Eating Disorders

morbidity and mortality

AN has the highest death rate of all psychiatric disorders; risk of death is 5x greater, financial burden, suicide, cardiac arrest

nursing assessment

build rapport, ask detailed questions about eating habits: binge eating, purging, other compensatory behaviors, dietary restrictions, weight hx, body image; psychosocial assessment: behavioral responses, self concept, stress and coping patterns, social assessment, quality of life, strengths of assessment

warning signs

• Change in usual eating pattern= regular intense dieting, fasting, skipping meals, buying large quantities of food, secretive eating patterns 

• Ritualized eating behavior= cutting food into tiny pieces, “binge foods” and/or “fear foods” 

• Weight preoccupation= frequent weights calorie counting, persistent desire to be thin fear of gaining weight 

• Excessive exercise 

• Bathroom routine immediately after meal 

• Physical signs= weight loss/fluctuations, swollen parotid glands, Russell’s sign, tooth decay

• “Disease of disconnection” (from self; others)

• SECRETS

psychiatric comorbidities

anxiety disorders, depression, personality disorders, bipolar, self injurious behaviors/impulsivity

Medical comorbidities

can impact all body systems, cardiac, GI, musculoskeletal, endocrine, neurological, electrolyte imbalances, fainting, tooth problems/sensitivity, Russell’s sign, lanugo

criteria for hospitalization (medical)

• Acute weight loss, <85% below ideal 

• Heart rate near 40 bpm

• Temp, <36.1 C 

• BP, <80/50 mm Hg

• hypokalemia, hypophosphatemia, hypomagnesemia

• Poor motivation to recover

criteria for hospitalization (psychiatric)

• Risk for suicide 

• Severe depression 

• Failure to comply with treatment 

• Inadequate response to treatment at another level of care (outpatient)

anorexia nervosa

restriction of energy intake, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health

anorexia nervosa characteristics

intense fear of gaining weight or becoming fat, or behavior that interferes with weight gain; body image disturbance, restricting type, binge-eating/purging

anorexia nervosa- restricting

• During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior )i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

• This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise

anorexia nervosa- binge-eating/purging

During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

mild anorexia

BMI >17 kg/m2  (5’8 adult: >112, 5’10 adult: >119)

moderate anorexia

BMI 16-16.99 kg/m2 (5’8: 105-112, 5’10: 112-119)

severe anorexia

BMI 15-15.99 kg/m2 (5’8: 99-105, 5’10: 105-112)

extreme anorexia

BMI <15 kg/m2  (5’8: <99, 5’10: <105)

anorexia associated features

• potential life threatening medical conditions

• nutritional affects major organ systems

• amenorrhea, VS abnormalities, loss of bone mineral density

• underweight patients= depressive s/sx

• binge-eating/purging types= higher rates of impulsivity and are more likely to abuse alc or other drugs

• Excessive levels of physical activity= increase in physical activity often precede onset of the disorder

• may misuse medications (manipulating dose)

• DM pts may omit or reduce insulin doses in order to minimize carb utilization

anorexia nervosa developmental

• commonly begins during adolescence or young adulthood

• rarely begins before puberty or after age 40, but cases of both and late onset have been described

anorexia nervosa courses

• Younger individuals= may manifest atypical features, including denying “fear of fat” 

• Older individuals= more likely to have a longer duration of illness, and their clinical presentation may include more s/sx of long standing disorders 

• Individuals have a period of changed eating behavior prior to full criteria for the disorder being met

• Some recover fully after a single episode 

• Some exhibiting a fluctuating pattern of weight gain followed by relapse 

• Others experiencing a chronic course over many years 

• Hospitalization may be required to restore weight and to address medical complications 

• Death most commonly results from medical complications associated with the disorder itself or from suicide

anorexia nervosa suicide risk

second leading cause of death is anorexia nervosa

AN nursing assessments

• Early attitude test (EAT-26)

• Eating disorder Examination Questionnaire (EDE-Q)

AN nursing interventions

weight monitoring=do not disclose with certain patients, assess for comorbitities+treat, pharmacological

pharmacological for AN

no FDA approved medications; olanzapine (Zyprexa) may promote weight gain and decrease ruminative thoughts; wellbutrin contraindicated

Bulimia Nervosa define

recurrent episodes of binge eating + purging

bulimia nervosa characterisitics

• eating in a discrete period of time (e.g. within any 2-hr period), an amount of food that is definitely larger than what most individuals eat in a similar period of time under similar circumstances, 

• a sense of lack of control over-eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating)

• Recurrent, inappropriate compensatory behaviors in order to prevent weight gain (self induced vomiting; misuse of laxatives, diuretics, or other meds; fasting; or excessive exercise)

• Binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months 

• Body image disturbance

bulimia nervosa mild

1-3 score

bulimia nervosa moderate

4-7 score

bulimia nervosa severe

8-13 score

bulimia nervosa extreme

14 or more

BN associated features

• Individuals typically are within the normal weight or overweight range

• Occurs but is uncommon among obese individuals 

• Individuals restrict their total caloric consumption and preferentially select low-calorie foods while avoiding foods that they perceive to be fattening or likely to trigger a bing

BN physiological disturbances

• Menstrual irregularities or amenorrhea often occurs among females 

• Hypokalemia resulting from purging 

• Potentially fatal comps: esophageal tears, gastric rupture, and cardiac arrhythmias   

• Serious cardiac and skeletal myopathies following repeated use of syrup of ipecac to induce vomiting

• Individuals who chronically abuse laxatives may become dependent on their use to stimulate bowel movements 

• GI symptoms are commonly associated with bulimia nervosa

BN development

commonly begins during adolescence or young adulthood, rarely begins before puberty or after age 40, frequently begins during or after an episode of dieting to lose weight or experiencing multiple stressful life events

BN course

disturbed eating behavior often persists for at least several years, may be chronic or intermittent, with periods of remission alternating with recurrences of binge eating, may diminish with or without tx, periods of remission longer than 1 year are associated with better long-term outcome

BN suicide risk

elevated

BN interventions

weight monitoring, assess for comorbidities + treatment

BN pharmacological

fluoxetine (Prozac) is FDA approved for tx; ondansetron (Zofran) and topiramate (Topamax) may be useful to reduce binge episodes; wellbutrin contraindicated

BN inpatient interventions

• Establishing mental health and wellness goals 

• Physical care= nutritional rehab, promotion of sleep, meds, management of complications, therapeutic interactions, enhancing cognitive functioning, psychoeducation (pt and family), promote safety 

• Safety= mortality is high, suicide and cardiopulmonary arrest are the leading cause of death, nurses pay special attention to high suicide risks, self-injury high amongst patients with AN

Binge eating define

recurrent episodes of binge eating (no recurrent, compensatory behavior) at least once a week for 3 months

BEN characteristics

• Binge-eating episodes are associated with three (or more) of the following 

  • Eating much 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 

• Marked distress is present 

• Does not occur exclusively during episodes of anorexia nervosa or bulimia nervosa

BEN mild

1-3

BEN moderate

4-7 score

BEN severe

14 or more

BEN associated features

• Occurs in normal weight/overweight and obese individuals 

• Eating in secret 

• Associated with overweight and obesity in tx seeking individuals 

• Distinct from obesity

  • Consume more calories in lab studies of eating behavior 

  • Have greater functional impairment, lower quality of life, more subjective distress, and greater psychiatric comorbidity 

  • Most obese individuals do not engage in recurrent binge eating

BEN nursing interventions

EAT-26, EDE-Q, weight monitoring, assess for comorbidities + treat

BEN pharmacological

lisadexafetamine dismeylate (Vyvanse) was FDA approved for tx in 2015; antidepressants and topiramte (Topamax) may be useful

psychotherapies for eating disorders

cognitive behavioral therapy, dialectical behavioral therapy, family therapy, interpersonal therapy, nutritional therapy/meal planning, group therapies for individual or families, mindfulness, many others

anorexia summary

restricting + binge-eating/purging; self starvation/extreme food restriction leading to significantly low weight; intense fear of gaining weight

bulimia nervosa summary

eating large amounts of food discreetly within a 2 hr period, and a sense of lack of control over-eating→inducing vomiting to get rid of the calories gained (purging); maintaining a normal or higher body weight

binge eating summary

eating large amounts of food, more rapidly, even when not physically hungry; no compensatory behaviors

underweight

less than 18.5

healthy

18.5-24.9

overweight

25 to 29.9

obese

30 or above