Understanding the Role of Nutrition in the Treatment of Anorexia Nervosa

Written in consultation with Janet Schebendach, PhD.

You have been diagnosed with anorexia nervosa. Eating enough to sustain a medically advised weight has become impossible. You bravely sign on for intensive treatment to get help improving your eating and weight. At breakfast, you are served orange juice, granola with whole milk yogurt, and fruit. When lunchtime arrives, you are presented with a small salad with dressing, a grilled chicken sandwich, French fries, and ice cream.

You wonder:

“Isn’t this all too much?”

“Aren’t these foods ‘unhealthy’?”

“Why can’t I eat the same amount of calories in ‘good’ foods that are easier for me to eat?”

These are really great questions. I hear them all the time on our inpatient eating disorders unit, and the asking certainly makes a lot of sense. After all, many adults are told to limit consumption of some of these foods. But your circumstance is different– you are among the roughly 0.5% of individuals with a disorder that carries amongst the highest health risks of all psychiatric problems.

Why does it matter what you eat, as long you’re eating?

The severe malnutrition that results from anorexia nervosa leaves patients in extenuating circumstances both physically and psychologically.

Total body fat and muscle, including internal organs, are severely depleted in those with the disorder relative to healthy adults. Weight restoration is in part challenging because resting energy expenditure increases over the course of the refeeding process. This means the body progressively burns up more calories with re-nourishment. Caloric intake must then increase to promote a consistent rate of weight and lean body mass restoration.  For a number of practical reasons – the volume of food that would be required or the amount of time it might take to eat, for example –it’s helpful to include energy dense items at meal and snack time.

Behaviorally, the stereotyped selection of low energy foods is a key feature of anorexia nervosa, as is avoidance of fats. Restrictive food choice may become locked in as a function of habit over time. In the underweight state, people with the disorder tend to become more anxious, fearful, and obsessional about certain foods and rigid in terms of eating behavior. Challenging assumptions about particular foods and behaviors related to eating is, therefore, a critical part of all aspects of recovery (that is, weight restoration and maintenance).

Taken together, what we know from research supports the clinical recommendation that patients with anorexia nervosa be offered a wide variety of foods in treatment – including a broad range of energy-dense foods – to replenish nutritional deficits, safely and effectively restore the body – and enhance psychological flexibility around eating. A diet characterized by greater energy density and variety during treatment is associated with a more successful treatment outcome one year following discharge from the hospital.

Simply put, for a person with anorexia nervosa, an eating plan that is high in diet variety and energy density may actually help restore physical health, psychological wellbeing, and prevent future relapse. (For more on what exactly these terms mean, keep reading!)

Diet Variety

What is it and how is it quantified?

Diet variety occurs when one’s diet is comprised of foods that differ from one another in flavor, texture, shape and color.

Researchers describe an individual’s “daily diet variety score” as the cumulative number of distinct energy-containing foods and beverages consumed in one day. Foods eaten at multiple meals are counted once, and foods are considered different if they are prepared differently (i.e. baked potato vs. mashed potato or steamed vegetables vs. sautéed vegetables). Non-caloric fluids, non-nutritive sweeteners, and condiments do not contribute to overall diet variety.

What are some examples?

A breakfast with high variety would consist of something like an omelet, two pieces of toast with butter, a banana, and a glass of milk, as opposed to a breakfast of oatmeal. The former breakfast has items from many different food groups and provides more complete nutrition. To increase the diet variety of the latter, nuts and an assortment of mixed berries could be added to oatmeal that is made using milk.

Why is this important?

Remember, research has shown that among recently weight-restored patients with anorexia nervosa, diet variety played a role in treatment outcome a year after hospitalization. Specifically, those reporting intake that was not as balanced – either consisting of a greater proportion of energy from protein sources or lower in fat overall – were shown to have poorer treatment outcomes.

Garnering energy from all the macronutrients – that is protein, fats, and carbohydrates – can be physically and psychologically therapeutic, and may enhance your response to treatment. Therefore, eating a breadth of different kinds of foods during meals and snacks can not only help your mind and body recover more efficiently but may also increase your chances of recovery well into the future.

Energy Density

What is it and how is it quantified?

Energy Density is the caloric value (in kilocalories) of a food or beverage divided by the weight of the food or beverage (in grams).

What are some examples?

Energy density is on a spectrum. Examples of higher energy dense foods include dried fruit, granola, nuts and nut butters, graham crackers, whole milk yogurt and ice cream. Lower density foods include fruits such as berries, pears and apples, cottage cheese, corn, and potatoes.

Why is this important?

As in the case of greater diet variety, patients with anorexia nervosa who consume a greater proportion of foods that are energy-dense prior to discharge from the hospital are more likely to have a positive outcome one year later than those reported a low energy density intake pattern. This finding has been replicated across multiple studies.

Given some of the psychological aspects of the disorder, consumption of energy-dense foods may be an especially challenging aspect of treatment. Your team of providers will support you as you take on this approach to eating and help you to handle your fears without letting them play out in your behavior.

What is the goal in the long-term?

Ultimately, meal plans are carefully constructed and balanced to meet your unique nutritional needs for weight restoration, weight maintenance, and the behavioral and psychological flexibility required for continued progress/relapse prevention. During weight gain and early phases of weight maintenance, the meal plan is designed to maximize your body’s ability to extract nutrients and energy from food so that you can restore your health in the safest and most effective way possible. Although some options may not seem “healthy” for someone without an eating disorder, long-term health is – for most of us – associated with eating all kinds of foods in moderation.

The types and variety of foods you receive in a structured program are judiciously selected by a team of nutritionists and physicians to maximize your chance of recovery. Certain aspects of the meal plan prescription are temporary. For example, once you reach a healthy weight, nutritionists, therapists, and doctors can help you adjust your diet so that the caloric plan is in accordance with the goal of weight maintenance. Other aspects of the meal plan prescription – a broad variety of foods, meals and snacks eaten on a regular basis, etc. – are likely for the long haul. Remember, these parts of the meal plan are also aimed to support you having a long, physically and psychologically healthy life.

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