Eating Disorders?

Eating disorders 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

The most common eating disorders found in the mental health setting are anorexia nervosa, bulimia
nervosa, binge-eating disorder, pica, rumination disorder, avoidant or restrictive food intake disorder
(ARFID), and other specified feeding or eating disorder (OSFED).
 Anorexia Nervosa. Anorexia nervosa 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. Bulimia nervosa, 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). Binge-eating disorder is another eating disorder characterized by
recurrent episodes of binge eating but it is not associated with the recurrent use of
inappropriate compensatory behaviours 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. Pica 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. Rumination disorder 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). Avoidant or restrictive food intake disorder
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). Other specified feeding or eating disorders
or (OSFED) 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.

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Causes
A specific cause for eating disorders is unknown; initially, dieting may be the stimulus that leads to their
development.
 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.
 Developmental factors. Onset of anorexia nervosa usually occurs during adolescence or young
adulthood; some researchers believe its causes are related to developmental issues.
 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.
 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.

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.

Clinical Manifestations
The following are the signs and symptoms of eating disorders:
Symptoms of anorexia nervosa include:
 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.

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Symptoms of bulimia nervosa include:
 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.

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.

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  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. Interpersonal psychotherapy (IPT) 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
Several classes of drugs have been studied, but few have shown clinical success.
 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 Management for Eating Disorders

Nursing care for a client with eating disorder include the following:
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.
 Though 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
Nursing diagnoses for clients with eating disorders include the following:
 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.

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Nursing Care Planning and Goals
Nursing care plans and goals for clients with eating disorders:
 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
Nursing interventions for clients with eating disorders are:
 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 broadens client’s perceptions of themselves.

Evaluation
Goals are met as evidenced by:
 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.

Documentation Guidelines
Documentation in a client with eating disorder include:
 Individual findings, including factors affecting, interactions, nature of social exchanges, specifics
of individual behavior.
 Cultural and religious beliefs, and expectations.
 Plan of care.
 Teaching plan.
 Responses to interventions, teaching, and actions performed.
 Attainment or progress toward the desired outcome.