (out-patient, report; in-patient, measure and assess for normalcy)
• metabolic rate -- measure or calculate to guide dietary prescription  Caloric prescription -- weight gain:
         1.3 X measured resting energy expenditure (REE) for sedentary male or female
            or
         1.3 X adjusted Harris-Benedict equation (HB), for predicted REE in females as follows:
             a) Calculate HB Equation:
                         Calculated REE = 655 + (9.6 X wt in kg) + (1.85 X ht in cm) – (4.7 X age in yr)
             b) Adjust for hypometabolic rate:
                         Adjusted HB, for initial hypometabolism = (1.84 X calculated REE) - 1435
             c) Caloric prescription = 1.3 X Adjusted HB
           (Schebendach 1999, Schebendach & Nussbaum 1992)
   
• food and weight related behaviors, beliefs and knowledge (are they compatible with health, reality and factual information?)
• sensations of hunger and satiety (perceived need to eat and stop eating)
  
  Note: No single measure will provide an accurate nutritional status evaluation.

Prescribe a diet during crises

• about 1200 – 1400 kcal energy daily when admitted to hospital for malnutrition, based on measured or calculated energy needs
• 100 kcal daily increase* in acute phase
• 200 kcal daily increase* in refeeding phase until normal intake for individual is reached
• nutrients balanced and adequate

Set limits

• regulate energy expenditure to allow repletion and maintenance of energy stores 

Establish weight-for-height-for-age goals 

• 1-3 lb per week gain during life-threatening phase of malnutrition 
• ½-1 lb per week gain in acute outpatient phase of malnutrition 
• intermediary goals (10th,15th, 25th percentile) weight-for-height-for-age until normal  (25-75th percentile) is reached, with normal menstrual status for pubertal stage

Plan treatment with patient

• include patient in planning treatment to the extent possible to encourage autonomy

Teach 

• how nutrition supports life and health
• principles of balancing energy
• methods to manage weight healthfully
• selecting food in any setting

Support through counseling

• help patient nourish self, with professional guidance then independently

Refer 

• to all members of interdisciplinary team if not in same institution
• for dental care, especially if vomiting

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