Eating Disorders

Eating disorders patho

- Biological aspects complex, not fully understood
- During active illness, patient has disturbances in neuroendocrine, neurochemistry, neurotransmission circuitry and signal pathways
- In anorexia nervosa, alterations of brain structures result from malnourishment, emaciation
- Genetic heritability comparable to that of other biologically based mental illnesses
- Puberty has powerful impact in activating genes of etiologic importance
- Regulation of feeding behavior involves complex system of positive, negative feedback mechanisms to maintain energy homeostasis
- Binge eating may reflect dysregulation in negative feedback system resulting in increased meal size and duration of meals
- In some people, stopping engaging in eating-
disordered behaviors → normalization of hormone states
- In others, hormones remain dysfunctional, more studies needed!

Biological theories

- Genetic, neurologic factors
- Neurotransmitter dysfunction
- Low levels of serotonin = reduced fullness, increased consumption
- High levels of serotonin = increased fullness, decreased food intake
- Norepinephrine, neuropeptide Y increase food consumption
- Dopamine inhibits eating
- Endogenous opioids increase food intake, elevate mood

Cognitive-behavioral theories

- Feeding and eating seen as learned patterns based on irrational thoughts, beliefs
- Person’s thought patterns → destructive behavior patterns
- Irrational thoughts are at the heart of problems leading to feeding and eating disorders

Impact of Covid-19 and social media

Worsened the symptoms of eating disorders among both
adults and adolescents
- Isolation
- More sedentary lifestyle and altered eating habits
More hours of leisure time filled with social media
- Vulnerable to marketing messages that may be
inaccurate
Lack of access to in-person health care
- Assessment of weight, vital signs challenging
- Physical exam, labs, ECG

Biological risk factors

•Genetic factors → major risk
•Affect behavioral, neurobiological, temperamental variables

Sociocultural risk factors

Culture’s portrayal of men’s, women’s bodies
•Pervasive idea that trim body = “ideal” → unrealistic expectations for weight
•Cultural obsession with thinness → bias against people considered overweight
•Girls, women hardest hit
•Recently, cultural ideal of male attractiveness also moved toward
unhealthy
•Negative body image, degraded self-worth, body dissatisfaction → stress that leads to feeding and eating disorders

Family risk factors 

- Family enabler of disorder, not cause
- Person with disorder may be survivor of childhood, adolescent abuse
- Impaired conflict resolution skills in family
- Family-wide emphasis on achievement, performance
- Family may become enmeshed
- Weak boundaries between members
- Intensified interactions
- More dependence between members
- Decreased autonomy
- Each family member becomes more unstable
- Parents may become overprotective
- Food can take on extreme importance

Eating disorder prevention

Reduce negative risk factors

Increase protective factors

Providers should target two types of audiences

School based instruction, interventions hold promise

Reduce negative risk factors

• Body dissatisfaction
• Depression
• Basing self-esteem on appearance

Increase protective factors

• Replacing unhealthy dieting with appreciation of body's natural functionality

Providers should target two types of audiences

• Universal prevention: aimed at general public
• Promote healthy development, understanding of factors leading to disorder
• Targeted prevention: aimed at those who are beginning to show symptoms
• Provide enough information to stop disorder from developing

School based instruction, interventions hold promise

All years of K–12 education

Anorexia clinical manifestations

Compels individuals to lose more weight than is healthy for
their age, height
Patient has intense fear of gaining weight even when
dangerously underweight
Engage in dieting, excessive exercise to the point of
dangerous malnutrition
- Typically begins in teen years
- More common among Caucasian females

Two subtypes

- Hair, nails become brittle
- Skin becomes dry, yellow
- Lanugo on previously hairless parts of body
- May constantly feel cold
- Starvation causes damage to brain, heart, kidneys

Anorexia subtypes 

Restricting - Most common

Binge eating/purging 

Anorexia diagnostic criteria

-Restriction of energy intake relative to requirements
-Intense fear of weight gain and persistent behaviors that interfere
with weight gain
- Distorted body image
- Amenorrhea is no longer a diagnostic criterion
Other behaviors
- Offset food consumption with excessive exercise
- Self-induced vomiting
- Unwilling to eat in presence of others
- Using diuretics, laxatives, diet pills
- Cutting food into small pieces while pretending to eat
-Second highest mortality rate of mental illness
- Complications of malnutrition
- Suicide

Anorexia heart, brain, and kidney damage

Pulse rate and blood pressure drop
Irregular heart rhythms → heart failure
Lack of nutrients → brittle bones, changes in brain

Bulimia clinical manifestations

Binging on food or episodes of overeating in which person feels loss of control
After binging, purge food to avoid weight gain
- Vomiting
- Laxative abuse, enemas
Obsessed with body appearance
Binging and purging to control weight

Bulimia diagnostic criteria

Binge eating in association with unhealthy compensatory
behaviors at least once/week over 3-month period
- Compensatory behaviors may be purging, excessive exercise

Binge eating 

Rapid consumption of uncommonly large amount of food in short
amount of time
- Individuals feel out of control during the episode
- Often involves junk foods, fast foods, high-calorie foods
- Feels pleasant at first, then distressing
- Binge usually ends when abdominal pain becomes powerful, individual is interrupted or runs out of food
- Afterward, the person feels guilt, engages in purging to rid
body of excess calories

Purging

Wide variety of activities to remove food from body
- Self-induced vomiting
- Laxatives
- Enemas
Restricting dieting and extreme exercising also common
Purging becomes purification ritual and means of regaining
self-control
Frequently dangerous

Bulimia etio

Frequently undiagnosed
- Many who have BN are normal weight or overweight
Typical age of onset is late adolescence or early adulthood
- 90% female, 10% male
- Occurs in ~3% of population
Often comorbid with other psychiatric disorders
- Mood disorders
- Anxiety disorders
- Substance use
- Self-injurious behavior

Bulima indicators 

- Incessant obsession with food, body weight
- Physical signs of binging/purging
- Trash produced by large quantities of food, enemas, laxatives
- Menstrual irregularities
- Depressed mood
- Unexplained stomach pain, sore throat
- Unexplained damage to teeth, scarring on backs of fingers,
swollen cheeks

Toxicity from chronic ingestion of syrup of ipecac

- Lethal cardiac arrhythmias
- Low blood pressure
- Heart failure
- Electrolyte disturbances
- Bloating, slow peristalsis

Binge eating disorder

Periods of rapid food consumption with inability to stop
- May keep eating long after satiety
- May be embarrassed by behavior
- May feel initial sense of relief or fulfillment that gives way to feelings of disgust, guilt, worthlessness, depression as episode continues

Binge eating disorder diagnosis

No specific test to diagnose
- Based on assessment including formal history, collateral information
Patient should have full physical exam to
screen for complications
- Obesity and complications of extreme weight gain
- High cholesterol
- Type 2 diabetes
- Heart disease

Collaboration

Diagnosis through combination of laboratory and diagnostic testing, consultation with medical professional

Essential goals of treatment

Treatment plans tailored to individual needs

Essential goals of treatment

- Reestablish adequate nutrition
- Stop binge–purge behavior
- Reduce excessive exercise

Treatment plans tailored to individual needs

Hospitalization in extreme cases
•To treat severe malnutrition
•To establish new eating patterns in supportive environment

Anorexia labs/tests

Complete metabolic panel (CMP)
Complete blood count (CBC)
Bone density test
Electrocardiogram (ECG)
Kidney, thyroid, liver function test
Urinalysis

Bulimia labs/tests

Dental assessment, physical examination
Lab tests may show electrolyte imbalances, dehydration

Binge eating disorder labs/test

Physical exam, blood and urine tests
Psychologic evaluation

Anorexia medications 

- Antidepressants (SSRIs)
- Not clear whether medications prevent relapse
- No medications assist weight gain

Bulimia/binge eating medications

fluoxetine: only FDA-approved medication
- May help individuals when depression, anxiety are at the root of bulimia
- Lessens binging and purging behaviors
- Reduces likelihood or relapse
- Improves attitudes toward eating

Anorexia nonpharmacologic therapy

• Individual, group, family-based psychotherapy
• Maudsley approach
• Combination medical attention and psychotherapy →
more complete recoveries than psychotherapy alone

Bulimia/binge eating nonpharmacologic therapy

• Cognitive–behavioral therapy (CBT) most effective
• Individualized or group-based

Day programs 

• First-line treatment when more structure is needed
• Allow engagement with patient’s educational, occupational, social
contexts
• More conducive to active involvement of family members

Inpatient therapy

• For more acute disorders
• Structured environment with clinical support available always
• Availability of medical centers reduces chance of relapse, improves chances of recovery
• Now often affiliated with daytime programs
• Patient can move back and forth to correct level of care
• Allows sufficient monitoring for refeeding syndrome

Refeeding syndrome

Potentially fatal condition that occurs when severely malnourished patient begins to eat again

Admission criteria 

- Patients at immediate risk or for whom previous treatment failed
- <85% ideal body weight
- Ongoing weight loss despite intensive management
- Rapid or persistent decline in weight despite maximal
interventions
- Hemodynamic instability
- Cardiovascular risk
- Electrolyte abnormalities
- Psychiatric assessment such as risk of harm to self and others

Complementary health approaches

No conclusive evidence that complementary or alternative therapies helpful in feeding and eating disorders
- Some therapies may help to reduce anxiety
- Acupuncture, massage, yoga, meditation improve mood, reduce stress associated with the disorders
- Mindfulness-based approaches becoming popular
- Some evidence that they can be effective in decreasing binge, emotional eating
- Mixed evidence on whether effective in treating weight loss

Patients may use alternative approaches to achieve unhealthy goals of disordered eating

Patients may use alternative approaches to
achieve unhealthy goals of disordered eating
- Herbal dietary substances as appetite suppressants or weight loss aids
- Can be dangerous when interact with products, such as diuretics and laxatives

Children lifespan considerations 

Avoidant/restrictive food intake disorder
(ARFID) most significant in this age group
- Diagnosis carefully distinguished from “picky eating”
- Picky or fussy eating
- Limitations on varieties of food eaten
- Unwillingness to try new foods
- Aberrant eating behaviors, such as refusing to eat foods with certain textures, colors, or smells
- Seen in 15–50% in preschool children, 7–27% in older children
- Eating disorders (EDs) underdiagnosed by pediatric professionals
- Higher rates now seen in younger children, boys, minority groups

ARFID

Only children with clinically significant restrictive eating problems that result in persistent failure to meet nutritional and/or energy needs

Adolescents and college-age adults lifespan considerations

Disorder peaks in late adolescence and young adulthood
- Young females at risk often have co-occurring anxiety disorders or have
obsessional traits in childhood
- Young women who develop bulimia often have temperamental traits, such as
weight concerns, low self-esteem,depressive symptoms, social anxiety
disorder, overanxious disorder of childhood

Risk factors for bulimia

- Thin body ideal
- Childhood sexual or physical abuse
- Childhood obesity, early pubertal maturation

Disorders co-occurring with BED

- Bipolar disorders, depressive disorders, anxiety disorders
- Substance use disorders

Factors influencing development of an ED

- Perceived pressure to be thin
- Thin-ideal internalization
- Body dissatisfaction
- Dieting
- Depression

Adults lifespan considerations

- Eating disorders that develop in adolescence often persist into adulthood
- Risk factors and associated behaviors remain the same with one exception
- Adults who develop obesity from ED are more likely to undergo
bariatric surgery as intervention

Those with AN have poor outcomes
- Some limited clinical success with Maudsley model

Factors that increase odds of BED (adults)

- Eating more times/day
- Medication for psychiatric or emotional problem
- Symptoms of alcohol use disorder
- Lower self-esteem
- Greater depressive symptoms

Pregnant women lifespan considerations 

Disordered eating in pregnancy persists in substantial proportion of women who had EDs before pregnancy
- Most women with AN and BN make adaptive changes in eating behaviors
during pregnancy
- Disorders often remit during, after pregnancy
- In some women, maladaptive changes in eating behavior
- Risk for onset of BED in vulnerable women
- Increased incidence of pica during pregnancy
- Especially where prevalence of anemia is increased

Eating disorder can negatively affect the pregnancy

- Weight gain (not healthy amount)
- Delivery (cesarean, preterm)
- Offspring (birth weight)

Men lifespan considerations

Newer studies report up to 25% of patients with ED being male
- Mildly to moderately obese before developing ED
- Especially susceptible if obese during childhood
- Compensatory behaviors such as exercises used more by men
- More often to lose or gain weight for sports-related reasons
- Many have history of sexual abuse

Factors predicting ED in a male

- Childhood bullying
- Being gay or bisexual
- Depression, shame
- Excessive exercise coupled with increased diet success
- Comorbid substance use
- Media pressure resulting in body dissatisfaction

Older adults lifespan considerations 

Most common concern: physiologic anorexia of aging
- Decrease in appetite, energy intake even in healthy people
- Possibly caused by changes in digestive tract, gastrointestinal
(GI) hormone concentrations, neurotransmitters, cytokines
- Unintentional weight loss may result from
protein-energy malnutrition, cachexia, physiologic anorexia of aging
- Feeding and eating disorders can be particularly damaging to bodies of older
adults
- Exacerbate preexisting osteoporosis, cardiovascular problems, GI reflux disease

Typical ED symptoms common in older adults

- Binging and purging
- Unhealthy methods to lose weight, maintain thinness

Nursing process

Keep in mind that denial is often inherent to eating disorders

Deceit, manipulation by patient are characteristics of the disorder, not necessarily consciously chosen behaviors

Assessment

Thorough review of physiologic, psychosocial function

Focuses assessment of nutritional status

Thorough review of physiologic, psychosocial function

- Observe for physiologic manifestations of feeding and eating disorders
- When patient presents with significant weight gain or loss, do not assume an ED
- Many physiologic conditions can lead to muscle wasting, weight loss
- Weight gain may have a variety of causes
- Rule out other illnesses before establishing ED diagnosis

Focuses assessment of nutritional status

- Data from patient interview, physiologic assessment findings, review of lab and
diagnostic test results
- Height, weight, body mass index (BMI), mid-arm circumference (MAC), waist-to-
hip ratio
- Assessment of skin, oral mucosa and tongue, shape of abdomen, bowel
sounds, teeth and gums

Physical assessment of patient with AN

- Emaciated appearance
- Skin dry, covered with lanugo, may appear jaundiced
- Brittle hair, nails
- Impairment of any body system by undernutrition
Cardiovascular manifestations
- Bradycardia, hypotension, cardiac dysrhythmias

Assessment of patient with BN

- Physical exam, psychologic evaluation, laboratory diagnostics
- Focused assessment of oral cavity may be revealing
- Patients who purge by vomiting have ruptured blood vessels in eyes
- Susceptible to metabolic acidosis
- Manifestations of dehydration

Analysis

- Risk of Injury
- Fluid Volume Deficiency
- Under Nutrition
- Decreased Cardiac Output
- Disrupted integrity of oral mucous membranes
- Poor dentition
- Body image disturbances
- Inadequate coping
- Low self-esteem
- Anxiety

Planning

- Remain free from injury
- Demonstrate manifestations of fluid volume balance
- Demonstrate normal electrolyte levels
- Demonstrate measures to avoid/control purging behaviors
- Verbalize a realistic positive view of self, appearance, and self-worth
- Actively participate in individual, family, and/or group therapy
- Remain free of self-injurious behaviors
- Report any suicidal ideation

Implementation Priorities include

- Protecting patient from physiologic effects of the ED
- Identifying stressors and treating the cause of the ED
- Promoting wellness by preventing injury and encouraging healthy behaviors, thought patterns

Implementation prevent injury

Patients are at constant or near-constant risk of injury due
to undernutrition, its consequences, effects of purging behaviors
- Inpatient intake of nutrients, fluids may be medically ordered and
administered
If patient’s life is at risk
- If patient is hospitalized for medical stabilization
- Limit patient’s activity and energy expenditure
- Monitor vital signs, food and fluid intake and output (I&O), electrolyte levels
- Assess for signs of fluid overload (refeeding syndrome)
- Weigh daily
- Observe for one hour after meals
- Monitor trips to the bathroom
- Look for food hoarding
- Assess/monitor GI and cardiac functioning as necessary

Implementation Promote a therapeutic relationship and positive
self-regard

Many patients have been secretive about
nutritional habits, purging behaviors
- Treatment requires openness about behaviors, discussion of sensitive, painful
topics
- Transition requires courage on patient's part, establishment of trust between patient,
healthcare provider
- Respect, consistency, patience: keys to building trust
- Other interventions equally appropriate in outpatient and inpatient settings
- Help patient identify triggers that promote disordered eating behaviors
- Help patient reframe feelings of purging behavior that contribute to sense of
empowerment, control, relief
- Provide positive reinforcement
- Help patient set realistic short-term goals they can easily achieve
- Encourage patients to reconnect with enjoyable activities, experiences

Evaluation

- Patient remains free from injury
- Patient's vital signs and serum electrolytes remain within normal limits
- Patient produces non-concentrated urine
- Patient denies light-headedness, dizziness
- Patient does not demonstrate purging behaviors
- Patient participates in individual and/or group therapy
- Recovery may include relapses and setbacks along the way
- Care plan may need to be modified periodically if patient not responding to planned interventions
- Nurses, clinicians may need to reevaluate triggers and treatment regimens, help patient identify alternative methods of coping