Eating Disorders

▪ These are illnesses that are characterized by irregular eating habits and extreme distress or
concern about body weight or shape.
▪ Eating disturbances may involve inadequate or excessive food intake which can basically cause
harm to a person’s well-being.
▪ These are characterized by a repeated disturbance of eating or eating-related behavior that
results in the altered consumption or absorption of food and that significantly diminishes
physical health or psychosocial functioning.
▪ Eating disorders can be viewed on a continuum, with clients with anorexia nervosa eating too
little or starving themselves, client with bulimia eating chaotically, and clients with obesity eating
too much.
▪ Although many believe that eating disorders are relatively new, documentation from the Middle
Ages indicates willful dieting leading to self-starvation in female saints who fasted to achieve
purity.
▪ In the late 1800s, doctors in England and France described young women who apparently used
self-starvation to avoid obesity.
▪ It was not until the 1960s, however, that anorexia nervosa was established as a mental disorder.

▪ Bulimia nervosa was first described as a distinct syndrome in 1979.

Types of Eating Disorders
Anorexia Nervosa
▪ It is a life-threatening eating disorder characterized by the client’s refusal or inability to maintain
a minimally normal body weight, intense fear of gaining weight or becoming fat, significantly
disturbed perception of the shape or size of the body, and steadfast inability or refusal to
acknowledge the seriousness of the problem or even that one exists.
Bulimia Nervosa
▪ It is often simply called bulimia, is an eating disorder characterized by recurrent episodes (at
least twice a week for 3 months) of binge eating followed by inappropriate compensatory
behaviors to avoid weight gain such as purging, fasting, or excessively exercising.
Binge-Eating Disorder (BED)
▪ It is an eating disorder characterized by recurrent episodes of binge eating but it is not
associated with the recurrent use of inappropriate compensatory behaviors as in bulimia
nervosa, and does not occur exclusively during the course of bulimia nervosa, or anorexia
nervosa methods to compensate for overeating, such as self-induced vomiting.
Pica
▪ It is an eating disorder that involves persistent eating of non-nutritive substances such as hair,
dirt, and paint chips for a period of at least one month.
Rumination Disorder
▪ This is characterized by repeatedly and persistently regurgitating food after eating, but it’s not
due to a medical condition or another eating disorder such as anorexia nervosa, bulimia nervosa,
binge-eating disorder, or avoidant/restrictive food intake disorder.
Avoidant/Restrictive Food Intake Disorder (ARFID)
▪ It is an eating or feeding disturbance characterized by persistent failure to meet appropriate
nutritional or energy needs due to having no interest in eating regarding food with certain
sensory characteristics, such as color, texture, smell or taste; or fear of choking.
Other Specified Feeding or Eating Disorder (OSFED)
▪ These are eating behaviors that cause clinically compelling distress and impairment in areas of
functioning, but do not meet the full criteria for any of the other feeding and eating disorders.
Causes
Biologic factors
▪ Studies of anorexia nervosa have shown that these disorders tend to run in families; genetic
vulnerability also might result from a particular personality type or a general susceptibility to
psychiatric disorders.
▪ individual with relatives having eating disorders is 4-5 times more likely to develop the disorder.

▪ Due to abnormalities in the activity of hormones and neurotransmitters (serotonin and nor
epinephrine) that preserve the balance between energy output and food intake.
▪ High levels of enkephalins and endorphins, opiate-like substances produced in the body,
influence eating disorders.
▪ Postulates that anorexia results from an imbalance of hormones due to physical activity.

▪ Serotonin irregularities in the hypothalamus where feelings of satiety are controlled.

▪ There is a link between obsessive- compulsive behavior and eating disorders.

▪ The elevated levels of vasopressin, neuropeptide Y, peptide YY, or decreased level of

cholecystokinin contribute to obsessive-compulsive eating behavior patterns seen in anorexia
nervosa.
Developmental factors
▪ Onset of anorexia nervosa usually occurs during adolescence or young adulthood; some
researchers believe its causes are related to developmental issues.
▪ Psychodynamic theories- One theory addresses the theme of starvation as a form of
self-punishment, with an unacknowledged purpose of pleasing an introjected or internalized
parent who is seen as imposing harsh restrictions on the otherwise well-behaved, orderly,
perfectionist, hypersensitive individual.
▪ Fasting restores a sense of order to a female who fears adult femininity and fears becoming like
her mother.
▪ Female starves themselves to suppress or control feelings of emotional emptiness.

▪ Females develop an eating disorder because they believe their parents have never responded
adequately to their initiatives or recognized individualities.
Family influences
▪ Girls growing up amid family problems and abuse are at higher risk for both anorexia and
bulimia; disorders eating is a common response to family discord.
▪ Anorexia is considered to be a symptom of a rigid family system’s need and inability to change.

▪ It focuses on parental expectations of children

▪ Both anorectic and bulimic individuals are insecure about their physical shape and size.

▪ It is a form of rebellion, in which the child gains a sense of control through the behavior.
Sociocultural factors
▪ Adolescents often idealize actresses and models as having the perfect “look” or body even
though many of these celebrities are underweight or use special effects to appear thinner than
they are; pressure from others also may contribute to eating disorders.
▪ (Peer pressure) what the society dictates

▪ There is the pressure to be thin

Other etiologic factors

▪ Childhood sexual abuse
 ▪ Participation in weight-restrictive sports

▪ Participation in high-achieving occupation

Statistics and Incidences
Obesity has been identified as a major health problem in the United States; some call it an epidemic.
Millions of women are either starving themselves or engaging in chaotic eating patterns that can lead to
death.
▪ 30% to 35% normal-weight people with bulimia have a history of anorexia nervosa and low body
weight, and about 50% of people with anorexia nervosa exhibit bulimic behavior.
▪ More than 90% of cases of anorexia nervosa and bulimia occur in females (American Psychiatric
Association, 2000).
▪ The prevalence of both eating disorders is estimated to be 1% to 3% of the general population in
the United States.
Anorexia Nervosa
▪ A patient deliberately starves herself or engages in binge eating and purging.

▪ A patient with anorexia nervosa wants to become as thin as possible and refuses to maintain an
appropriate weight.
▪ There is an intense fear of gaining weight.

▪ If left untreated, anorexia nervosa can be fatal.

▪ Psychosocial findings revealed that anorectics are introverts

▪ It is an ego-syntonic disorder (client views her behaviors as congruent with her self-image.
Contributing factors
▪ Age (most prominent in adolescent)

▪ Distorted body image

▪ Gender (primarily affects the female)

▪ Genetic predisposition

▪ low- self-esteem

▪ Neurochemical changes

▪ Poor family relations

▪ Poor self-esteem

▪ Pre-occupation with weight and dieting

▪ Sexual abuse
Clinical Manifestations
Anorexia Nervosa
▪ Fear of gaining weight or becoming fat even when severely underweight.

▪ Body image disturbance.

▪ Amenorrhea or absence of menstrual period.

▪ Depressive symptoms such as depressed mood, social withdrawal, irritability, and insomnia.

▪ Preoccupation with thoughts of food.

▪ Feelings of ineffectiveness.
 ▪ Inflexible thinking.

▪ Strong need to control environment.

▪ Limited spontaneity and overly restrained emotional expression.

▪ Complaints of constipation and abdominal pain.

▪ Cold intolerance.

▪ Lethargy.

▪ Emaciation.

▪ Hypotension, hypothermia, bradycardia.

▪ Hypertrophy of salivary glands.

▪ Elevated BUN.

▪ Electrolyte imbalances.

▪ Leukopenia and mild anemia.

▪ Elevated liver function studies.

▪ Odd food habits (hiding foods, hoarding)

▪ Obsessive rituals concerning foods

▪ Overly compliant attitude

▪ Perfectionist attitude

▪ Refusal to eat

▪ Lanugo, dry skin, hair loss, sunken eyes

Bulimia Nervosa
▪ Characterized by episodic binge eating, followed by purging in the form of vomiting.

▪ The patient may use laxatives, enemas, diuretics.

▪ Patient’s weight may remain normal or close to normal

▪ The patient often views food as a source of comfort.

Bulimia Nervosa
▪ Recurrent episodes of binge eating.

▪ Compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enema or

other medications, or excessive exercise.
▪ Self-evaluation overly influenced by body shape and weight.

▪ Usually within normal weight range, possible underweight or overweight.

▪ Restriction of total calorie consumption between binges, selecting low-calorie foods while
avoiding foods perceived to be fattening or likely to trigger a binge.
▪ Depressive and anxiety symptoms.

▪ Possible substance use involving alcohol and stimulants.

▪ Loss of dental enamel.

▪ Chipped, ragged, or moth-eaten appearance of teeth.

 ▪ basic tests Increased dental caries.

▪ Menstrual irregularities.

▪ Dependence on laxatives.

▪ Esophageal tears.

▪ Fluid and electrolyte abnormalities.

▪ Metabolic alkalosis (from vomiting) or metabolic acidosis (from diarrhea).

▪ Mildly elevated serum amylase levels.

▪ Alternating episodes of binge eating and purging

▪ Anxiety

▪ Avoidance of conflict

▪ Constant preoccupation with food

▪ Abdominal pain/ abdominal distention is experienced after the binge eating

▪ Possible use of amphetamines or other drugs to control hunger

▪ Problems caused by frequent vomiting

▪ Repression of anger and frustration

▪ Russel sign (bruised knuckles due to induced vomiting)

▪ Sporadic, excessive exercise

Assessment and Diagnostic Findings
The following diagnostic tests and assessment cues are commonly used for patients suspected with
eating disorders
▪ Physical and mental status evaluation.

▪ Complete blood count (CBC). The hemoglobin levels are typically normal, although elevations
are observed in states of dehydration; the white blood cell count (WBC) is typically low due to
increased margination, and thrombocytopenia is also observed.
▪ Blood chemistries. Hyponatremia (reflects excess water intake or the inappropriate secretion of
antidiuretic hormone), hypokalemia (results from diuretic or laxative use), hypoglycemia (results
from the lack of glucose precursors in the diet or low glycogen stores; low blood glucose may
also be due to impaired insulin clearance), elevated blood urea nitrogen (renal function is
generally normal except in patients with dehydration, in whom the BUN level may be elevated),
Hypokalemic hypochloremic metabolic alkalosis (observed with vomiting), acidosis (observed in
cases of laxative abuse).
▪ Liver function tests. Liver function test results are minimally elevated, but levels encountered in
patients with active hepatitis are not observed; albumin and protein levels are usually normal,
because although the amount of food intake is restricted, it usually contains high-quality
proteins.
Medical Management
Medical management focuses on weight restoration, nutritional rehabilitation, rehydration, and
correction of electrolyte imbalances.
Nutritional rehabilitation and weight restoration
▪ Clients receive nutritionally balanced meals and snacks that gradually increase caloric intake to a
normal level for size, age, and activity.
Family-based Therapy
 ▪ Individuals with anorexia nervosa may respond best to family-based treatment, also known as
the Maudsley method, an established therapeutic modality for achieving and maintaining
remission from anorexia nervosa.
Cognitive Behavioral
Therapy (CBT)
▪ CBT is an evidence-based, effective treatment for bulimia nervosa (BN); behavioral approaches
to avoiding undesirable eating habits are used, including diary keeping; behavioral analyses of
the antecedents, behaviors, and consequences (so-called ABCs) associated with binge eating and
purging episodes; and exposure to food paired with progressive response prevention regarding
binge eating and purging.
Interpersonal Psychotherapy
▪ It addresses specific issues in the interpersonal arena that create the context for and stimulate
dynamic tensions that spur the patient’s symptoms; these generally encompass such processes
as grief, role transitions, role conflicts or disputes, and interpersonal deficits.

Pharmacologic Management
Electrolyte Supplements
▪ Electrolyte repletion is necessary in patients with profound malnutrition, dehydration, and
purging behaviors; repletion may be done orally or parenterally, depending on the patient’s
clinical state.
Fat-soluble Vitamins
▪ Vitamins are used to meet necessary dietary requirements.

▪ They are utilized in metabolic pathways, as well as in deoxyribonucleic acid (DNA) and protein
synthesis.
Antidepressants, SSRIs
▪ These agents have been reported to reduce binge eating, vomiting, and depression and to
improve eating habits, although their impact on body dissatisfaction remains unclear.
Nursing Assessment
Although anorexia and bulimia have several differences, many similarities are found when assessing.
History
▪ Family members often describe clients with anorexia nervosa as perfectionists with
above-average intelligence, achievement oriented, dependable, eager to please, and seeking
approval before their condition began; clients with bulimia, however, often have a history of
impulsive behavior such as substance abuse, shoplifting, as well as anxiety, depression, and
personality disorders.
General appearance and
motor behavior
▪ Clients with anorexia appear slow, lethargic, and fatigued; they may be emaciated depending on
the amount of weight loss; clients with bulimia may be underweight or overweight but are
generally close to expected body weight for age and size.
Mood and affect
▪ Clients with eating disorders have labile moods that usually correspond to their eating or dieting
behaviors.
Thought processes and content
▪ Clients with eating disorders spend most of the time thinking about dieting, food, and
food-related behavior.
Self-concept
▪ Low self-esteem is prominent in clients with eating disorders.
Nursing Diagnosis
 ▪ Imbalanced nutrition: less than body requirements related to purging or excessive use of
laxatives.
▪ Ineffective coping related to inability to meet basic needs.

▪ Disturbed body image related to being excessively underweight.

Nursing Care Planning
and Goals
▪ The client will establish adequate nutritional eating patterns.

▪ The client will eliminate use of compensatory behaviors such as excessive exercise and use of
laxatives and diuretics.
▪ The client will demonstrate coping mechanisms not related to food.

▪ The client will verbalize feelings of guilt, anger, anxiety, or an excessive need for control.

▪ The client will verbalize acceptance of body image with stable body weight.
Nursing Interventions
▪ Establishing nutritional eating patterns.

✔ When clients can eat, a diet of 1200 to 1500 calories per day is ordered, with gradual increases
in calories until clients are ingesting adequate amounts for height, activity level, and growth
needs.
✔ the nurse is responsible for monitoring meals and snacks and often initially will sit with a client
during eating at a table away from other clients; after each meal or snack, clients may be
required to remain in view of staff for 1 to 2 hours to ensure that they do not empty the stomach
by vomiting.
▪ Identifying emotions and developing coping strategies.

✔ The nurse can help clients begin to recognize emotions such as anxiety or guilt by asking them to
describe how they are feeling and allowing adequate time for response.
▪ Dealing with body image issues.

✔ The nurse can help clients to accept a more normal body image; this may involve clients agreeing
to weigh more than they would like, to be healthy, and to stay out of the hospital; helping clients
to identify areas of personal strength that are not food related broaden client’s perceptions of
themselves.
Evaluation
▪ The client was able to establish adequate nutritional eating patterns.

▪ The client was able to eliminate use of compensatory behaviors such as excessive exercise and
use of laxatives and diuretics.
▪ The client was able to demonstrate coping mechanisms not related to food.

▪ The client was able to verbalize feelings of guilt, anger, anxiety, or an excessive need for control.

▪ The client was able to verbalize acceptance of body image with stable body weight.