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.