Feeding & Eating

Disorders
Psychiatric Mental Health Nursing
 Objectives
• Describe the clinical presentation of
anorexia nervosa, bulimia nervosa,
obesity, and binge eating disorder
• Identify nursing diagnoses and
realistic outcome criteria
• Recognize therapeutic interventions
• Evaluate the effectiveness of care

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 Objectives
• Recognize the risk factors for
refeeding syndrome.
• Apply practice standards to regain
physiological integrity and
adaptation.

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 All Eating Disorders
• Must be differentiated from:
– Mood disorders
– Personality disorders
– Thought disorders
– Obsessive compulsive disorder
– Substance-related disorders
– Medical disorders

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 Epidemiological Factors
• Prevalence rate of anorexia nervosa
in the U.S. is about one percent.
• Anorexia nervosa occurs
predominantly in girls and women
ages 12 to 30 years.

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 Epidemiological Factors
• Bulimia nervosa is more prevalent
than anorexia nervosa, with
estimates of up to 4 percent of
young women being affected.
• Onset occurs in late adolescence or
early adulthood.
• More young men are being diagnosed.

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 Epidemiological Factors
• 68.5 percent of adult Americans are
overweight
• 35 percent of these are in the obese
range
• Obesity has been defined as a body
mass index of 30 or greater.

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 Biological Etiologies
• Hypothalamus contains the appetite regulation
center; regulates the body’s ability to recognize
hunger and satiety
• Low serotonin & norepinephrine in bulimia nervosa
• Low dopamine: role in obesity and binge eating
• Gene Links: twin studies (56% concordance rate in
anorexia)
• K Wang, H Zhang, C S Bloss, V Duvvuri, W Kaye, N J Schork, W Berrettini, H Hakonarson.
(2010) A genome-wide association study on common SNPs and rare CNVs in anorexia
nervosa. Molecular Psychiatry, 2010; DOI: 10.1038/mp.2010.107

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 Neurobiological/
Neuroendocrine
• Low levels of cholecystokinin found in bulimia
• Elevated cerebrospinal fluid cortisol levels
• Dysregulation in dopamine with anorexia
nervosa
• Anorexia may be associated with high levels
of endogenous opioids in cerebrospinal fluid,
which contribute to denial of hunger

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 Sociocultural Theories
• Societal values of being thin
• Influence of role conflict,
vulnerability to opinions of others in
adolescence
• Lack of approval

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 Psychological Model
• Issues of control in anorexia and
affective instability with poor
impulse control in bulimia
• Childhood trauma (abuse)

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 Sociocultural Models
• Cultural ideal is thinness
– “You never can be too
thin or too rich.”
Pro Ana websites
• $5 billion industry
• 50% of U.S. women are on
a diet

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 Anorexia Nervosa:
Assessment
•Prolonged loss of appetite
•Intense fear of gaining weight
•Gross distortion of body image
•Preoccupation with food and
refusal to eat
Weight loss >15% of expected
weight

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 Anorexia Nervosa:
Assessment
• Two types:
– Restricting Type: has not engaged in
binge eating or purging behavior during
last 3 months; dieting, fasting, extreme
exercise to accomplish weight loss
– Binge eating/Purging Type: engages in
binge eating or purging behavior during
last 3 months (diuretics, laxatives,
enemas, vomiting)
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 Anorexia Nervosa:
Assessment
• Current Severity:
1. Mild: BMI equal to or greater than
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2. Moderate: BMI 16-16.99
3. Severe: BMI 15-15.99
4. Extreme: BMI less than 15

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 Anorexia Nervosa
– Mortality Rates
• For anorexia after 10 years it is 6-
7%, and after 20-30 years 18-20%
• Mortality ranges from 5-15%, the
highest mortality of any psychiatric
disorders.
• Suicide occurs in 2% of the population

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 Psychodynamic theory
• Two P’s
– Powerlessness
– Perfectionism

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 Perfectionism
• Poor self-esteem: dependent upon
opinions of others
• Worth can only be measured by
accomplishments
• Never really “good enough”
• Will develop the “perfect body” by
controlling food

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 Powerlessness
• See themselves as inadequate and
powerless

• Lack of control

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 Pursuit of Thinness
• Body image disturbances
• Pride
• Become withdrawn; depressed mood
• Isolate
• Unable to identify hunger and satiety
• Lack of awareness
• Identity disintegrates

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 Cognitive Distortions

• Overgeneralization: “I was happy at a

size 6. I must get back to that
weight.”
• All-or-nothing: “If I allow myself to
gain weight, I will blow up like a
balloon.”
• Personalization & self-reference:
“People won’t like me unless I’m thin.”
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 Cognitive Distortions

• Emotional reasoning: “When I am

thin, I feel powerful.”
• Magnification: “If I gain weight, my
weekend will be ruined.”

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 Physical Features
• Skeletal muscle atrophy and atrophy of breast
tissue
• Amenorrhea
• Lanugo on face and body
• Dry, brittle hair
• Hypothermia
• Bradycardia, hypotension
• Cachexia
• Malnutrition

anorexia
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 Physical Features

• Bowel distention, edema

• Osteoporosis
• Growth retardation
• Dizziness, confusion
• Metabolic changes

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 Food Behaviors
• Skips meals or takes only tiny portions
• Ritualistic ways
• Disgusted with food formerly liked
• Low fat food
• Diet soda
• Obsessed with food
• Binging and purging
• Hiding and disposing of food
• Lying about food intake

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 Bulimia Nervosa
• Recurrent episodes of uncontrolled, compulsive,
rapid ingestion of large quantities of food over a
short period (bingeing)
• Episode is followed by compensatory behaviors to
rid the body of excess calories (self-induced
vomiting or misuse of laxatives, diuretics, or
enemas)

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 Bulimia Nervosa
• Fasting or excessive exercise may
occur.
• Usually maintain a normal weight
range, or slightly underweight or
overweight.
• Depression, anxiety, substance abuse
are common.

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 Usual Course of Bulimia
Nervosa

• Chronic and intermittent over a

period of many years.
• Binge periods alternate with periods
of restrictive eating, complicating
diagnosis and treatment.

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 Bulimia Nervosa
• May have had one or more suicide attempts
• Perceive their families as dysfunctional and
controlling
• Unduly influenced by body shape and weight
• Morbid fear of being fat and weight gain
• About 10% are within their expected body
weight; 33-50% have hx. of being overweight;
10-30% have previous hx. of anorexia
• Report significant impairment in functioning

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 Bulimia Nervosa:
Assessment
• Salivary gland enlargement
• Enamel erosion
• Esophagitis
• Dysrhythmias
• Diarrhea
• Biochemical changes

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 Signs and Symptoms
– Dental cavities
• Erosion of tooth enamel and discoloration
due to stomach acid.

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 Psychosocial Impact
• Perceived by others as perfect
• Depression
• Childhood trauma
• Parental obesity
• Self-worth issues

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 Binge Eating Disorder
• Recurrent episodes of eating
significantly more than most people
would eat in a similar period of time.
• Occurs at least once a week for 3
months.
• Most common eating disorder;
affects women twice as often as men.

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 Binge Eating Disorder
• Approximately 50-75% of people
seeking medical attention for severe
obesity have a binge eating disorder.
• The individual does not engage in
behaviors to rid the body of excess
calories.
• 50% have a history of depression.

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 Obesity
• Plays a role in binge eating disorder
• Does not engage in behaviors to rid
the body of excess calories
• BMI of 30.0 or greater (WHO)
• Increase in morbidity and mortality

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 Predisposing Factors to
Obesity
• Genetics
• Lesions in hypothalamus
• Hypothyroidism
• Lifestyle
• Stress – increased cortisol
• Depression

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 Assessment Guidelines
for Eating Disorders
• Complete H & P: medical and psych
• Explore patient’s perceptions
• Eating habits and history of dieting
• Methods used to achieve control
• Value attached to specific weight
• Mental status exam

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 Assessment Guidelines
• Interpersonal and social functioning
• Occupational functioning
• Family system
• Nutritional assessment
• Oral assessment
• Physical exam

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 Nursing Diagnoses for
Eating Disorders
• Imbalanced nutrition: less than or
more than body requirements
• Deficient fluid volume (risk for or
actual)
• Disturbed body image
• Low self-esteem

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 Nursing Diagnoses
• Anxiety (moderate to severe)
• Ineffective denial
• Risk for injury
• Powerlessness

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Outcomes (Anorexia and
Bulimia)
• Has achieved and maintained at least
80% of expected body weight
• Vital signs, blood pressure, lab
studies are within normal limits
• Verbalizes importance of adequate
nutrition

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Outcomes (Anorexia and
Bulimia)
• Establishes a healthy pattern of
eating.
• Verbalizes knowledge of
consequences of fluid loss from self-
induced vomiting.
• Verbalizes triggers that precipitate
anxiety & demonstrates coping skills.

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Outcomes (Obesity/BED)
• Establishes a healthy pattern of
eating for weight control, and weight
loss toward a desired goal is
progressing.
• Verbalizes plans for future
maintenance of weight control.

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TREATMENT OF EATING
DISORDERS

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 Therapeutic Alliance
• Pt. must trust the staff in order to participate
– Express support and acceptance
– Communicate that you respect ability to make healthy
and effective choices if presented with choices in an
appropriate way
– Empathize understanding and praise for positive
efforts
– Provide hope

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Therapeutic Alliance
• Promote positive self-concept and
perceptions of body image
• Cognitive behavioral therapy
• Help patient to restructure eating to
interrupt cycle of eating and purging
• Treat comorbid disorders
• Structure milieu: observation during and
after meals; health teaching; psychotherapy
• SSRIs can be helpful
• Monitor activity level

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 Planning and
Implementation
• Hospitalization may be necessary:
-Malnutrition, dehydration
-Electrolyte imbalance
-Cardiac arrhythmia or bradycardia
-Hypothermia, hypotension
-Suicidal ideation

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 Planning &
Implementation
• Nursing care is directed at restoring
nutritional/ fluid balance.
• Emphasis is placed on helping the
client gain control over life stressors.
• Self-esteem and positive self-image
are promoted in ways other than
appearance.

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 Client and Family
Education
• Nature of the illness
-symptoms
-causes
-effects of disorders on physical and

emotional status

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 Client and Family
Education
• Management of illness
-principles of nutrition
-ways to feel in control of life
-expression of feelings, fears
-alternative coping strategies
-relaxation techniques

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 Client and Family
Education
• Support services
-Overeaters Anonymous
-Weight Watchers
-National Association of Anorexia
and Associated Disorders
-National Eating Disorders Assoc.

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 Evaluation

• Evaluation of the client requires

reassessment of behaviors for which
the client sought treatment.
• Behavioral change will be required by
client and family members.

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 Refeeding Syndrome
• Prolonged fasting: the body conserves muscle
and protein breakdown by switching from
ketone bodies to fatty acids as the main energy
source
• The liver decreases its rate of gluconeogenesis
thus conserving muscle and protein
• Intracellular minerals become severely depleted
during this period
• Insulin secretion is suppressed

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 Refeeding (cont.)
• During refeeding, insulin secretion resumes
resulting in increased glycogen, fat and
protein synthesis
• Refeeding increases the basal metabolic rate
• Syndrome can occur at the beginning of
treatment for anorexia nervosa when patients
are reintroduced to a healthy diet
• Shifting of electrolytes and fluids increase
cardiac workload and heart rate, which can
lead to acute heart failure
• Must refeed SLOWLY; may start with liquid
diet via NG feedings
• 54
 Refeeding (cont.)
• Closely monitor the refeeding rate
• Start slowly, at a rate that delivers 15 to 20
kcal/kg/day (about 1,000 kcal/day for adults) for
the first 1 to 3 days, before gradually advancing to
the desired daily levels over 5 to 7 days.
• Advance nutritional support when the serum
electrolytes are close to the normal range or are
actively being replaced.
• The client will gain no more than 1-2 pounds during
the initial week of refeeding.

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Treatment: Anorexia
• Involve client in establishing target
weight and interventions to achieve
• Negotiate food intake
• Supervise meals
• Limit discussion about food: focus is on
emotional issues
• Antidepressant therapy
• CBT

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 Treatment: Bulimia
• Help client interrupt the binge-purge
cycle and regain control.
• Help client become aware of factors
that result in binge eating.
• Learn new cognitive coping techniques
to help control binge eating.
• Antidepressant therapy

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 Overall Tx. Goals
• Medical stabilization
• Nutritional rehabilitation and weight
restoration
• Healthy eating patterns
• Able to recognize hunger and satiety
• Reduce binge eating and purging

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 Overall Tx. Goals
• Improve thinking patterns
• Restore normal exercise patterns
• Family therapy: to open up
communication and deal with conflicts
• Encourage expression of feelings
about stressful issues

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 Overall Tx. Goals
• Learn to enjoy food
• Eat at a table and make mealtime a
pleasant experience
• Eat with utensils to help client slow
down
• Eat frequent, small meals with snacks

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 Overall Tx. Goals
• SSRI antidepressants used to
improve weight gain and decrease
depressive symptoms
• Low dose neuroleptic drugs are
prescribed to manage anxiety and
severe obsessive thinking (Zyprexa)

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 Examples of Evaluative
Measures
• Client did not purge after scheduled
meals during hospital stay.
• Client identified 2 coping skills to
deal with increased anxiety.
• Client participated in group therapy
daily.
• Client ate 5 small meals each day.

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Medications for Obesity
• FDA-approved, 2012:
1. Lorcaserin (Belviq)
2. Phentermine/topiramate (Qsymia)
Anorexiants: high abuse potential;
withdrawal can result in rebound
weight gain; short-term use only

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