Topic 14: Eating and Feeding Disorders

eating disorders

disordered eating behavior and symptoms with high mortality rates and intensity, and types vary across the lifespan; the main ones are anorexia, bulimia, and binge-eating disorders

• women

• sports that emphasize aesthetics or thinness for advantage in competition: running, gymnastics, wrestling, rowing, and figure skating

• adolescents and young adults

• LGBTQ

• genetics

• MDD, OCD, anxiety

• social media and culture that values thinness

what are the RF for anorexia

• bipolar disorder

• anxiety disorder

• depressive disorder

• OCD

• PTSD

• alcohol or substance abuse

what are common comorbidities of anorexia

• intense fear of gaining weight

• very distorted view of their own body size and shape, viewing themselves as fat even when emaciated

• peculiar handling of food like cutting into small bites and pushing pieces of food around the plate

• purging behavior: excessive exercise, self-induced vomiting, use of laxatives and diuretics

• instant feelings of fear, depression, anxiety, guilt, and shame when eating or feel full so they don’t feel the need to eat

• restrict calories despite being underweight, pursuing and unrealistic ideal of thinness

• difficulty identifying and regulating emotions, loss of distress tolerance, and often frustration when faced with stressors, reactions with emotional dysregulation

• value the disorder and know it is harmful but believe the benefits outweigh the harm

• BMI less than 18

• denial

• constipation

• low VS

• lanugo

• cool, mottled, yellow skin

• peripheral edema

• muscle wasting

• impaired renal function

• decreased bone density

• amenorrhea

• fatigue, weakness

• obsessive thoughts and behaviors around food

• frequently weigh themselves and measure their bodies

what are the S/S of anorexia

lanugo

fine downy hair on the face and neck that is common in those with anorexia

mild anorexia

BMI of 18-17

moderate anorexia

BMI of 17-16

severe anorexia

BMI of 16-15

extreme anorexia

BMI of less than 15

• therapeutic milieu with predetermined meals designed by dieticians, clients eat with staff, clients are provided support for emotions during and after meals, clients' bathroom privileges are restricted after meals

• monitor for refeeding syndrome

• weight restoration program

what are the nursing interventions for anorexia

• extreme electrolyte imbalance

• weights below 75% of the ideal body weight

• less than 10% body fat

• daytime HR of less than 50 bpm

• SBP of less than 90 mmHg

• temp less than 96 F

• arrythmias

what can lead to an anorexic patient being hospitalized for treatment

• no FDA-approved meds

• psych meds are used to address s/s of depression, anxiety, and other comorbid disorders

• SSRIs, anxiolytics, SGAs, and mood stabilizers may be used

what does pharmacotherapy for anorexia include

• individual, group, and family therapies

• family based treatment (F-BT)

• CBT

• adolescent focused treatment (AFT)

• yoga, massage, acupuncture, bright light therapy

what therapies are available for anorexia

family based treatment

found to be more effective than individual therapy in patients with anorexia; outpatient 6-12 weeks of treatment that helps parents disrupt their child’s starvation and excessive exercise, and encourages the child to develop a more constructive approach to weight

bulimia

diagnosed when the client has combined binge eating large amounts of food with compensatory measures designed to avoid weight gain at least once per week for at least 3 months

binge

the consumption of 1500-5000 calories in a 2 hour period that is a larger amount of ood that would be eaten in a similar period of time under similar circumstances

purging by self vomiting

in reinforced in bulimia because when it occurs, it can increase plasma endorphin levels, which provides a feeling of well-being or relief

• self-induced vomiting

• laxative use

• diuretic use

• fasting

• excessive exercise

what compensatory mechanism to avoid weight gain are common in bulimic patients

• women

• late adolescent to young adulthood

• genes that regulate serotonin transport, regulate nutritional intake, impulsive or craving behaviors, and that are tied to stress response, are not working properly

• difficulty with friends, intimacy, and parental attachments

• unmet emotional needs

• physical and emotional trauma

• family or society focus on body, weight, and eating behavior

what are the RF for bulimia

• black and white thinking

• rigidity

• excessive generalization

• errors of attribution

• viewing overweight as negative

• perceive parents as unsupportive of independence

what cognitive distortions do bulimic patients experience

• depressive disorders

• anxiety disorders

• bipolar disorder

• alcohol and substance abuse

• PTSD

• borderline personality disorder

what are common comorbidities associated with bulimia

• large amounts of food with compensatory measures designed to avoid weight gain at least once per week for at least 3 months

• doesn’t appear acutely ill

• normal or slightly low BMI

• enlarged parotid glands, dental erosion, and dental caries from vomiting

• Russell’s sign (calluses on knuckles) from self-inducing vomiting

• electrolyte imbalances from repeated vomiting or laxative use

• binging and purging in secret

• relationship difficulties

• low self-esteem, anxiety, depressive symptoms, social anxiety, were an overly anxious child

• impulsive, shoplifting, stealing, substance abuse

• peripheral edema

• muscle weakening

• cardiomyopathy

• seizure

what are the s/s of bulimia

• syncope

• potassium < 3.2

• chloride < 88

• esophageal tears

• arrhythmias

• intractable vomiting

• hematemesis

• suicide risk

what will cause hospitalization of a bulimic patient

• therapeutic milieus with external controls that prevent access to binge foods, excessive exercise, and opportunities to puge

• revere room restriction: bathrooms are locked for 2 hours after meals and meals are planned, prepared, and observed by staff

• registered dietitian meals and monitoring

• reverse weights

• close supervision for self-harm

• identification of the emotions behind the compulsive eating behaviors

what are the nursing interventions for bulimia

fluoxetine (Prozac)

SSRI that is FDA approved for use of bulimia in adult patients and is helpful even in the absence of depressive symptoms; doses tend to be higher when used for bulimia compared to when used for MDD

• SSRIs: sertraline, paroxetine, citalopram

• TCAs: imipramine, nortriptyline, desipramine

• MAOIs: tranylcypromine

what antidepressants (besides fluoxetine) can be used for bulimia

buproprion

contraindicated for use in bulimic patients due to increased risk for seizures

CBT

what is the 1st line psychotherapy for bulimia

• CBT

• DBT

• interpersonal therapy (IPT)

• acceptance and commitment therapy (ACT)

what psychotherapies are used to treat bulimia

binge eating disorder

the MC eating disorder that is characterized by recurrent episodes of binge eating at least weekly for 3 months that is characterized by eating in a discrete period of time (within any 2 hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances accompanied by a lack of self control over eating during the episode

• 3 or more of the following

  • eating more rapidly than normal

  • eating until feeling uncomfortably full

  • eating large amounts of food when not feeling physically hungry

  • eating alone because of feeling embarrassed by how much one is eating

  • feeling disgusted with oneself, depressed, or very guilty afterward

• client feels uncomfortably full and distressed

• lack of control over eating

• no compensatory behaviors performed

• may initially be of normal weight and become overweight or obese

• high BMI

• low self esteem/negative body image

• DM, HTN, CVD

• addictive tendencies toward high-fat and high-sugar foods

• GI issues

• psychosocial issues

what are the s/s of binge eating disorder

• females

• overweight populations

• genetics

• poor impulse control and inhibit of behaviors

• body dissatisfaction, low self-esteem, difficulty coping with feelings

• addictive tendencies toward high-fat and high-sugar foods

• influence to be then from media, friends, and family

• stigma against obesity can lead to perpetual cycles of bingeing

• history of trauma, especially emotional neglect

• history of food insecurity

what are RF for binge eating disorder

Most have another psychiatric disorder (specific and/or social phobias, PTSD, alcohol abuse)

what are common comorbidities with binge eating disorder

• obtain a history of weight gain/loss

• identify binge foods, triggers, and frequency

• identify what was happening and/or feelings that occurred prior to bingeing

• assess nutritional patterns

• balance the volume and frequency of food

• assess for SI

• encourage healthy physical activity

• develop positive coping skills and support

• identify and address underlying emotional issues

• monitor for acute GI and cardiac issues

• avoid judgmental terms about weight or overeating to establish rapport and trust

• understand bingeing is not about the food, it’s about the emotion

• encourage community and small group activity because they often avoid socializing

• have patient avoid eating between planned meals

what are the nursing interventions for binge eating disorder

• lisdexamfetamine dimesylate

• SSRIs

• SNRIs: duloxetine, venlafaxine

• under investigation: TCAs, antipileptics

what are the medications used to treat binge eating disorders

lisdexamfetamine dimesylate

a stimulant used to treat ADHD that is also FDA approved to treat moderate to severe binge eating disorder in adults

SE: dry mouth, insomnia, decreased appetite, increased HR, constipation, feeling jittery, anxiety

has a risk of abuse and dependence

bariatric surgery

Surgical treatment for binge eating disorder is controversial and usually unsuccessful long-term, with feelings of anxiety and depression returning, and as the stomach expands after surgery, behaviors resume; it can also lead to impaired fasting glucose levels, high TGs, and urinary incontinence

• CBT

• DBT

• Interpersonal therapy (IPT)

what therapies are used for binge eating disorder

CBT

used in binge eating disorder to help clients identify and change cognitive distortions about themselves and their bodies and the world

DBT

used for patients with binge eating disorder to assist with distress tolerance, impulsivity, and feelings of conflict in relationships

interpersonal therapy (IPT)

used in binge eating disorder to help the client navigate close relationships without resorting to overeating to cope with conflicts or painful emotions in relationships

pica

ingestion of non-food items that have no nutritional value like paint, dirt, stones, etc that onsets in early childhood and lasts for a few months

• institutionalized children

• intellectually disorders clients

what are the RF for pica

• interferes with eating nutritional items

• ingestion of paint can cause brain damage

• objects that cannot be digested like stones can cause intestinal blockages

• sharp objects can cause intestinal damage or laceration

• bacteria from objects can cause infection and dental problems

• Enamel on teeth may be eroded from chewing on abrasive and erosive substances

• Lead poisoning may occur depending on what is eaten

what are the complications of pica

• close monitoring

• behavioral interventions such as rewarding appropriate eating

what are the nursing interventions for pica

rumination disorder

undigested food returning to the mouth, leading to rechewing and reswallowing of food for no GI/medical reason, and not a part of any other mental illness; disorder is diagnosed after 1 month of symptoms

• intellectually disabled kids

• childhood neglect

what are the RF for rumination disorder

• repositioning infants and small children during feeding

• making meals a pleasant experience

• distracting the child when the behavior starts

• family therapy

what are the nursing interventions for rumination disorder

avoidant restrictive food intake disorder (ARFID)

avoiding or restricting food that onsets in childhood and can cause malnutrition and growth defects, and leads to significantly low BMI in the child due to appearance, color, smell, texture, temperature, or taste of food that may lead to dependence on supplements and EN feeding; Tx: behavior modificaiton to increase regular food consumption

• prematurity

• autism

• genetic syndrome

• personal or family anxiety

what are the RF for avoidant restrictive food intake disorder (ARFID)