Eating disorders and management in detail

1. EATING
DISORDERS
Premnath R
Lecturer,
Govt. College Of Nursing,
Thiruvananthapuram

2. Eating disorders are disorders of eating
behavior deriving primarily from an
overvaluation of the desirability of weight
loss that result in functional medical,
psychological, and social impairment.

3. The two most important eating disorders
are;
• Bulimia nervosa and
• Anorexia nervosa

5. BULIMIA NERVOSA

6. • Bulimia- “ox-hunger”
• Nervosa- “nervous involvement”

7. Definition
Bulimia nervosa is an eating disorder
characterized by binge eating and purging, or
consuming a large amount of food in a short amount
of time followed by an attempt to rid oneself of the
food consumed (purging), typically by vomiting,
taking a laxative or diuretic, and/or excessive
exercise. These acts are also commonly accompanied
with fasting over an extended period of time.
(Barker P)

8. Epidemiological factors
• Cultural: Societal endorsement of weight loss and
dieting
• Gender: Women > men
• Age: Peaks occur at early and late teen years.
• Family patterns: Enmeshed or disengaged
• Socioeconomic class: independent of social class

9. • Prior psychiatric disturbance: Childhood and early-
adolescent anxiety, mood, and obsessive-compulsive
disorders
• Monozygotic to dizygotic ratio - 3:1
• Rural vs. urban: increased with move from rural to
urban setting
• Medical comorbidity: Possible increase with type I
diabetes mellitus

11. Etiology
Biological
• More common in first-degree, biological relatives of
people with bulimia.
• Abnormal levels of serotonin, Brain-Derived
Neurotrophic Factor (BDNF)
• Specific area of chromosome 10p linked to families with
history of bulimia
• There is an association between polymorphisms in the
ERβ (estrogen receptor β) and bulimia.

12. Social
• Media portrayals of an 'ideal' body shape is a
contributing factor to bulimia.
• Family disturbances or conflict
• Sexual abuse
• Learned maladaptive behavior
• Struggle for control or self-identity

13. Types
There are two sub-types of bulimia nervosa:
• Purging type bulimics self-induce vomiting (usually
by triggering the gag reflex or ingesting emetics such
as syrup of ipecac) to rapidly remove food from the
body before it can be digested, or use laxatives,
diuretics, or enemas.
• Non-purging type bulimics exercise or fast
excessively after a binge to offset the caloric intake
after eating.

14. Clinical features

15. • Intense fear of becoming obese
• Persistent sore throat, heartburn
• Eating amount of food larger than what most
people would eat
• Sense of lack of control on binge eating
• Thin, normal, or slightly overweight appearance,
• Frequent weight fluctuations
• Abdominal and epigastric pain

16. • Amenorrhoea
• Fluid and electrolyte imbalances
• Exaggerated sense of guilt
• Feelings of alienation
• Peculiar eating habits or rituals
• Excessive exercise regimen
• Withdrawal from friends and usual activities
• Frequent weighing

17. Callused or scarring on
back of hands and
knuckles. (Russell’s sign)
Tooth staining or
discoloration, loss of
dental enamel, and
increased dental caries

18. • Esophagitis
• Boerhaave
syndrome, a rupture
in the esophageal
wall due to vomiting

19. Complications
Metabolic Hypokalemic alkalosis or acidosis, hypochloremia,
dehydration
Renal Prerenal azotemia, acute and chronic renal failure
Cardiovascular Arrhythmias, myocardial toxicity from emetine (ipecac)
Dental Lingual surface enamel loss, multiple caries, gum
infections
Gastrointestinal Swollen parotid glands, elevated serum amylase levels,
gastric rupture during periods of binge eating, gastric
distention, irritable bowel syndrome, melanosis coli from
laxative abuse
Musculoskeletal Cramps, tetany

20. • Melanosis coli evident from a colonoscopic
image.

21. Diagnosis
• Medical evaluation to rule out upper gastro
intestinal disorder
• Psychological evaluation and BDI (Becks
Depression Inventory)
• History, laboratory investigations (serum
electrolytes, blood glucose, baseline ECG)
• ICD-10 criteria

22. Treatment of Bulimia Nervosa
• Psychiatric hospitalization
• Psychoeducation sessions emphasizing healthy nutrition
• Interpersonal psychotherapy, Psychodynamically
informed psychotherapies, self-psychology, and focal
analytic therapies.
• Psychopharmacologic treatment with SSRI, (Fluoxetine
60 to 80 mg/day), TCAs and Monoamine Oxidase
Inhibitors (MAOIs).

23. Cognitive-Behavioral Therapy
• Done in 4 phases.
• The first focuses on educating patients about bulimia
nervosa, helping them to increase the regularity of
eating and resist urges to binge or purge.
• The second phase uses various structured procedures
and homework assignments to help patients broaden
their food choices and identify and correct
dysfunctional attitudes and beliefs.

24. • Next, patients are taught to identify interpersonal
stressors and deal more effectively with them by
employing more adaptive coping styles.
• Finally, relapse prevention strategies are used to
reduce the likelihood of relapses in the future.

25. NURSING MANAGEMENT
Assessment
• nature and episodes of eating
• type of disorder(purging or non purging)
• inappropriate compensatory behaviors
• self-degradation and depressed mood
• self-induced vomiting
• fasting or excessive exercise, erosion of tooth enamel
• substance abuse or dependence
• body mass index, electrolyte status, complete blood count
• associated psychiatric disorders

26. Possible Nursing Diagnoses
• Imbalanced nutrition less than body requirements
related to refusal to eat
• Deficient fluid volume (risk for or actual) related to self-
induced vomiting; laxative and/or diuretic abuse
• Ineffective denial related to fear of losing the only aspect
of life over which he or she perceives some control
(eating)
• Imbalanced nutrition more than body requirements
related to compulsive overeating
• Disturbed body image related to feelings of
dissatisfaction with body appearance
• Anxiety related to feelings of helplessness.

27. Nursing interventions
• Dietitian will determine number of calories required to
provide adequate nutrition and realistic weight gain.
• Explain to the client that privileges and restrictions will
be based on compliance with treatment and direct weight
gain.
• Do not focus on food and eating.
• Weigh client daily, immediately upon arising and
following first voiding.
• Keep strict record of intake and output.
• Assess skin turgor and integrity regularly.
• Assess moistness and color of oral mucous membranes.
• Stay with client during established time for meals (usually
30 min) and for at least 1 hour following meals.

28. • If nutritional status deteriorates, tube feedings will be initiated.
This is implemented in a matter-of-fact, nonpunitive way.
• Develop a trusting relationship. Convey positive regard.
• Help client to develop a realistic perception of body image and
relationship with food.
• Through positive feedback, help client learn to accept self as is,
including weaknesses as well as strengths.
• Help client realize that perfection is unrealistic.
• Formulate an eating plan that includes food from the required
food groups with emphasis on low-fat intake.
• Plan progressive exercise program.

29. ANOREXIA
NERVOSA

30. • an – lack of
• orexis – appetite
• Nervosa - nervous
origin

31. Definition
Anorexia nervosa (AN) is a psychiatric
disorder with severe physiologic consequences,
characterized by the inability or refusal to maintain
a minimally normal weight. Patients have a
profoundly disturbed body image as well as an
intense fear of weight gain despite being
moderately to severely underweight.

32. Epidemiological risk factors
• Cultural: Societal endorsement of weight loss and dieting
• Gender: Women > men
• Age: Peaks occur at early and late teen years.
• Prevalence: approximately 1% of young women.
• Socioeconomic class: increases with social class.
• Personality role: increases with Cluster C personality type.
• Prior psychiatric disturbance: Childhood and early-
adolescent anxiety, mood, and obsessive-compulsive
disorders
• Monozygotic to dizygotic ratio: 3:1
• Rural vs. urban: Incidence increases with move from rural
to urban setting
• Medical comorbidity: Possible increase with type I diabetes
mellitus

33. Etiology
Genetic causes
• 6-10 % more chance of developing anorexia nervosa
in siblings of diagnosed cases.
A disturbance in the hypothalamic function
Social factors
• High prevalence among female students and in
occupational groups particularly concerned with
weight.
• Influence of mass media, beauty contests

34. Individual psychological factors
• A disturbance of body image
• a struggle for control and a sense of identity
• traits of low self esteem and perfectionism
Familial causes
• Disturbance in family relationships
• over-protection, family members having unusual
interest in food and physical appearance

35. Clinical features
• Voluntarily reduces & maintains unhealthy weight loss
• Insomnia, irritability, sensitivity to cold, withdrawal
from friends
• Drastically reducing food intake
• The body weight is 15% below the standard weight.
• The patient is unable to perceive the body size
accurately.
• Some try to achieve weight loss by inducing vomiting,
excessive exercise, and misusing laxatives.
• Lack of interest in & resistance to therapy
• Refuse to eat with families or in public places

36. • Constantly thinking about food - passion for collecting
recipes, preparing elaborate meals for others while
eating, dispose off food in napkins or hide in pockets,
cut meat into small pieces, spend time rearranging
them.
• Self-injurious behavior
• Variety of electrolyte disturbances, like hypokalemia.
• Ritualistic exercising walking, cycling, aerobics, jogging.
• Rigid & perfectionist personality traits

37. • Adolescents - delayed psychosocial sexual
development
• In adults - decreased interest in sex
• Concealment & avoidance of treatment
• Psychological findings- Preoccupation with body size,
distorted body image, description of herself as fat.
• Physical Examination reveals Wasting, Cold
extremities, Dry skin, Lanugo hair, Bradycardia (50-
60/min), Hypotension, Proximal myopathy

39. Diagnosis
• Laboratory Studies for Patients with Eating
Disorders
• Complete blood count (anemia is
frequent), Electrolytes, Blood urea nitrogen,
creatinine, Thyroid-stimulating hormone, free
thyroxine, Total protein and albumin, Amylase, if
purging occurs Fasting glucose, Electrocardiogram

40. Complications
Related to weight loss:
• General – Myopathy, loss of fat
• BMI < 15 – hospitalization
• Vital signs – Cold intolerance
• Neuropsychiatric – Abnormal taste sensation, mild cognitive
impairment
• Renal –ARF,CRF
• Skeletal – Osteoporosis
• CVS – Peripheral oedema, long QT, Ventricular Arrhythmias
• GIT –delayed gastric emptying, bloating, constipation
• Blood – Anemia, leukopenia
• Metabolic–Hypercholesterolemia, hypoglycemia

41. Related to Rapid Refeeding
Metabolic disturbances that occur as a result of
reinstitution of nutrition to patients who are starved or
severely malnourished.
Related to vomiting/purging
• Metabolic – Hypokalemia,Alkalosis, hypomagnesemia,
Dehydration, Acidosis
• GIT – Inflammation of salivary gland, GI erosion, IBS
• Dental – Enamel loss, Caries
• Renal: ARF
• CVS-Myocardial toxicity
• Musculoskeletal – Cramps, tetany
• CNS – Seizures, EEG changes, neuropathy

42. MANAGEMENT
• Hospitalizations needed in case of:
– Life threatening malnutrition
– Suicidal risks
– Ill-health for several months
– Patients who avoid treatment
– Failure to respond to OP treatment or Day care
– Serious physical complications

43. Weight Restoration
• Restore patients to the ideal healthy range of weight for
age, height, and gender
• Patients above 70 percent of healthy weight can start at
1,500 calories per day, which can be increased 500
calories per day every 4 days during inpatient or partial
hospital treatment or each week in outpatient care.
• Typically, women require a maximum of 3,500 calories
per day, while men may need 4,000 calories or more.

44. • Incorporating a wider variety of foods.
• Encourage eating food from all food groups and eating
a variety of food within each food group.
• Encourage eating family meals and eating out with
family & peers to allow normal social interaction.
• Ensure enough calcium rich foods.
• Ensure an adequate amount of protein, vitamins &
minerals (iron).

45. Medication
• Selective serotonin reuptake inhibitors (SSRIs) or
atypical antipsychotics—
• Antianxiety medications may enable patients to deal
with the anticipatory anxiety of confronting meals.
• Zinc (50 to 100 mg elemental zinc) to improve
weight restoration.
• Appetite stimulants

46. Psychotherapies
• Increasing patient’s own self-awareness and
motivation for change
• Persuading and helping them to recognize, challenge,
and replace their overvalued beliefs regarding the
desirability of weight loss and their phobic fear of
fatness.
• Encourage acceptance of healthy, normal,
individualized body weights and the skills for self-
regulation.

47. • Family involvement is essential, with various
elements of family education, counseling,
instruction, and therapy incorporated into
treatment.
• Interpersonal therapies, family therapies, or
psychodynamically informed psychotherapies

48. NURSING MANAGEMENT
Possible nursing diagnoses are
• Imbalanced nutrition: less than body requirements related
to ingestion of large amounts of food followed by self-
induced vomiting.
• Deficient fluid volume related to abnormal fluid loss caused
by self-induced vomiting.
• Ineffective coping related to feelings of helplessness.
• Anxiety related to lack of control in life situation.
• Disturbed body image/low self-esteem related to unrealistic
expectations (on the part of self and others)

49. Interventions
•If client is unwilling to maintain adequate oral intake,
liquid diet is to be administered via nasogastric tube.
•Explain to client, the details of behavior modification
program.
•Sit with client during mealtimes. A limit (usually 30
minutes) should be imposed on time allotted for meals.
•Client should be observed for at least 1 hour following
meals.
•Client may need to be accompanied to bathroom if self-
induced vomiting is suspected.

50. •Keep strict record of intake and output.
•Strict documentation of intake and output.
•Daily weight monitoring
•Assess skin turgor.
•Assess moistness and color of oral mucous membranes.
•Encourage frequent oral care.
•Establish a trusting relationship.
•When nutritional status has improved, begin to explore
with client the feelings associated with his or her extreme
fear of gaining weight.

51. •Remain calm and provide reassurance of safety.
•Review client’s methods of coping and identify his
strengths and weaknesses.
•Teach client to recognize signs of increasing
anxiety.
•Offer positive reinforcement for independently
made decisions.
•Help client realize that perfection is unrealistic.