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THE IMPORTANCE of NUTRITION AS the BEST MEDICINE for EATING DISORDERS Carolyn Coker Ross, MD, MPH

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THE IMPORTANCE of NUTRITION AS the BEST MEDICINE for EATING DISORDERS Carolyn Coker Ross, MD, MPH DIET AND NUTRITION THE IMPORTANCE OF NUTRITION AS THE BEST MEDICINE FOR EATING DISORDERS Carolyn Coker Ross, MD, MPH ver seven million girls and women groups. Current research demonstrates to 24, and the suicide rate was 75 times and one million boys and men that eating disorder symptoms may be as higher. will suffer from an eating disorder common or more common among certain Medical consequences of eating disor- in their lifetime. Up to 3.7% of ethnic groups (Asians, blacks, and Hispan- ders include arrested sexual maturity and O 6 females will be diagnosed with anorexia ics) when compared with whites. There growth failure in prepubertal patients. nervosa and an estimated 4.2% will have was no difference found in dieting and Many with eating disorders may look and bulimia nervosa.1 The majority of adoles- restraint scores between Asian, Latino, feel deceptively well and may have normal cent patients seen in referral centers fit and white adolescent girls and boys7 and electrograms but are still at high risk for into a third category, “eating disorder not no difference in binging or BED in obese cardiac arrhythmias and sudden death. otherwise specified” or EDNOS and do patients who sought to lose weight with Prolonged amenorrhea is associated with not fit strict criteria for either anorexia or bariatric surgery.8 These changes may be an increased risk of osteopenia and rate of bulimia.2 Nineteen percent of college- related to an extension of cultural ideals in fractures. Neuroimaging studies with com- aged females are bulimic; many go undi- these ethnic populations of what is attrac- puterized tomography (CT) have demon- agnosed until much later. At the other end tive as seen through the public media, or strated structural brain abnormalities in of the spectrum, 1% to 5% of the popula- may represent past underreporting. How- both anorexics and bulimics.14,15 Bulimia tion falls into the category of binge eating ever, an analysis of 18 studies (1987-2001) is associated with electrolyte, fluid, and disorder, not yet an approved psychiatric concluded that African-American women mineral imbalance; increased cardiac risk; diagnosis.3 Anorexics are more likely to be were less likely than white women to have gastrointestinal bleeding; dental enamel female (90%-95%); 80% of bulimics are an eating disorder.9 As well, a study in erosion; peripheral muscle weakness; car- female and 60% of BEDs are female.4 In school age girls demonstrated that Native diomyopathy; and hypometabolism.16 the United States, food and weight are sig- American girls had higher rates of restrict- Despite normal weight, bulimics and BED nificant issues, as witnessed by the fact ing/purging and dieting than white or patients may be severely malnourished. that almost half of the population is con- nonwhite/non-Native American popula- The effects of poor nutrition are no- sidered overweight and/or obese. tions.10 where as pronounced as in the case of eat- Eating disorders begin early, with 10% Eating disorders have one of the highest ing disorders. Although many may think being diagnosed in children less than 10 death rates of all psychiatric diagnoses. that undernutrition or malnutrition is a years of age. One third of patients are di- The number of deaths in anorexics is 11.6 side effect of eating disorders, studies have agnosed as preteens and adolescents up to times what would be expected in others of documented that it can be the cause of age 15. In total, 86% of patients are diag- their same age and sex; for bulimics, this many of the symptoms seen in eating dis- nosed with eating disorders before the age number is 1.3 times greater than expected. orders. The earliest study to demonstrate of 20. For this reason, the Society for Ad- The most shocking number is the 56.9 this was done by Ancel Keys and his col- olescent Medicine5 issued this statement: times increased number of observed ver- leagues at the University of Minnesota in “Because of the potentially irreversible ef- sus expected deaths in anorexics from sui- 1950.17 Young, healthy, psychologically fects of an eating disorder on physical and cide. If either of these groups abused alco- normal males were recruited for the study emotional growth and development in ad- hol, the death rates were even higher.11 as an alternative to military service. Of 100 olescents, because of the risk of death, and Depression is a major risk factor for both who applied, 36 were selected for being in because of the evidence suggesting im- substance use disorder and bulimia and the best physical and psychological proved outcome with early treatment, the explains to a great degree the association health. This study is known as the “starva- threshold for intervention in adolescents between substance use disorder and eating tion study,” and its intent was not to study should be lower than in adults.” Irrevers- disorders.12 A meta-analysis by Sullivan13 eating disorders but to develop a better ible risks are growth retardation, pubertal found 178 deaths in 3,006 patients: 54% understanding of how best to manage the delay or arrest, impaired acquisition of died from complications of their eating refeeding of concentration camp survi- peak bone mass, and increased risk of os- disorder, 27% from suicide, and 19% from vors. teoporosis. other and/or unknown causes. The overall In the study, the men ate normally and Earlier studies of eating disorders sug- rate of .56% mortality per year in this continued their normal activities for the gested disparities in the occurrence of eat- study was 12 times greater than the ex- first three months while their behavior, ing disorders among different ethnic pected mortality rate for women aged 15 personality, and eating patterns were stud- Diet and Nutrition EXPLORE March/April 2007, Vol. 3, No. 2 153 ied. Over the next six months, their diet vosa or BED showed that a protein sup- pressants. Both low B12 and low folic acid was restricted to half of what they nor- plement given three hours before a meal have been noted in patients with depres- mally ate, resulting in a 25% loss of reduced binge eating as compared with a sion. As well, in population studies, an weight. Of note, the amount of calories carbohydrate supplement. Participants in association has been found between de- prescribed in the study is the same as that the study also consumed less food at meals pression and low levels of these two vita- being used in treating obesity. After this and had less hunger after receiving the mins. Low levels of folate have been im- period of weight loss, the men were slowly protein supplementation.18 A small study plicated in poor response rates to standard refed. The results of the study were re- by Dalvit-McPhillips19 in the 1980s antidepressant therapy.26 B vitamins also ported for only 32 of the original 36 par- showed that a nutrient-dense diet (one convert glucose into energy in the brain ticipants, as four dropped out either dur- without blood sugar destabilizers—white cells and assists in the manufacture of neu- ing or at the end of the “semistarvation” flour, refined sugar, alcohol, caffeine, fla- rotransmitters. B12 is essential for nerve phase. All participants experienced very vor enhancers, and decreased salt) given to cell health. Studies in animals document dramatic changes—physical, psychologi- bulimic women had a dramatic effect on that it can slow the rate at which rats learn. cal, and social. binge behavior. This type of diet today Other micronutrients have been shown The striking changes included an in- may be consistent with a diet without to be missing in eating disorder patients. crease in preoccupation with food. During foods that have a low glycemic index. Par- Symptoms of zinc deficiency include de- the 12-week refeeding period, binging ticipants were also given vitamin C, a B- crease in smell and taste, loss of appetite, continued, and several of the men experi- complex vitamin, and a multivitamin. mental lethargy, generalized hair loss, di- enced nausea and vomiting. Serious binge Those on the nutrient-dense diet ceased arrhea, rough and dry skin, slow wound eating occurred in a subset of volunteers. binging and were able to lose weight ef- healing, and delayed puberty. Binges consisted of up to 10,000 calories, fortlessly and remained binge free for 2.5 Zinc and the mineral copper must be with volunteers reporting continued hun- years. When the control group was put on kept in balance. Copper, calcium, and ger even after binging to the point of be- the nutrient-dense diet, they also stopped phosphorus all increase the effectiveness coming ill. Normalization of eating be- binging. This study suggests that malnutri- of zinc. Zinc is also vital in the metabolism haviors took approximately five months tion and blood sugar–insulin level are im- of essential fatty acids—levels of essential for the majority of the volunteers. portant factors in the binging behavior of fatty acids were decreased in anorexics. Es- The volunteers also experienced emo- bulimics. Therefore, the use of nutrition sential fatty acids are important in zinc tional changes, including depression, irri- supplements can be a valuable addition to absorption, and zinc is necessary for two tability, anxiety, and apathy. Two devel- standard dietary therapy in the treatment stages of essential fatty acid metabolism. of eating disorders for the following rea- oped psychosis. These changes persisted Zinc is a cofactor in the absorption of the sons: for some time during the refeeding period. B vitamins, as is manganese and magne- The men became increasingly isolated sium. Zinc is vital in the regulation of gene during the semistarvation period and re- REPLACING MISSING NUTRIENTS expression, immune function, wound ported decreased sex drive, which took al- Studies have shown deficiencies in a num- healing, reproduction, growth and devel- most eight months to be restored to their ber of specific nutrients in patients with opment, behavior and learning, blood previous level of functioning.
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