Disease Topic: Anorexia Nervosa

Medical Nutrition Therapy

Jacob Baranowski
3/10/16

Anorexia nervosa (AN) is an eating disorder which is believed to stem from many different risk
factors. It can be classified as disordered eating characterized by symptoms such as selfstarvation, extreme weight loss, reduced appetite, and aversion to food. Unlike some disease
states which may be inherently genetic or psychological, it is difficult to determine with certainty
whether the disease is biological or psychological. AN can affect anyone regardless of age or
gender; however, Hudson, Hiripi, and Pope Jr. (4) reported that the prevalence of AN among
women is .9 while the prevalence among men is .3. In addition to this statistic, the incidence of
AN among women has been measured to be nearly eight out of every 100,000 women in the
United States (6). While the research presented on AN will be centralized about the disease
topic, much of the information will be relevant to a case study involving a 19 year old college
female suffering from the disease.
As mentioned above, the incidence of AN among women is eight out of every 100,000 women in
Western countries. Many studies have indicated that the incidence of AN has been relatively
stable since sometime between 1970-1990 but were increasing up until that point (5). The
concepts of fasting and self-starvation have been around for centuries; there are many accounts
of ritualistic approaches to starvation for religious and self-righteous purposes. Fasting was seen
as a righteous way to cleanse the body and soul of toxins to make one pure for spiritual purposes.
Conversely, fasting was also used as punishment by some to purge the body of evil. While the
means for fasting have varied from culture to culture, the basis has remained constant over time.
Today, the practice of self-starvation has taken on a new approach in addition to age-old
practices. Perhaps some of the earliest cases of diagnosable AN were recorded by Gull of
England and Leseque of France in the late 1800s. It was initially thought that AN was merely
psychogenic in nature; that people could be cured of the disease by deterring them from their
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self-inflicting behaviors (2). As research has advanced, there have been biological findings that
indicate the disease may have hereditary tendencies which only serve to complicate the etiology
of the disease.
There are many theories which serve to explain the pathogenesis of AN; however, there are three
recurring factors which seem to explain the cause. These factors are individual, familial, and
cultural in nature. Individual factors are generally psychological, such as depression, anxiety,
obsessive-compulsive disorder, and body dysmorphia to name a few. Familial factors are
biological in nature, such as heredity and genetics. Cultural factors are the pressures found within
the community and media which effect at-risk individuals. While all three vary widely, direct
linkages have been found between them and patients with AN. For example, the prevalence of
depression in patients with AN is 68%, showing a strong correlation between the two (3).
Similarly, females were at an increased risk of developing AN by a factor of 11.3 if they were
related to someone with the disease, which demonstrates a genetic predisposition for developing
the disease (c). The prevalence of media and advertising may also play a role in how individuals
view themselves. Marketing mindsets of thin is in shape the way advertisements and diets are
formulated, with waistlines shrinking on the models on display and fad-diets becoming
ubiquitous. The stigma placed on larger individuals may reduce the self-esteem of the effected
individuals and redirect the minds of children who are exposed to these ads towards restrictive
eating habits. Smolak (8) determined that females begin expressing concerns about weight and
body image by age six, with up to 60% of a sample of females between the ages of 6-12
expressing the same concerns. This demonstrates the toxicity of the pressures that are developed
culturally, especially in Western countries, and how it can work its way into younger populations.

Another major factor that increases the risk of developing AN is puberty. Puberty is marked as
the time in which the most physiological changes are occurring throughout the body. During
puberty, females may have up to a 40% increase in body weight (5). Because there are many
physiological, cognitive, and social changes occurring at this time, the stress induced has been
correlated with increased risk for developing an eating disorder. This is of utmost concern
because of the many other clinical manifestations this can have on the individual. Some of these
include bradycardia, hypotension, dehydration, osteoporosis, fatigue, and chronic illness.
Because AN is depriving the body of food and nutrients, the body slowly deteriorates. For a 19
year old female, this is especially detrimental because of the long-term consequences that would
play out over the lifespan. For example, decreased food consumption would be directly related
to decreased calcium and vitamin D consumption. Lower calcium consumption increases bone
brittleness, which puts the individual at risk for developing osteoporosis later on in life. Because
of the weaker bone structure, the individual may be susceptible to increased risk of bone injuries
early on, especially if an active lifestyle is maintained. Osteoporosis will affect them later in life,
which puts them at risk for developing bone fractures from potentially menial tasks. Regardless
of the outcomes, it will be difficult to heal efficiently without adequate macro- and micronutrient
consumption.
Limited food intake can also negatively affect the heart. The heart maintains its health primarily
through electrolyte balance. The four essential electrolytes that maintain heart health and fluid
balance are magnesium, calcium, potassium, and sodium; all of which are found in the foods we
eat and the fluids we drink. However, this is limited by the restricted food intake and
compounded by dehydration. When the body is dehydrated, the electrical impulses that the heart
sends out can become irregular and an arrhythmia may develop. A long term arrhythmia may be
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treatable with medication; however, it is an issue that will be life-long. Many of daily activities
can be completed without hindrance from heart arrhythmias, but with arrhythmias come
increased risk of stroke and heart attack which may shorten her life even more than AN.
Another issue that may compound the problem stems from a decrease in metabolism. When
food and nutrient intake becomes insufficient, the body goes into a state of shock. This state of
shock triggers the brain to believe the body is malnourished and starved. Because of this,
metabolism slows down to maximize the food and nutrients that are taken in. Most food is
converted into glycogen and then stored in the muscles for energy. Glycogen is the bodys main
source of energy because it is so readily available and easy to burn, with fat being a secondary
source once glycogen is depleted and eventually protein when fat is unavailable. When someone
with severe AN consumes food, the body is under the impression that it is starved, so the food is
converted into fat as opposed to glycogen. While fat may not be the easiest form of energy to
burn, it does provide sustained energy. Muscles may also atrophy as the bodys turns to protein
stores for energy as well. Due to the slower metabolism, people will generally feel run down,
fatigued, sluggish, and bloated. These symptoms may trigger a negative response in the patient
which can exacerbate the problem further. Chronic fatigue syndrome and chronic illness are not
uncommon, which will result in feeling worn out and depleted doing menial tasks. Not only
does this affect the person physically, but it can affect them mentally and emotionally as well.
While AN can be a complex and multifaceted disease, diagnosing it is a little bit easier. There
are many symptoms associated with AN as mentioned earlier; however the Diagnostic and
Statistical Manual of Mental Disorders (DSM) was developed by psychiatric physicians as a part
of the American Psychiatric Association (APA) to help effectively diagnose mental disorders.
The APA developed a list of criteria for many different mental disorders as a guideline in order to
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mitigate and care for many disorders. By having a list of the symptoms, physicians, clinicians,
and dietitians can effectively treat the problem(s) specific to each patient. The DSM has proven
effective due to the regularity at which it is updated. The most current model, the DSM-5, was
last updated in 2013, which has helped represent the symptoms and disorders more accurately.
According to the DSM-5, the main criteria for diagnosing AN are as follows: (a) consistent
restriction of food, nutrient, and caloric intake resulting in reduced body weight relative to the
minimum requirements for age, gender, health, and developmental trajectory, (b) an extreme fear
of fat or weight gain, or consistent behaviors which inhibit weight gain although already
undernourished or having low body weight, and (c) disturbed experience in the way one views
their body image, consistent downplaying of the seriousness associated with low body weight,
and negative influence of body weight and size on self-evaluation efforts. These criteria are
widely accepted and can help properly diagnose and care for those with AN (1)
There are extensive resources available for the treatment of anorexia nervosa; however, most lie
in therapy and counseling. A 19 year old college female has access to a wide variety of treatment
options. Universities typically offer counseling and psychological services to assist students in
coping with the stress of being in a new environment. This can extend into psychiatric
examinations, alcoholics anonymous programs, support groups, or nutritional consultations. The
first step in treatment for someone with AN is admitting there is a problem and actively seeking
out help. Because there is a stigma with eating disorders, denial, shame, and reluctance are often
incurred by the afflicted person. It is crucial for those reaching out to the afflicted person are
especially careful to be non-confrontational, non-judgmental, and supportive. There are many
boundaries which can be easy to cross, so it is of utmost importance to realize and respect those
boundaries. If the afflicted person seeks out help, therapy may be a great place to start. Some
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universities may have therapists specialized in eating disorders; however, seeking out community
outreach programs may be necessary if this is not the case. The main type of therapy used in
these instances is cognitive-behavioral therapy. This type of therapy seeks to determine the
triggers that fuel negative or unrealistic thoughts about oneself and food consumption and how to
combat them. It may also include nutrition education, weight management, and relaxation skills.
In addition to therapy is nutrition counseling, which seeks to educate the patient about healthy
eating patterns and how to incorporate foods into the diet that will be beneficial in maintaining a
healthy weight. While both of these interventions require professionals, self-help can also be
beneficial in eliminating AN. This may include developing healthier coping skills or improving
self-body image through practices such as challenging negative thinking or making lists of other
positive attributes to reflect on. Writing, journaling, or talking to a friend are all productive
activities that can help alleviate AN (7).
The effectiveness of these interventions depends on each individual. For a 19 year old college
female, body image may play a key role in self-affirmation. Talking to a professional may have
a more lasting impact than self-help. Many times having somebody to talk and listen to can be
the biggest step forward in combatting AN. Reformulating how one may see his or herself
through therapeutic practices is important in effective rehabilitation. A common symptom
associated with AN is having a feeling of control, so having more structure in a diet plan outlined
by a professional may be beneficial. Self-help can be viewed with skepticism; unhealthy coping
habits such as exercise addiction may develop in place of the eating disorder. While adequate
nutrients may be consumed, becoming fixated on a habit such as excessive exercise can be just
as detrimental to ones health and body image. It is important to take the necessary steps to

figure out which intervention or combinations of interventions are going to be most beneficial for
the afflicted individual.
If left untreated, AN can manifest into many other health problems and cognitive issues; in the
most severe cases, death may result. A 21 year study conducted by Zipfel, Lowe, and Reas (9)
concluded that AN can be successfully treated; out of the 84 patients who were admitted to the
hospital with severe AN, over 50% of patients reached a full-recovery while just over 10% still
retained diagnostic criteria of AN and 15% had died from AN related causes. This study should
demonstrate that majority of cases are treatable with appropriate measures. In some instances,
AN may develop into bulimia nervosa or other forms of eating disorders.
Current issues with anorexia are primarily as a result of the surrounding environment. As
mentioned at the beginning of this paper, the way that culture portrays individuals in idealistic
settings and proportions severely distorts the reality of the world. The media is one of the
biggest culprits in this battle; however, there are many public movements to abolish traditional
marketing and advertising strategies. There is a push for plus-size clothing to be distributed
more equally among businesses, and positive self-body image is encouraged globally. There are
movements among college campuses as well, such as the Celebrate Every Body campaign at
Indiana University alone. These initiatives can help combat stigmas and negativity often
associated with eating and body image. Another issue revolves around the accessibility of food.
As the rate of urbanization has increased globally, the introduction of areas known as food
deserts has increased proportionally. Overpopulation is a problem that is beginning to take hold
in current times, and there is a high demand to provide enough food to feed everyone. This
results in a push for affordable food, which often means highly proceed, calorie-dense foods as
opposed to healthful food options. Because there may be limited availability of fresh foods to
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consume, fast food options flourish. If people are unwilling to eat unhealthy options or cannot
afford healthful alternatives, restrictive eating patterns may develop which can manifest into AN
or another eating disorder. While this may seem like a farfetched outcome, it does lie within the
realm of possibility.
In summary, AN is an eating disorder classified primarily by restrictive eating behaviors.
Incidence has been increasing from first known accounts until the 1970s, but has since leveled
off. AN can be explained by three main factors: individual, familial, and cultural. Individual
factors may stem from psychological manifestations, whereas familial is genetic and cultural is
the environment surrounding individuals. AN can cause a multitude of problems and health
implications that not only affect the individual while they have the disease, but throughout the
life cycle long after treatment in some instances. The APA has developed a list of criteria for
diagnosing and caring for AN and other associated eating disorders which has been revised to
assist physicians, clinicians, and dietitians in optimizing treatment plans for specific patients.
There are many treatments available for combatting AN, especially through services typically
provided through college campuses. While some treatments rely on professionals, self-help may
be just as effective depending on the individual; precautions should be taken to prevent relapse
and/or other psychosocial habits in place of AN. While severe cases may result in death, a 21
year study has shown that 50% of patients admitted to a hospital with severe AN can make a full
recovery, which is a positive step forward in reactionary practices.

Works Cited
1) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2) Bemporad JR. Self-starvation through the ages: reflections on the pre-history of anorexia
nervosa. Int J Eat Disorder 1995;19(3):217-237
3) Garner DM. Pathogenesis of anorexia nervosa. Lancet 1993;341(8861):1631-1635
4) Hudson JI, Hiripi E, Pope HG, Jr., Kessler RC. The prevalence and correlates of eating
disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.
5) Schmidt U. Epidemiology and aetiology of eating disorders. Psychiatr 2005;4(4):5-9.
6) Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence
and mortality rates. Curr Psychiatry Rep. 2012;14(4):406-414
7) Smith M, Segal J. Eating disorder treatment and recovery. Retrieved March 10, 2016,
from http://www.helpguide.org/articles/eating-disorders/eating-disorder-treatment-andrecovery.htm#treatment
8) Smolak, L. Body image: a handbook of science, practice, and prevention. New York: Guilford
2011.
9) Zipfel S, Lowe B, Reas D, Deter H, Herzog W. Long-term prognosis in anorexia nervosa:
lessons from a 21-year follow-up study. Lancet 2000;355(9205):721-722

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