Your Guide to Nutrition Counseling for Eating Disorders

Over 5 million Americans suffer from eating disorders [5]. To help those suffering, medical professionals need to understand that eating disorders are more than a mental illness.

The expertise of dietitians specializing in eating disorder treatment is necessary in overcoming nutritional and medical problems eating disorders present.

Treatment for all eating disorders, at any level of care, requires a collaborative interdisciplinary approach with the patient at the center.

Nutrition therapy for eating disorders will address the whole person, repairing relationships with nutrition, mind, body image, movement, and more.

Diet Culture and Eating Disorders

Diet culture is everywhere we turn from commercials to grocery stores. For those vulnerable to its influence dieting may morph into disordered eating or lead to eating disorders.

Motivation to start a diet may be well-intentioned. Diets may be started to improve health, allergies, intolerances, or weight loss. The question is, how do you know when the line is crossed between dieting and disordered eating?

Dieting vs. Eating Disorders

When someone goes on a diet they eventually must come off of a diet. In other words, diets are not maintainable.

Today there are a million different fad diets catching fire in the media. Maybe you can name a few brought up in sessions you’ve had to debunk?

Some of the most common fad diets today include the Keto Diet, Clean Eating, the Paleo Diet and the list goes on and on. Only about 5% of dieters are actually successful.

The reasons diets “fail” are because they contain common factors:

  • Restriction
  • Deprivation
  • Guilt
  • Shame

All fad diets, in some way, omit or demonize certain foods or food groups [4].

It’s important to understand, research shows that diets are restrictive and can lead to deficiencies and health complications [4]. This doesn’t sound too different from an eating disorder.

The difference between dieting and eating disorders is:

  • Severe restriction
  • Debilitating beliefs and attitudes related to food
  • Binge eating
  • Purging
  • Abuse of laxatives, diuretics, diet pills, etc.
  • Preoccupation with food, unable to focus on other tasks
  • Paralyzing fear of eating more or gaining weight
  • Isolation from friends, family, etc.
  • Avoiding social situations to exercise, unable to function without it
  • Inability to participate in many aspects of life including school, career, relationships, and more

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Can Dieting Lead to Eating Disorders?

It is estimated that 20-30% of adolescent girls participate in unhealthful dieting behaviors [7]. Sadly, these numbers continue to increase as we live in a society that glorifies a thin ideal.

When diets are taken too far eating disorders start to form. Preoccupation with physical appearance leads many to engage in efforts to change their body at any cost.

A 3-year cohort study found that girls who dieted at a severe level were 18 times more likely to develop an eating disorder [7]. In this same study girls who dieted at a moderate level were at least 5 times more likely [7].

Dieting has also been found to increase the likelihood of overeating or binge eating [7]. This is due to the body increasing hunger cues, trying to compensate for what it has been deprived of.

Eating disorders are all-consuming, moving an individual away from their initial motivation of starting a so-called diet to be healthy towards malnutrition and potential long-term health concerns.

Related Reading

Diet and Nutrition Concerns from Eating Disorders

No matter the eating disorder a toll is taken on the body. As nutrition professionals, there is a need to have awareness of nutritional concerns related to all eating disorders.

Nutrition concerns arise related to all macronutrients and micronutrients. Individuals are often unaware of how poorly their body is functioning.

This calls for the need to be aware of potential complications and provide support through patient education.

Vitamin & Mineral Deficiencies

The majority of severely malnourished patients suffering from an eating disorder have at least one micronutrient deficiency [3].

Common mineral deficiencies include zinc, iron, copper, and selenium. A study revealed zinc was the most common deficiency in severely malnourished patients with copper and selenium following [3].

Other mineral deficiencies such as iron can lead to anemia. Selenium deficiency impacts the immune system and deteriorates the ability to regulate mood [1].

Common vitamin deficiencies include vitamin D, vitamin B1, vitamin B12, and vitamin B9. A recent study found 54.2% of eating disorder patients were deficient in vitamin D [3].

Vitamin D deficiency is strongly related to a decline in hip bone mineral density [3]. Bone mineral density loss is the most common chronic complication in anorexia nervosa [3].

Supplementation for vitamin D is recommended in the majority of anorexia nervosa cases to prevent osteoporosis [3].

As nutrition professionals, it is important to recommend patients have blood work to complete a full vitamin panel. These results aid in assessing the need for supplementation and support need for a variety of foods.

Hydration in Nutrition

Hydration and Water Intake

Those suffering from eating disorders may have compromised electrolyte levels due to purging episodes and/or abuse of medications including diuretics, diet pills, and laxatives.

Electrolyte disorders can lead to hypokalemia, hypomagnesemia, and potentially lead to sudden cardiac arrest [4].

Purging and other methods of dehydrating the body such as diuretics, laxatives will promote fluid retention resulting in edema [6].

It is important to monitor edema or fluid retention, as these may be signs of a need for immediate medical attention.

Hydration may also be compromised due to restriction of fluid or not drinking water out of fear of weight gain.

Nutrition Counseling for Eating Disorders

Nutrition therapy for eating disorders should be individualized, placing the patient at the center.

No two patients, regardless of having the same type of eating disorder, are alike. Each patient will struggle with individual fears or beliefs and may present entirely different medically and psychologically.

Start by recognizing the clinical symptoms, attitudes, and food beliefs. Then, support patients while providing corrective nutrition education exploring facts vs. eating disorder beliefs and nutrition misinformation.

Beliefs may also overlap with adverse childhood experiences. Treatment should involve working with therapists to overcome somatically engrained traumatic experiences [2].

Anorexia Nervosa

Anorexia affects individuals of all shapes and sizes. It is important to understand treatment is not centered solely on weight gain, but all patients will need to restore weight to a certain extent.

Nutrition therapy for anorexia should involve initially assessing the patient’s nutritional status and applying individualized meal plans. Meal plans should incorporate all macronutrients and encourage variety.

Patient meal plans should be increased 1-2x per week as needed while monitoring and evaluating labs and physical signs and symptoms or refeeding syndrome.

Weight gain goals should be 1-2lb per week for outpatient care and 2-3lb per week for inpatient care [6]. When restoring weight patients fear gaining fat.

It should be acknowledged that yes gaining fat is a part of weight restoration along with muscle, organ tissue, bone mass, and water.

Weight restoration education should be a part of this process as well as the incorporation of Cognitive Behavioral Therapy (CBT) and Dialectical behavior therapy (DBT).

As nutrition professionals, it is important to support patients and understand when a higher level of care or more intense interventions are needed.

Bulimia Nervosa

Eating disorders are not always detectable from physical appearance. The majority of those suffering from bulimia are of normal weight.

Bulimia is often a result of biological vulnerability to depression or other mental health diagnoses [6]. Perceived family or societal expectations may even exacerbate bulimia.

When providing nutritional therapy the goal is to support consistency in eating patterns including at least 3 meals and 1-3 snacks daily. There can often be a cycle of restriction leading to binge eating and purging behaviors. Purging behaviors may include vomiting, laxative abuse, or excessive exercise.

Nutrition therapy should also include monitoring electrolytes, vital signs, weight, meal plan compliance, and behaviors. If laxatives are used, work with the patient and their physician to gradually reduce to prevent bowel obstructions [6].

Nutrition therapy and education should involve exploring food rules related to good vs. bad foods, what should be eaten, and how much. When a binging episode occurs there is a feeling of being out-of-control leading to a purging episode [6].

Medical conditions as a result of bulimia may include esophageal reflux disease (GERD), delayed gastric emptying, ulcers, H.pylori, and more. These conditions may increase the discomfort or pain, triggering a patient to feel purging is necessary [6].

Patients may want to recover from their eating disorder, while at the same time losing weight. Education should be included acknowledging recovery and dieting cannot coexist.

Again, CBT and DBT should be incorporated into treatment to support healing not only the body but also the mind.

Healing the mind involves learning to regulate and manage emotions. Medication may also be a useful component if other comorbid conditions are present.

Binge Eating Disorder (BED)

Patients with binge eating disorder (BED) will often present with concerns surrounding weight management [6]. Nutrition professionals may be one of the first treatment team members to recognize the disorder.

In treating BED, a dietitian will support patients in providing a structured and consistent meal plan including 3 meals and 1-3 snacks. Meal plans should incorporate all macronutrients as well and introduce binge foods.

Patients with BED may have a lack of variety in their current diet and be suffering from vitamin and minerals deficiencies.

To support clients in healing always request patients have a full vitamin and mineral panel completed. Insight is key to providing proper vitamin recommendations.

Nutrition professionals should also support clients in exploring triggers through binge food exposures and learning to replace maladaptive coping mechanisms.

Binge eating can be a way of meeting emotional needs as well. It is important to explore if food is used to feel specific emotions or turn off emotions. For some food fills a void and this requires support again through an interdisciplinary team.

Again, the addition of CBT and BDT are necessary for decreasing binge eating episodes, compensatory responses, and normalizing cognitions [5].

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  • [1] Achamrah, N., Coëffier, M., Rimbert, A., Charles, J., Folope, V., Petit, A., Déchelotte, P., & Grigioni, S. (2017). Micronutrient Status in 153 Patients with Anorexia Nervosa. Nutrients9(3), 225.
  • [2] Hackert, A. N., Kniskern, M. A., & Beasley, T. M. (2020). Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders. Journal of the Academy of Nutrition and Dietetics120(11), 1902–1919.e54.
  • [3] Hanachi, M., Dicembre, M., Rives-Lange, C., Ropers, J., Bemer, P., Zazzo, J. F., Poupon, J., Dauvergne, A., & Melchior, J. C. (2019). Micronutrients Deficiencies in 374 Severely Malnourished Anorexia Nervosa Inpatients. Nutrients11(4), 792.
  • [4] Nevin, S. M., & Vartanian, L. R. (2017). The stigma of clean dieting and orthorexia nervosa. Journal of Eating Disorders5(1).
  • [5] Ozier, A. D., & Henry, B. W. (2011). Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Eating Disorders. Journal of the American Dietetic Association111(8), 1236–1241.
  • [6] Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders not Otherwise Specified (EDNOS). (2001). Journal of the American Dietetic Association101(7), 810–819.
  • [7] Spear, B. A. (2006). Does Dieting Increase the Risk for Obesity and Eating Disorders? Journal of the American Dietetic Association106(4), 523–525.

Author: Raylene Hungate, RDN,LD/N