Eating DisordersBy: Amanda SensabaughHayley Fennessy

Anorexia NervosaPsychiatric disorderCharacterized by low body weightBody image distortionObsessive fear of gaining weightDepressionWeight loss viewed as a sign of achievementControl Weight by:Voluntary starvationPurgingExcessive exerciseDiet pills or diuretic drugs

Bulimia NervosaRecurrent binge eating followed by feelings of guilt, depression, and intentional purging to prevent weight gain from occurring.Purging may consist of:VomitingFastingUse of laxatives, enemas, diuretics, or other medicationExcessive exercise

Bulimia NervosaTypically within normal weight range, underwt. or overwt.More open to treatment that AN (tire of binge/purge cycle)

Binge Eating DisordersBinge without the purgePsychiatric disorderEats a large amount of food at one time-more than what a normal person would eat at the same time.Eats until physically uncomfortably fullFeels depressed or guilty after a bingeEats large amounts of food even if there not really hungry

Variations of Eating DisordersBinging/purging ANRestrictive ANPurging BNNon-purging BNEDNOS (eating disorderNot otherwise specified)

Purging vs. Non Purging BulimiaPurging: over consumption of calories then using laxatives/edemas/excessive exercise to rid calories

Non-Purging: over consumption of calories without ridding them from the body

Medical Consequences of Anorexia NervosaDizziness, confusionDry, brittle hairLanugo-type hairLow blood pressure, pulse, ECG voltageOrthostasisCachexiaBiochemical changesDecreased WBCDecreased glucoseIncreased cholesterolIncreased carotene

Medical Consequences of Anorexia NervosaLoss of mensesMuscle wastingDiminishing DTRsOsteoporosisDry skinEdemaGrowth retardationHypothermia

Medical Consequences of Bulimia NervosaSalivary gland enlargementEnamel erosionEsophagitisArrhythmiasNormal weight or underweight or overweightCalluses on handsEdemaDiarrhea

Medical Consequences of Bulimia NervosaBiochemical changes Decreased potassium Increased carbon dioxideIncreased amylase

Role of treatmentMultidisciplinary teamPhysiciansCheck wt. other physical signs/symptoms Electrolyte imbalancesHeart arrhythmiasMay prescribe antidepressants

Role of TreatmentRegistered DietitiansDiscuss food intakeExercise and weight related behaviors

Role of TreatmentPsychotherapistsDiscuss issues leading to disordered eating patterns.

PsychiatristPhysician that specializes in treating mental disorders.

Goals of Treating Disordered EatingNormal eatingEating based on physical signs that is free from fear, guilt, anxiety, obsessive thinking or behaviors or compensatory behavior.Improved body imageWeight normalizationDiscontinue extreme behaviors such as bingeing, purging, starvationOften client exchange one coping tool for another equally destructive coping tool.

Prevention Strategies to Reduce Risk of Disordered EatingPractice intuitive eating concepts by accepting your body type. Healthy at every size.

Paris Description34 year old female attorneyShe experiences a high amount of stressSpent lots of hours at the recreation center in high schoolSwam for 1 hr. before classesWalked 3 miles on the indoor track after lunchShe did aerobics in the afternoon for 1 hr.

Paris DescriptionShe learned how to purge using her toothbrushShe took OTC laxatives every other dayShe hasnt had a menstrual period in over two yearsTried to maintain her weight below 120 lbs.Smokes 1 pack of cigarettes a dayMultiple food allergies: all meats, dairy foods, most desserts

Paris DescriptionShe tried to stop restricting her intake of food and purging on her own but once she experienced stress she reverted back to her old coping mechanisms.

She was hospitalized while in law school for a weekend because of severe dehydration but released after 24 hrs.

Paris DescriptionShe appears emaciated She appears tired and older than age 34She loves to cook but gives most of the food awayShe admitted that she knows she has a problem dealing with food and eating

Paris AnthropometricsHeight: 58Weight: 115 lbs.BMI: 17.48Interpretation: underweight

Basal Energy MetabolismHarris Benedict:655 + (9.6 x 52.8) + (1.8 x 172.72) (4.7 x 34)=1313 x activity factor(1.3)= 1707 KCALS

Paris 24 Hr. RecallAM: whole wheat bagel, 4 oz. calcium fortified orange juice, 6 oz black coffeeLunch: Black coffee 2-3 cAfternoon snack: 12 oz can Diet CokeDinner: 6 green peas, 18 oz waterSnack: 12 oz Diet Coke

Nutrition ProblemsRough dry skin with lanugoBruisingBrittle finger/toenailsErosion of dental enamelMultiple food allergiesGastric/abdominal problemsEasy Bleeding/anemia

Paris Lab Value ResultsLow albumin of 3.0 LLow pre-albumin of 14.5 LLow potassium of 3.0 LLow magnesium of 1.7 LHigh glucose of 115 HHigh CPK of 146 HHigh HDL of 60 HLow WBC of 4.6 L

Characteristics of Refeeding SyndromeIncreases BMRMay lead to confusion, coma, convulsions and death.Caused by introducing food to quickly to a malnourished person.Prevent refeeding syndrome by slowly introducing foods in small amounts and advancing as tolerated.

Questions regarding Paris purging behaviors1. What types of food trigger your bingeing/purging episodes?2. What food rituals do you have?3. What foods do you consider fear foods?4. What other behavior could you do when you feel a bingeing/purging episode about to occur?5. What weight would you consider healthy for yourself?

DiagnosisInadequate energy intake(NI-1.4) related to restricting food and purging as evidenced by her underweight BMI of 17.48.

InterventionNutrition-Related Behavior Modification Therapy C-1A supportive process to set priorities, establish goals and create individualized action plans that acknowledge and foster responsibility for self-care by setting goals for ParisFrom Paris description and 24 hr. food recall we determined that Paris has anorexia nervosa with binge/purge tendencies.

Education InterventionTeach Paris the hunger/fullness scaleLearn not to classify foods as good versus badDiscuss physical activity in terms of health rather than using it to control her weightDiscuss with her the idea about trusting her body to fluctuate between a goal range weight for herGradually increase her caloric intake to prevent refeeding syndromeTeach her to add foods that she considers safe into her diet. She stated she felt safe foods were all vegetables and salads.

Although we intend to attempt to try these intervention techniques with Paris, we realize that this may be an extremely slow process and take a very long time depending on how she reacts to treatment.

Sample Diet2 eggs, 1 C granola, 1 C skim milk1/2 C grapes2 oz turkey on 2 slices whole wheat bread, light mayo, mustard, 2 slices tomato, lettuce1 C apple juice2 cups mixed green salad, 2 oz tuna, 4 slices cucumber, tomato, carrots, balsamic dressing

This diet is low in calories and not meant for the long term, but it can be a good place to start.

Action Goals1. Have Paris choose one food item of her choice at every meal. This can be a vegetable, fruit, or anything she wants. 2. To better understand intuitive eating, have her read a chapter a week from Intuitive Eating (Tribole, Resch, 1995) and focus her behavior change on that particular chapter.3. Have Paris keep a journal of her feelings prior and post eating.

Outcome Goals: Goal WeightsParis should aim to gain about 1 lb. per week, however this may be unrealistic at first, and that is alright in the beginning, as long as she does not lose any more weight.Goal: 140 lbs. based upon Hamwi 1 Month Goal: 119 lbs.3 Month Goal: 131 lbs.1 Year Goal: 126-154 lbs.Insure a slow and steady weight gain to prevent refeeding syndrome.

Follow-UpFollow up with Paris in one week due to being in the beginning stages of treatment.Then follow-ups may occur every two weeks.Have weekly talks/meetings with the other healthcare professionals on the team (physician, psychologist, etc)

Parameters to measureWeight Coping mechanismsMonitor purging behaviorContinual discussion with the other members of the treatment team for Paris

ReferencesScarano M.G., Kalodner-Martin R.C. A description of the continuum of eating disorders: Implications for intervention and research. Journal of Counseling & Development. Vol. 72, 1994.Williams L.R., Schaefer A.C., Shisslak M.C., Gronwaldt H.V., Comerci D.G. Eating Attidtudes & Behaviors in Adolescent Women: Discrimination of Normals, Dieters, & Suspected Bulimics Using the Eating Attitudes Test & Eating Disorder Inventory. International Journal of Eating Disorders. Vol. 5, 1986Kitsantas A., Gilligan D.T., Kamata A. College Women With Eating Disorders: Self-Regulation, Life Satisfaction, & Positive/Negative Affect. The Journal of Psychology. Vol. 137, 2003. Garner M.D., Garner V.M., Rosen W.L. Anorexia Nervosa Restricters Who Purge: Implications for subtyping Anorexia Nervosa. International Journal of Eating Disorders. Vol. 13, 1993.Robinson H.P. Review article: recognition and treatment of eating disorders in primary and secondary care. Alliment Pharmacol Ther. Vol. 14, 2000. http://encyclopedia.thefreedictionary.com/anorexia+nervosaTribole E., Resch E. Intuitive Eating. St. Martins Press, 1995.