Eating Disorders Presented by Janice Hermann, PhD, RD/LD OCES Adult and Older Adult Nutrition Specialist Eating Disorders Eating disorders are considered medical illnesses diagnosed based on psychological, behavioral, and physiologic characteristics. Eating disorders can have considerable impact the health of affected individuals, and can be life-threatening. Who Is At Risk It is difficult to determine the number of people with eating disorders because conditions may exit for some time before they are diagnosed. Many people go undiagnosed because of the secrecy and sensitivity of the behaviors. Who Is At Risk The greatest incidence of eating disorders is among women; however, men also suffer from eating disorders. The incidence of eating disorders, particularly bulimia nervosa, is also quite common among both male and female athletes. Classifications In general, eating disorders are classified into three types: anorexia nervosa bulimia nervosa eating disorders not otherwise specified (EDNOS) including binge eating disorder Characteristics Anorexia nervosa is characterized by exaggerated desire for thinness. Symptoms include: refusal to maintain a body weight above a standards minimum (less than 85% of expected weight) intense fear of becoming overweight self-worth based on body weight or body shape evidence of endocrine disorder (amenorrhea in females and lose of sexual potency in males). Characteristics Bulimia nervosa is characterized by: fear of being overweight lack of sense of control regarding food consumption overwhelming urges to overeat followed by inappropriate compensatory behaviors or purging (vomiting, excessive exercise, alternating periods of starvation, and abuse of laxative or drugs) Characteristics Eating disorders not otherwise specified (EDNOS) include eating disorders not entirely consistent with anorexia nervosa or bulimia nervosa. Frequency and severity of symptoms are more variable: anorexia with menses bulimia with binge eating less than twice per week, or inappropriate compensatory behaviors after eating small amounts of food. Described as sub-threshold disorders. Characteristics One type of EDNOS is binge eating disorder which often exists with obesity. Binge eating disorder is characterized by recurrent periods of binge eating without inappropriate compensatory behavior, a lack of self-control during binges, and distress after a binge. Characteristics Above characteristics used in diagnosing eating disorder; however, there is extensive variability in eating disorders. In addition, it believed that a continuum may exist in disordered eating from consistent dieting to sub-threshold disorders to defined eating disorders. Consequences Complications of eating disorders include weight status and nutritional factors related to eating behaviors. Consequences Clinical sings Anorexia Nervosa Bulimia Nervosa Electrolyte imbalances Hypokalemia with refeeding syndrome; hypomagnesemia; hypophosphatemia Hypokalemia accompanied by hypochloremic alkalosis; hypomagnesemia Cardiovascular effects Hypotension; irregular, slow pulse; othostasis; sinus bradycardia Cardiac arrhythmias; palpitations; weakness Consequences Clinical sings Anorexia Nervosa Bulimia Nervosa Gastrointestinal Abdominal pain, bloating; effects constipation; delayed gastric emptying; felling of fullness; vomiting Constipation; delayed gastric emptying; dysmotility; early satiety; esophagitis; flatulence; gastroesophageal reflux disease; gastrointestinal bleeding Endocrine imbalances Menstrual irregularities; rebound fluid retention with edema Cold sensitivity; diuresis; fatigue; hypercholesterolemia; hypoglycemia; menstrual irregularities Consequences Clinical sings Anorexia Nervosa Bulimia Nervosa Nutrient deficiencies Protein-energy malnutrition; various micronutrient deficiencies Variable Skeletal and dental effects Bone pain with exercise; osteopenia; osteoporosis Wasting; weakness Dental caries; erosion of the surface of the teeth Muscular effects Weakness Consequences Clinical sings Anorexia Nervosa Bulimia Nervosa Weight status Underweight status Variable Cognitive status Poor concentration Poor concentration Growth status Arrested growth and maturation Typically not affected Influencing Factors Personal factors that may influence eating disorders include: Gender Ethnicity Early childhood eating and gastrointestinal problems Body weight and shape concerns Poor self-esteem Sexual abuse and other detrimental experiences General psychiatric conditions Influencing Factors Biological factors implicated with eating disorders include Genetic predisposition Gene-environment interactions Alternations of the central nervous system serotonin activity which may also affect other psychological conditions (depression, obsessivecompulsive behavior). Influencing Factors Environmental factors that may influence the development of eating disorders include: Cultural idealization of slimness including media and family Treatment Of particular importance is the multidisciplinary approach required in the care of individuals with eating disorders and the role of nutrition in preventing complications related to eating disorders. Treatment In addition, individuals with eating disorders often suffer from other psychological disorders complicating treatment including: Depression Anxiety Body dysmorphic disorder Chemical dependency Borderline personality disorder Treatment Because eating disorders involve psychological, behavioral and physiological aspects, treatment requires a multidisciplinary approach consisting of psychological, nutritional, medical, pharmaceutical, and possibly dental. Treatment The treatment site is often determined based on the individual’s medical and psychiatric needs. In some cases, hospitalization may be necessary. Treatment may continue for 1 to 5 years depending on the disease and need for support. Anorexia Nervosa Two subtypes of anorexia nervosa: Restricting Bingeing/purging, passed on presence of bulimic symptoms The peak age of onset, although not exclusive, is 15 to 19 years. Genetics is considered an important risk factor, in that certain people may be more sensitive to environmental pressures for thinness. Risk Factors Risk factors for anorexia nervosa, as with eating disorders in general, related to weight and control issues including: Dieting behavior High level of exercise Presence of body dysmorphic disorder Obsessive compulsive disorder Acculturation Perfectionism Negative self-esteem Diagnosis Weight status is a critical marker for anorexia nervosa, with refusal to maintain weight greater than or equal to 85% of weight for age and height. Sever underweight, less than 75% ideal body weight, medical instability occurs indicating a need for hospitalization. Diagnosis Diagnostic characteristics of anorexia nervosa include: Refusal to maintain body weight Intense fear of gaining weight Distortions in the perception of one’s weight Denial of seriousness of body weight Hormonal alterations (amenorrhea). Complications Some of the most serious physical complications of anorexia nervosa include: Osteoporosis Refeeding syndrome Cardiac arrhythmia Complications Risks associated with aggressive feeding of cachectic individuals including: Hypophosphatemia Edema Cardiac failure Seizures and death As a result gradual increases in nutritional intake is required. Goals Nutrition goals for anorexia nervosa are to restore a healthful weight and normalize eating. Gradual changes in nutrient intake and weight status are recommended in an effort to achieve a weight gain of 0.5 to 1 pound per week. Goals How goals are accomplished varies by treatment site, degree of illness and progress with nutritional and psychological treatment. Largely dependent on the individual’s motivation because individuals with anorexia nervosa can be extremely resistant to nutritional intervention. Treatment Outcome Treatment outcomes for individuals with anorexia nervosa continues to be weak. approximately half recover. approximately one-fifth (21%) have moderate outcome. one-fourth (26%) have a poor outcome. Overall death rate due to anorexia nervosa is approximately 10% Hopes further research will continue to identify more effective treatment strategies. Bulimia Nervosa Bulimia nervosa is understood best in a biopsychosocial model. Individual who are at risk for bulimia nervosa who start dieting and/or experimenting with bingeing and purging are more vulnerable to develop the disorder. Risk Factors Possible risk factors include: Negative self-esteem Parental influences such as comments about weight Parental obesity Childhood obesity Use of escape-avoidance coping Low perceived social support Bulimia Nervosa Physiological and psychological factors can distort a individual’s concept of body shape, eating and weight and trigger an overwhelming need to gain control of their life. Dieting seems to provide a path for obtaining this control; however, food restrictions and rules about “good” and “bad” foods results in an unachievable dieting approach. Bulimia Nervosa Ironically, in an attempt to gain control, the person has a sense of lack of control. Binge eating provides an emotional escape possibly by increasing mood. Although the focus seems to be about food, the binge/purge behavior is a way to manage emotions and cope with negative factors such as stress. Bulimia Nervosa Unfortunately, the binge itself produces negative emotions and compensatory behaviors provide a way to purge both food and guilt. Common compensatory methods include self-induced vomiting with or without the use of laxatives, diuretics, enemas, fasting, and excess exercise. Complications Nutritional concerns for individuals with bulimia nervosa depends on the level of food restriction between binges and they type of purging method. Self-induced vomiting and laxative use can result in fluid loss and electrolyte imbalance. Self-induced vomiting can also result in cardiac and dental complications. Treatment An interdisciplinary approach to treatment of bulimia nervosa is essential. The goal of treatment is to eliminate binge eating and purging. Normalizing eating is important in breaking the chaotic eating behaviors. Treatment Helping individuals identify triggers of binge episodes is also useful. Gradual incorporation of binge foods or “forbidden foods” into the diet helps to overcome the “all or none” concepts. Medications seem to reduce bulimic behaviors and improve mood if depressions is also diagnosed. Treatment Approximately 50% of individuals treated recover and maintain recovery, and 30% maintain partial symptoms. Continual factors for those who recover may include: Over concern with weight and shape Tendency to restrict eating Tendency to overeat in response to negative factors Low self-esteem. Other Eating Disorders Eating disorders not other specified (EDNOS) consists of conditions that meet definitions for an eating disorder, but conditions for anorexia nervosa or bulimia nervosa. This category of eating disorders is just as common as anorexia nervosa and bulimia nervosa. Binge Eating Disorder Binge eating disorder is a type of EDNOS. Initiated by triggers such as negative feelings. Binge eating often a tension-releasing type of coping mechanism to deal with emotional stress. Distinguished from bulimia nervosa by the lack of compensatory behaviors. Binge Eating Disorder Different from anorexia and bulimia, binge eating often precedes dieting behaviors. Factors contributing to the development of binge eating disorder include: Repeated exposure to negative comments about weight, shape and eating Negative self-esteem Perfectionism Childhood obesity Binge Eating Disorder In addition, the following are also commonly observed among individuals with binge eating disorder: High levels of body concern Use of escape-avoidance Low perceived social support Complications Individuals with binge eating disorder are often overweight and are at risk for associated weight complications. 5 to 10% of individuals with type 2 diabetes have binge eating disorder. Many individuals seeking gastric bypass surgery have binge eating disorder. Which can have profound effects on post bypass surgery outcomes. Treatment Binge eating disorder and bulimia nervosa share common psychological and behavior characteristics, thus binge eating disorder treatment influenced by bulimia nervosa treatment. Modifications are needed because individuals with binge eating disorder have fewer dietary restrictions, higher incidences of overweight, and more chaotic eating patterns. Treatment Goals Primary goals for binge eating disorder are to reduce binge eating episodes normalize eating behaviors. Secondary goal is slow, reasonable weight loss; however, normalizing eating behaviors may be necessary to achieve weight loss. Weight maintenance may be a critical accomplishment in itself. Treatment Goals Treatment methods showing the most potential at this time include psychological counseling, behavioral weight-loss therapy, and possibly medication. Emerging Issues Further research needed to develop more effective eating disorder treatment and prevention strategies. In terms of treatment; relapses, high attrition rates, maintaining learned behaviors in therapy, and maintaining post therapy weight status are ongoing issues. Emerging Issues In terms of prevention, limited information for preventing eating disorders. Dieting and unhealthy weight-control methods may be predictive of eating disorders. Thus, nutrition messages need to be approached from a health-centered rather than a weight-centered perspective.