Eating Disorders

Anorexia Nervosa

• Self-starvation

▫ Essential nutrients are denied (no or little food) so the body slows down all normal
processes to conserve energy.

▫ Health consequences

▫ Low blood pressure / heart rate

▫ Muscle loss / weakness

▫ Dehydration

▫ Fainting / fatigue

▫ Dry hair and skin

• 90-95% are female so, 5-10% are male.

• Similar characteristics:

▫ Preoccupied with weight

• Males may have preoccupation with body building, weight lifting or toning.

▫ Compulsive exercise

▫ Frequently weighing oneself

▫ Distorted body image

Bulimia Nervosa

• Typically a binge – purge method

▫ Binge – secret periods of quickly eating high-

calorie dense foods.

▫ Purge – more than the typical vomiting.

Purging methods may include:

- self-induced vomiting

- extravagant use of diuretics

 - laxatives

intense exercise

• 80% are female

• Health consequences:

▫ Irregular heartbeat = heart failure = death.

▫ Tooth decay

▫ Ulcers

Two major types of Bulimia Nervosa:

a. Purging Type – people compensate the overeating behavior by self-induced vomiting or

excessive use of laxatives, diuretics, or related substances. Majority of the population suffers
from this type of eating disorder

b. Non-Purging Type – conversely, an individual approach for alternative (like intense exercise) to
compensate the binge episodes
Signs and Symptoms
(Anorexia & Bulemia)

ANOREXIA

• Weight loss

• No or irregular periods

• Fatigue

• Decreased concentration

• Stress fractures

• Muscle injuries

• Low heart rate/BP

• Heart irregularities

• May even have chest pain

BULIMIA

• Continued dieting

• Preoccupation with food/weight

• Frequent trips to bathroom during and after meals

• Using laxatives

• Brittle nails/hair

• Dental cavities

• Sensitivity to cold
Binge Eating Disorder

• The most common eating disorder.

▫ Affects about 3% of U.S. adults.

▫ Slightly more common in women than men.

• Signs & symptoms:

▫ Eat a large amount of food quickly during binge.

▫ Eating a large amount until uncomfortable full.

▫ Eating large amounts of food when not hungry.

▫ Eating alone because embarrassed about

amount of food.

▫ May have feelings of guilt or depression after

overeating.

• Large amounts of food consumed (binge) but typically NO purging.

▫ This is different than bulemia.

▫ Complications from binge eating disorder:

▫ Type 2 Diabetes

▫ High blood pressure

▫ High cholesterol

▫ Heart disease

▫ Certain types of cancer

Other Types Of Eating Disorders

Avoidant-Restrictive Food Intake Disorder (ARFID)

Avoidant-restrictive food intake disorder (ARFID) is an eating disorder that can appear as extremely
picky eating. Those struggling may demonstrate a lack of interest in food and experience unexplained
bodily discomfort. The limited range of “acceptable” foods narrows over time.

Warning signs of ARFID:

• Restricted or reduced food intake

• Frequent complaints about bodily discomfort with no organic cause

• Lack of appetite or interest in food

• Fear of negative effects of eating food (e.g., choking, vomiting)

• Inability or reluctance to eat in front of others

• Picky eating that is unresolved by late childhood

Health consequences of ARFID:

• Food restriction and lack of variety associated with ARFID may lead to severe nutritional
deficiencies. Some of the potential health consequences of ARFID may include failure to thrive,
which means not meeting expected levels of growth, anemia, weight loss, gallbladder disease,
and malnutrition, characterized by dry hair, hair loss, brittle nails, difficulty concentrating, and
Osteoporosis or osteopenia (reduction in bone density).

Other specified feeding or eating disorder (OSFED)

Other specified feeding or eating disorder (OSFED) is a broad category.

It includes conditions that do not meet the criteria for anorexia, bulimia, etc., but still cause significant
distress. For example, in atypical anorexia nervosa all of the criteria for anorexia is met, but the patient’s
weight is not below normal. The self-starvation and disordered thinking are psychologically and
physically destructive and must still be addressed. It is important that OSFED is recognized on par with
other eating disorders, and that its seriousness is not underestimated.

Warning signs and health consequences of OSFED:

Warning signs and health consequences of OSFED are more difficult to pinpoint, as it includes a number
of conditions. Watch out for all of the signs already listed. The most important thing to look out for is
attitudes about food and weight that conflict with a productive and satisfying life.

• Preoccupation with weight but not as consistent as found in AN, BN, BED

• Increased isolation, depression, or irritability

• Compulsive or obsessive exercising

NUTRITION AND TREATMENT

Medical comorbidities, including electrolyte disturbances and dehydration, should be treated and,
when possible, prevented. Treatment varies depending on severity of illness and concurrent
psychiatric issues.
Hospitalization is indicated for severe malnutrition (body weight less than 75% of ideal), suicidal
ideation, electrolyte disturbances, dehydration, abnormal vital signs (e.g., bradycardia, hypothermia),
cardiac arrhythmias, and failure of outpatient treatment

Vitamin and mineral supplementation may be necessary. An inpatient or outpatient structured eating
program may help restore healthy eating habits.

Psychotherapy is a mainstay of treatment for certain eating disorders. Because drug therapy is, for the
most part, ineffective for anorexia nervosa, psychotherapy is often the treatment of choice. However,
not all forms of therapy have undergone rigorous testing. Family-based therapy appears to be more
effective in anorexic adolescents (but not adults) than other therapeutic modalities. In adults,
psychotherapy has been found to reduce anorexic behaviors in up to 60% of patients. However, more
stringent assessment of the effects of cognitive-behavioral therapy indicated that only 17% of patients
treated with this modality could be considered fully recovered. Olanzapine, an antipsychotic medication,
might be helpful in restoring weight in acutely ill patients.

In persons with binge eating disorder, a disorder characterized by excessive bingeing without
compensatory behavior, cognitive-behavioral therapy and interpersonal therapy reduced binge eating
by 48%-98%and produced abstinence rates of about 60%.Medications such as antidepressants and
anticonvulsants may also play a role.

Lisdexamfetamine, a stimulant medication initially developed for the treatment of ADHD, has been
shown to be effective in binge eating disorder.

Most studies show cognitive-behavioral therapy to be more effective than drug therapy for persons
with bulimia nervosa.Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is considered to be first-
line pharmacotherapy for bulimia. A different SSRI (e.g., citalopram, sertraline) might be used as second-
line treatment and some tricyclic antidepressants (e.g., desipramine, imipramine) might also be used as
third-line treatments. Combining medication with psychotherapy improves overall treatment
effectiveness. Also, self-help manuals appear to be as effective as psychotherapy in reducing binge
episodes for some patients.

Group support in a structured setting is a useful intervention. Groups based on principles of cognitive-
behavioral or dialectic behavioral therapy have been shown to be effective. Twelve-step programs such
as Overeaters Anonymous are often effective as well .
Nutritional Considerations

Refeeding,

particularly in persons who are significantly underweight, electrolytes should be carefully monitored and
refeeding introduced gradually and progressively. Hypokalemia has been reported in 14% of patients
with bulimia nervosa, and hyponatremia may be brought on by the use of diuretics, vomiting, and/or
excessive water intake. Patients often ingest excessive water to curb hunger or provide the false
impression of weight stability during weight checks at medical appointments. If patients are aggressively
fed and rehydrated, hypophosphatemia-induced refeeding syndrome may occur, potentially involving
dysrhythmias, respiratory failure, rhabdomyolysis, seizures, coma, heart failure, weakness, hemolysis,
hypotension, ileus, metabolic acidosis, and sudden death. High sodium intake increases the risk of fluid
overexpansion. Limiting sodium intake to required amounts (500 mg/d) is recommended.

To further assist in preventing refeeding syndrome, supplemental phosphorus should be started early
and serum levels maintained above 3.0 mg/dL. Hypomagnesemia occurs in approximately 1 in 6 patients
with anorexia nervosa and may persist for weeks after

refeeding. Although weight gain is an eventual goal for anorexic patients, calories should be secondary
to protein during initial refeeding. Suggested guidelines include providing

• 1.2 grams of protein per kilogram of ideal body weight/day for the first week and ;

• no more than 20 kcal/kilogram/day during the first week

to avoid refeeding syndrome.

In addition to the need for a hypercaloric diet during weight restoration, evidence suggests that
individuals with

• anorexia nervosa require 200-400 calories per day more than matched controls in order to
maintain weight.

Emotional support.

It is essential to avoid power struggles over diet choices or weight gain. Individuals with eating disorders
often drop out of treatment programs because eating generates profound anxiety. Aggregate results of
surveys of eating-disordered patients found that they rated support, understanding, and empathic
relationships as critically important. Psychological approaches were viewed as the most helpful, while
medical interventions focused exclusively on weight were viewed as not helpful.Pressuring patients to
make commitments to improve (e.g., to enroll in treatment or gain weight) has not been demonstrated
as effective and may be counterproductive. Instruments used to asess patients’ readiness to stop
restricting foods, purging, or bingeing have been found to be good predictors of clinical outcome in
patients with anorexia nervosa.

Nonrestrictive vegetarian or vegan diets can be adequate.

Patients who follow vegetarian diets should not be pushed to alter that preference. Many healthy
people choose to avoid meat or avoid all animal-derived products, and these choices bring many health
benefits. People suffering from eating disorders also often report feeling disgusted by meat. However,
vegetarianism does not cause eating disorders. In one study vegetarians and vegans motivated by
ethical concerns had lower eating-related pathology than semi-vegetarians or “flexitarians.” Previous
research conflating vegetarianism with disordered eating often did not account for food avoid ance that
is normative in the context of vegetarianism. Healthful plant-based foods should be a part of eating
disorder recovery.

Weight-loss treatments for patients with binge eating disorder. Studies of the effects of both dietary
and behavioral approaches to weight loss show that weight-loss treatments reduce binge eating
frequency.Although it was once suspected that attempts at weight loss preceded binge episodes, the
stuctured meal plans provided for weight loss may give binge eaters a feeling of greater control over
food intake. Spontaneous remission of binge eating has also been reported.

Vitamin/mineral deficiency.

More than half of patients with anorexia nervosa failed to meet the recommended dietary allowance
(RDA) for:

 vitamin D

 calcium

 folate

 vitamin B 12

 zinc

 magnesium

 copper
. Deficiencies are also commonly found for several vitamins, including thiamine, B 2, niacin, B 6, folate,
C, E, and K. There have been case reports of patients with anorexia nervosa who were diagnosed with
pellagra due to niacin deficiency and scurvy due to vitamin C deficiency. There are also case studies of
patients with bulimia nervosa presenting with folate deficiency and coagulation abnormalities due to
vitamin K deficiency. Replacement of these and other nutrients is an important part of nutrition therapy.

Zinc in particular has been found to enhance the rate of recovery in anorexics by increasing weight gain
and improving anxiety and depression.

Bone health

Low intakes of calcium, vitamin D,and vitamin K can reduce bone mineral density and put eating
disorder patients at very high risk for osteoporosis. Weight gain itself reduces bone turnover in patients
with anorexia nervosa. In one study, treating bone disease in anorexic patients with

 calcium and vitamin D supplements was as effective as etidronate for reversing osteoporosis.

What to Tell the Family

Eating disorders are typically precipitated and perpetuated by a combination of genetic, developmental,
and psychological factors, requiring a multidisciplinary team approach (physician, psychiatrist,
psychologist, and dietitian) to treatment. Anorexia nervosa is particularly difficult to treat, often
necessitating repeated episodes of hospitalization to prevent extreme weight loss. Bulimia nervosa is
usually not life threatening and may respond well to cognitive-behavioral therapy, medication, or a
combination of the two. Binge eating disorder often responds well to behavior modification weight-loss
strategies alone. Family members can render assistance by providing regular, well-balanced meals and
emotional support.
Screening Tools for Eating Disorders

• Eating Attitudes Test (EAT -26)

• EDGE tool

• BED Screening

• Female Athlete Screening Tool

• SCOFF
 What is Eating Disorder?

• Eating disorders are neurobiological disorders rooted in the brain causing medical and
psychological issues

• They are NOT simply about “control” or weight management

• Genetics are responsible for 50-83%

• Two people can be living in the same house, undergo similar stressors, and both go on a diet.
The one that is wired differently may take the diet to the next level (ED patterns and
behaviors) while the other doesn’t

RISK FACTORS

About 90% of cases of eating disorders occur in women, with onset typically occurring in late

adolescence and early adulthood. Additional risk factors include:

History of obesity and/or dieting. A history of obesity is linked to increased risk for eating

disorders. Adolescents who reported dieting during mid-adolescence were significantly more
likely to develop eating disorders.

Participation in activities that emphasize leanness. Examples include ballet,

gymnastics,running, and wrestling.

Family history. Women who have a first-degree relative with an eating disorder are up to 10
times more likely to develop an eating disorder themselves. Eating disorders are also associated
with a family history of depression.

Psychiatric history. Histories that include depression, substance abuse, sexual abuse, weight
dissatisfaction, and low self-esteem are linked to higher risk for eating disorders.
Early puberty. Early sexual development may lead to increased self-consciousness regarding
body image and is associated with subsequent dieting behaviors.

9 Truths of ED

• #1 Many people with eating disorders look healthy, yet may be extremely ill.

• #2: Families are not to blame and can be the patients' and providers' best allies in treatment.

• #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.

• #4: Eating disorders are not choices, but serious biologically influenced illnesses.

• #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and
weights, sexual orientations and socioeconomic statuses.

• #6: Eating disorders carry an increased risk for both suicide and medical complications.

• #7: Genes and environment play important roles in the development of eating disorders.

• #8: Genes alone do not predict who will develop eating disorders.

• #9: Full recovery from an eating disorder is possible. Early detection and intervention are
important.

COMMON TYPES OF EATING DISORDERS

1. Anorexia Nervosa
2. Bulimia Nervosa
3. Binge Eating Disorder