Eating disorders

Eating Disorders

Learning Objectives

  • Discuss the role of body image.
  • Identify characteristics of someone with anorexia nervosa.
  • Identify treatment modalities.
  • Define and discuss the different weight-related disorders.
  • Identify the nurse's role.

What is an Eating Disorder?

  • Definition: Disturbed eating and eating-related behaviors.
  • Types of Eating Disorders:
    • Pica: Ingestion of non-food substances.
    • Rumination: Repeated regurgitation of food.
    • Avoidant/Restrictive Food Intake Disorder (ARFID).
    • Anorexia Nervosa.
    • Bulimia Nervosa.
    • Binge Eating Disorder (BED).

Anorexia Nervosa

  • Key Features:
    • Significantly low body weight.
    • Intense fear of gaining weight.
    • Disturbance in experiencing body weight or shape.
    • Distorted body image.
    • Inability to recognize the seriousness of low body weight.

Types of Anorexia Nervosa

  1. Restricting Type:
    • Diet/exercise without binge eating or laxative misuse.
  2. Binging and Purging Type:
    • Use of laxatives, diuretics, enemas.
    • Characterized by a preoccupation with food and weight.
    • Consequences include malnutrition, starvation, and death.

Clinical Course of Anorexia Nervosa

  • Onset: Typically occurs in early adolescence; often preceded by slow, serious dieting.
  • Treatment Difficulty: Often difficult to treat; recovery can take years with common relapses.
  • Prognosis: Highest death rate of all mental illnesses.

Body Mass Index (BMI) and Anorexia Nervosa

  • Typical BMI Categories:
    • Underweight: BMI < 18.5
    • Normal: BMI 18.5 - 24.9
    • Overweight: BMI > 24.9
    • Obese: BMI > 30.0
  • Anorexia Severity Scale:
    • Mild: BMI ≥ 17
    • Moderate: BMI 16 to 16.99
    • Severe: BMI 15 to 15.99
    • Extreme: BMI < 15

Risk Factors for Anorexia Nervosa

  • Predominantly affects females (90% of cases); males may be underdiagnosed.
  • Psych comorbidities include:
    • Anxiety disorders.
    • Obsessive Compulsive Disorder (OCD).
  • Personality traits: perfectionism.
  • Stressful life events can trigger onset.

Characteristics of Anorexia Nervosa

  • Severe body image distortion.
  • Drive for thinness.
  • Emotional dysregulation.
  • Perfectionism.
  • Significantly low body weight.
  • Intense fear of gaining weight.

Medical Complications of Anorexia Nervosa

  • Physical Symptoms Include:
    • Amenorrhea.
    • Gastrointestinal issues (bloating, constipation, gas, diarrhea).
    • Loss of body fat leading to sensitivity to cold.
    • Dry skin and hair loss.
    • Bradycardia and arrhythmias.
    • Electrolyte imbalances.
    • Sarcopenia: loss of muscle mass leading to weakness and increased fall risk.

Treatment of Anorexia Nervosa

  • Focus Areas:
    • Weight restoration.
    • Correction of electrolyte imbalances.
  • Treatment settings: outpatient or inpatient.
  • Inpatient Criteria:
    • Heart rate < 40 BPM.
    • Blood pressure < 80/50.
    • Electrolyte disturbances: hypokalemia, hypomagnesemia, hypophosphatemia.
    • Hypothermia.

Inpatient Treatment Details

  • Structured, supervised meals lasting less than 30 minutes.
  • Re-feeding at 1-2 lbs. per week.
  • Initial caloric intake at 1500 calories/day progressing to 3500 calories/day.
  • Replace and monitor electrolytes.
  • Incorporation of physical therapy.
  • Goal: Achieve at least 85% of ideal body weight.

Complications of Refeeding Syndrome

  • Clinical manifestations related to electrolyte imbalances, including:
    • Weakness.
    • Paresthesia.
    • Arrhythmias.
  • Cardiac failure can occur due to sudden shifts in electrolyte balances or thiamine deficiency.
  • Prevention: Increase caloric intake slowly.

Bulimia Nervosa

  • Characterized by:
    • Binge eating episodes.
    • Followed by purging (vomiting or laxatives), fasting, or excessive exercise.
  • Patients often present at a normal weight and typically seek treatment.

Medical Complications of Bulimia Nervosa

  • Parotid gland swelling due to over-activation of salivary response.
  • Enamel erosion from vomiting.
  • Electrolyte imbalances, especially hypokalemia.
  • Russell's sign: callouses on knuckles from inducing vomiting.
  • Esophageal erosion, indicated by the presence of blood in vomit.

Treatment of Bulimia Nervosa

  • Therapeutic approaches include:
    • Family therapy.
    • Individual therapy.
    • Enhanced Cognitive Behavioral Therapy (CBT) addressing:
    • Perfectionism.
    • Mood intolerance.
    • Low self-esteem.
    • Interpersonal difficulties.

Medication for Bulimia Nervosa

  • Selective Serotonin Reuptake Inhibitors (SSRIs): e.g., Fluoxetine or Sertraline.
  • Clients should be educated to eat small, frequent meals to reduce gastrointestinal side effects.
  • SSRIs may take up to 4 weeks to achieve full effect.
  • Second-generation antipsychotics such as Olanzapine may be prescribed for weight gain and reduction of anxiety.

Nursing Interventions for Bulimia Nervosa

  • Supervise meals and snacks to prevent purging behaviors.
  • Monitor patients after meals (including bathroom supervision).
  • Utilize positive/negative reinforcers to support treatment goals.
  • Monitor vital signs (VS) and intake and outputs (I&Os).
  • Consult with a registered dietician for nutritional planning.

Education for Families

  • Recommendations include:
    • Avoid discussing weight, calories, or eating habits.
    • Do not force food on the individual.
    • Express concerns and suggest professional help (e.g., a physician or specialists).
    • Avoid commenting on the individual's appearance.

Recovery Goals for Eating Disorders

  • Stabilize and normalize eating behaviors.
  • Restructure dysfunctional thought patterns related to body image and weight.
  • Develop coping mechanisms for comorbid issues, including anxiety and depression.

Other Eating Disorders

Binge Eating Disorder (BED)

  • Defined by recurrent episodes of binge eating, followed by distress and a sense of lack of control.
  • Commonly found in both males and females, particularly in those over 35 years old.
  • Patients are typically overweight or obese.

Pica

  • Characterized by the persistent ingestion of non-food substances, including:
    • Dirt.
    • Clay.
    • Paint.
  • Most commonly observed in:
    • Pregnant women.
    • Young children.
    • Individuals with autism spectrum disorder (ASD) or schizophrenia.
    • Those with iron deficiency anemia.

Orthorexia

  • Defined as an obsession with proper or healthful eating, often considered a form of anorexia or OCD.
  • Individuals will only eat "pure" or "healthy" foods and may spend excessive time thinking about food.

Night Eating Syndrome

  • Includes:
    • Morning anorexia.
    • Evening hyperphagia (insatiable hunger).
    • Nighttime awakenings to consume snacks (at least once per night).
  • Associated with low self-esteem, stress, anxiety, and depression.
  • Recommended treatment includes SSRIs.

National Eating Disorder Association Recommendations

  • Discard the notion that a specific diet, weight, or body size will ensure happiness and fulfillment.
  • Appreciate all the capabilities of the body, focusing on functionality rather than appearance.
  • Maintain a list of ten personal qualities unrelated to weight and refer to it regularly.
  • Engage in self-care activities that promote relaxation and joy, such as bubble baths or hobbies.
  • Surround oneself with positive individuals who foster a supportive environment.
  • Wear comfortable clothing that enhances body positivity.
  • Cease judgment based on body weight or shape, both for oneself and others.
  • Limit time spent on social media that may trigger negative body image thoughts.