Leave your drugs in the chemist’s pot if you can heal the patient with food.
—Hippocrates, 420 BC1
The etiology of disordered eating and eating disorders is not clear; in fact, there is much dissent among experts about their development and treatment. Yet, there is wide agreement that these disorders:
• Interfere with daily functioning (physical, psychological, and relational)
• Are a serious threat to life
• Are biologically based
Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder. They are second only to substance-abuse disorders in having the highest mental illness mortality rate. While mortality associated with anorexia nervosa has long been recognized, more recently disorders previously categorized as “eating disorder not otherwise specified,” and now categorized as “other specified feeding or eating disorders,” are reported to be most prevalent and to have the highest mortality of any category of eating disorder.2,3
Changes to DSM-5 recognize that patients with eating disorders fall along the weight continuum, their weight fluctuates over the course of the illness, and females with anorexia nervosa may menstruate even while severely malnourished. It is important that we not put too much stock on appearance—even those who appear physically healthy and fit may be struggling with eating disorders.
Neuroscience, pharmacology, nutrition, and eating disorders
Nutrition is emerging as a major player in the high prevalence and incidence of mental disorders, with growing evidence to suggest that diet and nutrition are critical.4,5 A host of eating disorder complications, which affect multiple organ systems and compromise health, are related to nutrition. The fact that eating disorders are biologically based underscores the key role nutrition plays in vulnerability, onset, severity, and duration.
Malnutrition due to underconsumption of energy-producing macronutrients (carbohydrates, proteins, fats) and/or micronutrients relative to individual need is a concern with anorexia nervosa, bulimia nervosa, and avoidant restrictive food intake disorder. Moreover, eating disorder behaviors may affect the availability of micronutrients (vitamins and minerals).6 The result may be overt nutrient deficiencies (eg, anemias), chronic fatigue, reduced immune function, loss of lean body mass, and altered brain function. Patients may also be at risk for inflammatory diseases, such as cardiovascular disease, diabetes, and some cancers.4
Research on pharmacological treatment of eating disorders often yields mixed results and is particularly challenging because of the low number of study participants and high attrition rates.7 Body composition changes due to loss of lean tissue and/or increased adipose tissue may alter the body’s response to medication. Starvation, characterized by anorexia nervosa (and in some cases, avoidant restrictive food intake disorder), affects metabolism, neurotransmitters, and brain development. As in the case of thiamin, which influences appetite, poor nutrition resulting in clinically low nutrient levels may further affect nutritional intake.8 Eating disorder–related behaviors such as physical activity or purging may also affect the metabolism of medications.
Only 2 FDA-approved medications are available for treating eating disorders: fluoxetine for bulimia nervosa and lisdexamfetamine for binge eating disorder. It is no surprise then that patients with eating disorders and providers often turn to nutritional supplements in hopes of finding symptom relief.
Ms Scribner teaches at Arizona State University, and she is the owner of Encompass Nutrition LLC, a private practice specializing in the treatment of eating disorders. She reports no conflicts of interest concerning the subject matter of this article.
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