Eating disorder (Bulimia, Anorexia nervosa, Pica,)

Anorexia Nervosa

dramatic weight loss as a result of decreased food intake & sharply increased physical exercise; life threatening

Bulimia Nervosa

cycle of normal food intake, followed by binge eating and purging; remains at expected weight

Binge-eating disorder

overeating, eating rapidly >> obesity >> type 2 diabetes

Avoidant/Restrictive Food Intake Disorder (ARFID)

limited food intake and avoidance of certain foods due to sensory sensitivities or fear of negative consequences, without a focus on body image or weight loss

Pica (peds 2-3 y/o)

eating non-nutritive material over a 1-month period (e.g. paint, clay, sand)

Rumination (peds infants)

regurgitate partially digested food/formula

Increased prevalence in industrialized countries; Industrialized – greater access to food (for EDs)

• US

• Equal Latinx & Caucasian

• Less referral in African

American

Canada

Europe

Australia

Japan

New Zealand

South Africa

Biologic Etiology for ED

Genetic vulnerability; Neurochemical changes; May use medication

Developmental Etiology for ED

Struggle for autonomy, identity; Overprotective or enmeshed families

Environmental Etiology for ED

• Body image disturbance/dissatisfaction (dysmorphia)

• Family Influences

• Sociocultural (wanting acceptance)

Other Risk Factors for ED

• More common in females than males; White;

• Preoccupied with weight

• Family history of eating disorder

• Experiencing harm during childhood (abuse)

• Activities emphasizing body shape/weight (e.g. gymnastics, track, modeling, ballet

• Associated conditions - depression, anxiety, OCD, substance use disorder (alcohol, stimulant use)

When to Suspect an Eating Disorder

• Mood: Withdrawn, anxious (anorexia)

• Avoids social situations (especially when involves food)

• Exercise: Excessive or compulsive (distorted belief about body)

• Purging, use of diet pills or laxatives

Anorexia Onset & Clinical Course

• Early onset 14-18

• Refusal or inability to maintain minimal normal body weight

• Fear of gaining weight

• Significantly disturbed perception of body shape or size

• Steadfast inability or refusal to see they have a problem

Anorexia Nervosa – assessment

Health history – include intake/weight concerns with other mental health screenings

Physical Problems in Anorexia Nervosa

• amenorrhea

• constipation (from not eating or drinking)

• overly sensitive to cold, laungo hair on body

• loss of body fat

• muscle atrophy

• hair loss

• dry skin

• dental carries

• pedal edema

• bradycardia, arrhythmias (heart murmurs)

• Electrolyte imbalance (hyponatremia, hypokalemia, hypophosphatemia, hypocalcemia)

• Enlarged parotid glands and hypothermia

Other s/s:

• Parent chief complaint – weight loss; patient underweight

• syncope

• Cachexia appearance

• decreased temp, decreased HR, decreased BP

Complications of Anorexia

• Electrolyte imbalance

• Low blood volume

• Cardiac dysrhythmias; heart murmur in @ 1/3 of patients with anorexic (lower K+)

• Menstrual problems; Amenorrhea; stop puberty development

• Constipation

• disturbances in reproductive hormones (eg, decreased estradiol levels in females)

• decreased bone density (low calcium)

• Dental caries (if purging)

• higher mortality; 25% of deaths among individuals with anorexia nervosa are from suicide

Sources of purging

vomiting, enemas, laxatives

Anorexia – Diagnostic Criteria

• Refuse or unable to maintain minimal normal body weight for age and height

• Intense fear of gaining weight or becoming fat

• Significantly disturbed perception of shape or size of body

• Unable or refuse to acknowledge the seriousness of problem

• Amenorrhea for 3 consecutive cycles

• Preoccupation with food

Anorexia Treatment & Prognosis

Treatment – inpatient or outpatient, depending on complication severity

• Multidisciplinary approach – individual & family therapy

• Nutritional therapy

• Meds – not initial/primary treatment

• Focus on achieving individual target caloric intake and weight gain

Patient perspective for Anorexia

• Denial early in the disease process

• Depression: may have a history of abuse

• Treatment is often difficult

• Patient resistant

• Uninterested

• Denies problem

Anorexia Treatment Settings

• Inpatient eating disorder unit

• Partial hospitalization/day treatments

• Outpatient therapy has best success if illness less than 6 months, not binging & purging, and family involved

• Hospitalize for serious medical (electrolyte imbalance; murmurs) or psyche complications (suicidal thoughts)

Anorexia Management

• Weight restoration (don’t directly praise weight gain, rather their strength or improving mental state)

• Nutritional rehabilitation

• Aim for a weight gain goal of 0.5 to 2 lbs per week

• Rehydration & correction of electrolyte imbalances

Anorexia Therapuetic Management

Psychotherapy

• Family therapy

• Individual therapy

Cognitive-behavioral therapy

• Keep a journal of intake and other food associated behaviors such as purging

Bulimia Onset & Clinical Course

Onset

• Late adolescence

• Early adulthood

• Average age 18-19

Recurrent episodes of binge eating (secretive)

Bulimia Mechanisms

Compensatory behaviors to avoid weight gain

• Purging

• Use of laxatives

• Diuretics

• Enemas

• Emetics

• Fasting

• Excessive exercise

Bulimia Clinical Course

Different from Anorexia:

• usually normal weight

• Know they have a problem

Recognize behaviors as pathologic

• Feelings of guilt, shame, remorse, contempt

Possible restrictive eating between binges

• Secretive storage/hiding of food

Physical Complications of Bulimia

• Electrolyte abnormalities

• Salivary gland and pancreas inflammation (vomiting)

• Esophageal & gastric erosion or rupture

• Dysfunctional bowel – bloating, pain, diarrhea, constipation

• Erosion of dental enamel (perimyolysis) particularly front teeth

• Seizures – related to fluids shifts & electrolyte imbalance

• Mild neuropathies, fatigue, weakness, mild organic mental symptoms

• Russells Sign—-redness or brusing of knuckles

Bulimia Nursing Assessment

• Expected weight or overweight

• Hands – calluses, back of knuckles

• Split finger nails

• Eroded dental enamel

• Red gums

• Inflamed throat

• Dental problems

Nursing Diagnosis – eating disorder

• Imbalanced Nutrition: Less than Body Requirements

• Ineffective Coping

• Disturbed Body Image

• Chronic Low Self-Esteem

Nursing Process: Outcomes for Bulimia

For severely malnourished patients, stabilize medical condition first

Establish adequate nutritional eating patterns

Eliminate compensatory behaviors

• Excessive exercise

• Laxative

• Diuretics

• Purging

Self Image:

• Verbalize feelings of guilt, anger, anxiety, or an excessive need for control

• Verbalize acceptance of body image with ideal body weight

Nursing role:

• Help patient take control of nutritional requirements independently

• Guide them on what to eat

Bulimia Treatment & Prognosis

Cognitive-Behavioral Therapy

• Most effective

• Strategies to change thinking and action

Psychopharmacology

• TCA

• SSRI

Nursing Interventions - Nutrition

• Establish nutritional eating patterns (inpatient treatment if severe)

• 1200 – 1500 calories/day with gradual increases

• Calories are in 3 meals and 3 snacks

• Liquid protein supplement if meals missed

• Nurse responsible for monitoring meals

• Monitor for purging

• Caution for refeeding syndrome

Stay with them after they eat to monitor for purging

Nursing Interventions - behaviors

• Observe for self-destructive behavior or suicidal intent

• Initially – limit staff assigned to and interacting with patient; Gradually – increase variety of staff

• Maintain consistency of treatment

• Supervise or remain aware of patient’s interactions with others and intervene as appropriate

• Do not restrict to their room as a restriction of privileges

• Relate to patient according to their age, expect age-appropriate behavior from the patient

Nursing Interventions – communications

• Expect healthy behavior from patient

• Encourage them to do school work if missing school

• Have positive support and honest praise for accomplishments

• Focus attention on positive traits and strengths – not on feelings of inadequacy

• Do not flatter or be dishonest in interactions or with feedback

• Foster successful experiences

• Arrange for patient to help others in specific ways – suggest activities that are within his or her realm of ability, then increase complexity

• DO NOT COMPLIMENT THEM – “You look great!” NO! Compliment them for eating

Nursing Interventions - interactions

• Allow food only at specified snack & mealtime – do not talk about emotional issues at these times

• Encourage patient to ventilate his or her feelings at other times in ways not associated with food

• Withdraw attention if patient is ruminating about food or engaging in rituals about food or eating

• Observe & record responses to stress – encourage them to approach the staff at stressful times

• Help the patient identify others in the home environment they can talk with and will be supportive

patient/family education

• If they purge – primary role is to stop them from purging – watch for 1-2 hours after meals/snacks

• Teach about harmful effects of purging – esophagitis, tooth loss; rupture esophagus/stomach

• If they can stop purging, more likely to stop binge eating

Nursing Interventions - Identify emotions and develop coping strategies for Anorexia

• difficulty expressing feelings

• Describe feeling fat or bloated

• Not good at describing emotions

Nursing Interventions - Identify emotions and develop coping strategies for Bulimia

• Self-monitoring

• Identify behavior patterns to replace them with good behaviors

Nursing Evaluation for ED

• Assessment tool such as Eating Attitudes Test to detect improvement

• Chronic condition

• Treatment successful if maintain body weight 5% to 10% of normal with no medical complications from starvation or purging

Nursing management for ED

• Vital signs

• Labs – monitor electrolytes,ECG

Community Based Care

• Hospital admission ONLY for medical necessity

• Community settings

Partial hospitalization or day treatment

• Individual or group outpatient therapy

• Self-help groups

• Healthy People 2020

Mental Health Promotion

• Educate parents, children, young people about strategies to prevent eating disorders

• Early identification, appropriate referral

• Routine screening for eating disorders

Self-Awareness Issues

• Feelings of frustration when client rejects help.

• Being seen as “the enemy” if you must ensure that the client eats.

• Dealing with own issues about body image and dieting.

• Be empathetic and nonjudgmental. Do not express approval or disapproval or be punitive

• Be aware of your own feelings, express feelings to other staff – not the client

• Be aware of your own behaviors – be consistent, truthful, and nonjudgmental