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tal health, nutrition, and medical spe- cialists (4-6). RDs contribute to the care process across the continuum of acute care, recovery, and relapse pre- vention or treatment. RDs’ messages and communication style (verbal and nonverbal) must match an individu- al’s treatment plan.

Types of Therapy

Cognitive behavioral therapy (CBT), a psychotherapeutic modality aimed at helping an individual identify mal- adaptive cognitions, involves cognitive restructuring. Faulty beliefs and thought patterns about the relation- ship between eating patterns and phys- ical symptoms are challenged with more accurate perceptions and inter- pretations such as discriminating be- tween bloating with resumption of food intake and body weight changes. As a leading therapy for individuals with bulimia nervosa (26), CBT has proven effective at lessening the frequency of binge eating behaviors, abnormal com- pensatory responses, and normalizing cognitions in individuals with bulimia nervosa. However, use of CBT with an- orexia nervosa is challenging because disruptions in neurotransmitter secre- tions and functions limit a patient’s re- sponse to treatment.

CBT for binge eating disorder places a primary emphasis on binge eating reduction and a secondary em- phasis on weight loss if indicated. In a randomized controlled trial, interper- sonal psychotherapy and CBT proved significantly more effective than be- havioral weight loss treatment in eliminating binge eating after 2 years (8). Treatment for binge eating disor- der has preliminarily shown equivo- cal outcomes for subthreshold binge eating disorder emphasizing the im- portance of using the diagnostic crite- ria as a guide to treatment modality and not strict rules. Modifications in psychotherapy are necessary in binge eating disorder treatments because these individuals show lower levels of dietary restraint, higher levels of overweight and obesity, and more chaotic eating patterns. Of note, one small CBT intervention study (27) for women who binge ate had positive re- sults. In that study (27), RDs inter- vened through discussions, didactic information, reflection questions, and homework exercises. Following the interventions, measurements of

binge-eating severity and frequency, depression, body image, and self- esteem, showed improvement, al- though weight did not change signif- icantly (27).

Dialectical behavior therapy (DBT) has become increasingly popular as an ED treatment wherein emotional dysregulation is considered an influ- encing factor for the ED and symp- tomatic behaviors to be maladaptive coping skills. Thus, new coping skills are taught and practiced. Therapeu- tic goals aim to replace these behav- iors with more constructive ones and decrease high-risk behaviors while also enhancing respect for self. Evi- dence suggests that DBT holds poten- tial for decreasing binge eating and purging symptoms in selected popula- tions (26). Other psychotherapy for adults includes interpersonal ther- apy, psychodynamic therapy, family therapy, and group therapy. Self-es- teem enhancement and assertiveness training may also be helpful (26).

Special Populations

Athletes. Dieting typically precedes the full-blown ED as an athlete re- stricts eating to achieve lower body weight for enhanced performance. This tends to occur more often in sports that encourage a lean phy- sique, such as running, wrestling, dance, and gymnastics (6). In female athletes, the interrelationships be- tween energy availability, menstrual function, and bone mineral density may prompt the distinct symptoms of amenorrhea, disordered eating, and osteoporosis known as female athlete triad (25). An athlete does not neces- sarily need to exhibit all three symp- toms to be at risk for compromised health and an ED; rather, the individ- ual is assessed across a spectrum of abnormal behaviors. RDs play a role in the identification and treatment of disordered eating patterns in this vul- nerable population.

Adolescents. The stage of adolescence, with its combined biological, psycho- logical, and sociocultural changes in proximity to puberty, has been iden- tified as a vulnerable period for ED symptomology (15). Body dissatisfac- tion, dietary restraint, and disordered eating may be influenced by peers and self-perception, thus influencing eating behaviors. For example, al- though not all adolescents consuming

vegetarian diets have EDs, this type of diet along with greatly limiting food choices can be a red flag of an ED (28). An emerging trend in adoles- cents with chronic diseases includes teens with type 1 diabetes, especially girls, who skip insulin as a means of weight control, commonly referred to as diabulimia. Health outcomes for adolescents with type 1 diabetes with ED behaviors include poor physical and psychosocial quality of life, poor metabolic control, and maladaptive coping skills (29).

Although not well studied, CBT, DBT, and dynamic therapy (30) may decrease ED symptoms in adolescents. A specialized intervention, family- based (Maudsley) therapy can be effi- cacious in adolescents with anorexia nervosa and is being investigated with bulimia nervosa treatment (6). Whereas family dysfunction is no lon- ger seen as the main cause of ED symptoms, for some, family-based therapy can be effective. To facilitate an adolescent’s transition to adult- hood, RDs should consider eating pat- terns and perceptions of developmen- tal changes in light of behaviors characteristic of EDs.

Bariatric Surgery. Although binge eat- ing disorder often presents itself in those patients seeking weight loss surgery, it is a contraindication to surgery (31). Regardless, many of these individuals will continue with the surgery. Thus, RDs can be pivotal team members in screening for disor- dered eating and treating patients. A discussion must occur with these pa- tients to help them understand the challenging role binge eating disorder plays in nutrition and lifestyle changes pre- and postsurgery.


RDs are typically poised to address tertiary conditions and provide ap- propriate medical nutrition therapy. However, because EDs are such irre- tractable illnesses, prevention may serve as the most logical and cost- effective treatment. Prevention ef- forts could emphasize concepts in the paradigms of health at every size and intuitive eating (32). Targeted pre- vention such as dissonance programs address thin-ideal internalization and challenge body distortions (33). Theory-driven approaches addressing high-risk groups appear most promis-

August 2011 ‚óŹ Journal of the AMERICAN DIETETIC ASSOCIATION


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