EATING DISORDERS

Eating disorders can be viewed on a continuum: the anorexic eats too little, the bulimic eats chaotically, and the obese person eats too much. Eating disorders overlap: 50% of clients with anorexia exhibit bulimic behavior, 35% of normal-weight clients with bulimia have a history of anorexia. More than 90% of clients with eating disorders are female.

ANOREXIA NERVOSA
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 Steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists 85% or less of expected body weight Amenorrhea Preoccupation with food and food-related activities Restricting subtype loses weight dieting, fasting, or excessively exercising Binge eating and purging subtype engages in binge eating followed by purging

Onset and Clinical Course Typically begins between 14 and 18 years of age Ability to control weight gives pleasure to the client Client may feel empty emotionally and be unable to identify or express feelings As illness progresses, depression and labile moods are common Client is socially isolated, mistrustful of others; may believe that others are trying to make her fat and ugly

Long-term studies show: 30% recover 30% partially improve 30% remain chronically ill 10% die of anorexia-related causes

BULIMIA NERVOSA
Characterized by recurrent episodes of binge eating, then compensatory behaviors to avoid weight gain (purging, use of laxatives, diuretics, enemas, emetics, fasting, excessive exercise) Binge eating is done in secret Client recognizes behavior as pathologic, causing feelings of guilt, shame, remorse, or contempt Usually normal weight

Onset and Clinical Course Begins at about age 18 or 19 Binge eating begins after an episode of dieting Between binges, eating may be restrictive Food is hidden in the car, desk at work, and secret locations around the house Behavior may continue for years before it is discovered Long-term studies show: 50% recover 20% continue to be bulimic 30% have episodic bouts of bulimia

RELATED DISORDERS
Rumination disorder, pica, and feeding disorder are diagnosed in infancy and childhood Binge eating disorder is binge eating without regular use of inappropriate compensatory behaviors Night eating syndrome (NES) is morning anorexia, evening hyperphagia (consuming 50% of daily calories after the last evening meal), and nighttime awakenings (at least once a night) to consume snacks

MORBID OBESITY
Diet and Inactivity. Genetics Psychological factors. Family/social factors. Definition Obesity means having a BMI (body mass index, a ratio of weight to height) of 30 or higher. Severe obesity -- also called morbid obesity -- begins at a BMI of 40. That's a weight of about 235 for a person who is 5 feet 4 inches tall and a weight of about 280 for a person 5 feet 10 inches tall. Stress Bored Angry Depression

Health Concerns
Directly affects the structure of the heart Left ventricular hypertrophy high blood pressure congestive heart failure chest pain.

ETIOLOGY
Biologic Factors Genetic vulnerability Disruptions in the nuclei of the hypothalamus relating to hunger and satiety (satisfaction of appetite) Neurochemical changes are seen, but it is not known if these changes cause the disorders or are a result of eating disorders

Developmental Factors Struggle to develop autonomy and identity Overprotective or enmeshed families Body image disturbance and body image dissatisfaction Separation-individuation difficulties

Family Influences Families without emotional support Physical neglect, sexual abuse, or parental maltreatment Little care, affection, and empathy Excessive paternal control, unfriendliness, or overprotectiveness

Sociocultural Factors Media Pressure from peers, parents, and coaches

CULTURAL CONSIDERATIONS
Eating disorders are more prevalent in countries where food is prevalent and beauty is linked to being thin Immigrants from cultures where eating disorders are rare may develop eating disorders as they assimilate the thin ideal body image

Eating disorders are equally common among Hispanic and white women but are less common among African American and Asian women

TREATMENT: ANOREXIA NERVOSA

Setting depends on severity of illness: Medical management; risk of suicide is significant Weight restoration Nutritional rehabilitation Rehydration Correction of electrolyte imbalances Supervised access to a bathroom to prevent purging

Psychopharmacology
Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) can promote weight gain. Olanzapine (Zyprexa) because of its effect on body image distortions Fluoxetine (Prozac) prevents relapse. Psychotherapy Family therapy Individual therapy

TREATMENT: BULIMIA NERVOSA

Most clients are treated on outpatient basis: Cognitive-behavioral therapy Psychopharmacology Antidepressants: desipramine (Norpramin), imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), phenelzine (Nardil), and fluoxetine (Prozac)

TREATMENT: MORBID OBESITY

Therapy for psychological issues Weight control and exercises Patient and family teaching

APPLICATION OF THE NURSING PROCESS

Assessment History: Anorexia: model child, no trouble, dependable (before onset of anorexia) Bulimia: eager to please and conform, avoid conflict, but may have history of impulsive behavior

General appearance and motor behavior: Anorexia: slow, lethargic, even emaciated; slow to respond to questions, difficulty deciding what to say, reluctant to answer questions fully; often wear baggy clothes; limited eye contact; unwilling to discuss problems or enter treatment Bulimia: normal appearance, open and talkative

Mood and affect: Anorexia: sad and anxious, seldom smile or laugh Bulimia: initially cheerful but express intense emotions of guilt, shame, and embarrassment when discussing binging and purging behaviors

Thought processes and content: spend most of the time thinking about food, dieting, food-related issues; body image disturbance is delusional Anorexia: paranoid ideas about their family and health care professionals being the enemy, trying to make them fat

Sensorium and intellectual processes: generally alert, oriented, intact; exception is the severely malnourished client with anorexia, who may have mild confusion, slowed mental processes, and difficulty with concentration and attention

Judgment and insight: Anorexia: very limited insight and poor judgment about health status Bulimia: insight into the pathologic nature of their eating behavior but feel out of control and unable to change that behavior

Self-concept: low self-esteem, see themselves as powerless, helpless, and ineffective Roles and relationships: Anorexia: may have failing grades in school, in sharp contrast to previous high-level performance; withdrawal from peers Bulimia: ashamed of binging and purging, hides it from others; the amount of time spent buying and consuming food can interfere with role performance

Physiologic and self-care considerations: exhaustion, trouble sleeping, sores in the mouth, dental problems

Data Analysis
Nursing diagnoses may include: Imbalanced Nutrition: Less Than/More Than Body Requirements Ineffective Coping Disturbed Body Image

Other diagnoses such as Deficient Fluid Volume, Constipation, Fatigue, and Activity Intolerance may be indicated Outcomes: Establish adequate nutritional eating patterns Eliminate use of compensatory behaviors such as laxatives, enemas, diuretics, and excessive exercise Demonstrate nonfood-related coping mechanisms Verbalize feelings of guilt, anger, anxiety, or excessive need for control

Verbalize acceptance of body image with stable body weight

Intervention Establishing nutritional eating patterns Helping client identify emotions and develop coping strategies Dealing with body image issues Client and family education

Evaluation Evaluation may involve use of an assessment tool to measure progress Body weight within 5% to 10% of normal No medical complications from starvation or purging

COMMUNITY-BASED CARE
Hospital admission is indicated only for medical necessity: Dangerously low weight, electrolyte imbalances, or renal, cardiac, or hepatic complications; clients who cannot control the binge/purging cycle

Community settings include partial hospitalization or day treatment programs, individual or group outpatient therapy, and self-help groups

MENTAL HEALTH PROMOTION Educate parents, children, and young people about strategies to prevent eating disorders Early identification and appropriate referral Routine screening of young women for eating disorders

SELF-AWARENESS ISSUES Feelings of frustration when client rejects help Being seen as the enemy if nurse must ensure the client eats Dealing with own issues about body image and dieting