eNutrition
a LaFrance Consulting Services™ e-Course
Nutrition for Nursing Students, independent study

Eating Disorders

Anorexia nervosa and Bulimia nervosa are serious medical conditions, requiring formal diagnosis [by a licensed diagnostician: MD or LNP], and medical intervention under supervision of qualified medical personnel! Patients presenting with signs and/or symptoms must be referred for diagnosis! The correct mechanism for this referral is the patient chart. The two other formally recognized eating disorders are Binge Eating Disorder and Pica.
    Do not attempt to intervene in suspected cases of Anorexia or Bulimia without medical diagnosis and formal care plan. You may counsel the patient to seek appropriate treatment, but should NOT tell the patient that you suspect an eating disorder [explained below].

    The most famous case of Bulimia involved a 26 year old patient. Terri Schiavo (reported by abcnews4, Charleston, SC, April 1, 2005 [at the beginning of the extensive legal maneuvering and media circus which the case became, I heard a single report of this on CBS News radio, WBBM AM 780, Chicago, but abcnews4 was the only reference to it that I was able to find online in 2007]) was diagnosed as bulimic and later suffered heart arrythmia leading to cardiac arrest at the age of 26. When she presented in the ER with full cardiac arrest, the ER staff immediately attempted to resusitate her, absent a DNR of record. After she was successfully resusitated, the attending physician began evaluating the extent of brain damage (over 50% loss of brain tissue from the frontal lobes to the posterior) and diagnosed “permanent vegetative state,” with a prognosis of no hope for recovery. On autopsy, the extent of brain damage was determined to be far more severe than previously thought, with only the brain stem intact [the entire cerebrum was described to the press as “liquified”]. The opportunity to educate the susceptible population concerning the severity of the disorder was lost as the courts (all the way to the U.S. Supreme Court more than once), and Florida state government, argued over the issue of discontinuing life support.
    One of the least famous cases was a former student of mine. When first I met her as a student in my Intro Biology class [fall semester], she was very thin [similar to illustration 11.2, pg 11-3] and pale in color, and I suspected she was suffering from Anorexia nervosa. The following semester I saw her on campus, and she appeared to be somewhat thinner than before. Early during the next fall semester I saw her walking across campus in front of me; this time she was so skinny that I could see her ribs under her loose-fitting clothes, and even was able to watch the articulation of her knees and elbows although these joints were completely covered by loose-fitting clothing. Her skin (where it was exposed at her wrists and hands) was pure white and non-transparent, like a sheet of paper. I never saw her again after that. I suspect she died of the disorder during the semester. The point is that these two disorders (Anorexia & Bulimia) are serious life threatening conditions.

Anorexia

The death rate is 7% within 10 yrs of diagnosis [the CDC typically quotes death rates as per 10,000, so this would be 700 deaths per 10,000 population; but this is an exaggerated version, because this “population” is the number of diagnosed cases, not the general population]. Treatment is reported to be effective in 50% of patients, but one third of these “cured” patients will relapse within 7 years. These numbers (50% efficacy, with 33% relapse) would not be considered acceptable in most diseases (communicable [bacterial or viral] or life-style related [such as emphysema]).

    A few of the signs need some explanation, so here we go…
  1. playing with food, examples include separating mixed vegetables into separate piles, then stirring them back together; moving all of a single food from one side of the plate to the other side, then back again; arranging a single food into patterns…
  2. exercise compulsively, here we use the term “compulsive” to imply that the patient will become agitated and upset if they can not complete what ever they have a compulsion to do at the moment, and they will resume the activity as soon as possible [no matter how long it has been since they were interrupted].
  3. accepts narrow range of foods, and the number of foods accepted continually gets narrower, until only a single food (such as garden peas) is accepted.
  4. hostile and withdrawn from family and friends, this is the biggest problem in referring the patient for diagnosis: if you mention ‘eating disorder,’ the patient may react as if you have been “nagging” them about it for days or weeks, and withdraw from you [so you will not get a second chance to refer them].
    Among the symptoms, lowered body temperature and cold intolerance are symptoms of reduced basal metabolism. The spontaneous bruising will often be mistaken for signs of physical abuse [but the once suggested correlation between Anorexia and abuse has not been confirmed]. Loss of tooth mass (and jaw bone density) leads to tooth loss as the teeth can simply fall out.

Bulimia

“Bulimia is estimated to affect … 3% of all women in the U.S. at some point in their lifetime. … Approximately 10% of identified bulimic patients are men. … The long-term prognosis for bulimics is slightly better than for anorexics, … However, many bulimics continue to retain slightly abnormal eating and dieting behaviors even after the recovery period.” (http://www.medicinenet.com/bulimia/article.htm downloaded by Dr. LaFrance 19 May 2009 9:07 am)
The relapse rates I have seen quoted for bulimia are as high as 50%, probably including the slightly abnormal eating and dieting behaviors mentioned above. Many patients who have been diagnosed as bulimic have been participants in structured weight loss programs for self-diagnosis of over-weight conditions. At some point, the patient feels guilty about their failure to lose enough weight, leading to episodes of starvation dieting followed by the classic “binge and purge” associated with the disorder. Many of the diagnosed males were high school wrestlers who had “yo-yo” diets characterized by over-eating during weight training to bulk up, and starvation dieting to drop weight for the next meet [it is commonly believed (incorrectly) by High School wrestling coaches that the heaviest wrestler in any weight class has an advantage, and that the easiest way to be the heaviest wrestler in the class is to lose weight down to the next class; after all to gain up to the top of the current class would involve adding fat]. Participants in appearance based sports [see Female Athlete Triad below] are at risk for bulimia.
A former student who disclosed that he/she had a history of bulumia nervousa, reported: “My dad intervened and helped me get back on the track to becoming healthy. I got a gym membership, and started eating normal meals and got back to an acceptable weight of 130 pounds. Its scary to think that something like that can go on for so long without anyone noticing. I am very lucky I don't have any permanent damage ... from that.
To this day I am still worried one day I will get fat like other [persons] in my family. However, now I know how to keep track of what I eat and I exercise all of the time. It is very important to me to stay healthy and in shape. I see a lot of my aunts and uncles who are extremely over weight and never exercise. They suffer from high blood pressure, clogging arteries, and heart disease. Staying in shape is a big part of my life I don't ever want to suffer from any eating disorders again.”

    There is a documented correlation between Bulimia and disfunctional families; a high percentage of bulimic patients are from disfunctional families, but the percentage of disfunctional families with bulimic members is not clearly higher than for families without diagnosed disfunctional behaviors [we don't have data on disfunctional families that have not been diagnosed as such]. Patients who have been diagnosed as Bulimic tend to exhibit other impulsive behavior as well, while those diagnosed as Anorexic tend to exhibit other compulsive behavior. Compulsive implies that the patient will become upset if anything prevents them from (or interrupts them during) carrying out the activity they feel a compulsion to do; impulsive implies that the patient will immediately attempt whatever activity they feel an impulse to do, but if prevented (or interrupted) will neither become upset [just disappointed] nor resume the activity later since the impulse has passed. I infer from the descriptions of both of these disorders use the expression “exhibit other [compulsive / impulsive] behavior” that these disorders are tentatively identified as compulsive (anorexia) or impulsive (bulimia) behaviors. For the bulimic impulsive exercise, unfortunately, the patient will probably get an new impulse to exercise as soon as they have time alone to think about their “need” to lose weight.

    Again, to elaborate on some of the signs and symptoms:
  1. Bulimia nervosa is characterized by binge and purge eating. On the binge side, I have seen quotes of up to 3,000 kcal of high carbohydrate food which is eaten rapidly. The binges occur as recurrent episodes, and once started become compulsive.
  2. On the purge side; the purge is now believed to be an impulsive activity brought on by the feeling of guilt caused by the binge.
  3. bite marks: compulsive finger-nail biting produces bite marks lateral to (and sometimes also medial to) the fingernails; compulsive knuckle biting produces bite marks parallel to the phalanges at the knuckles. Bulimic bite marks will be perpendicular to the phalanges, and tend to be close to the knuckles. These bites are not intentional, but accidental due to involuntary mouth movements in response to the mechanical stimulation of the posterior of the mouth [to induce vomiting].
  4. in previous references, the excessive exercise is described as impulsive, but more recent references suggest that the impulse to exercise is likely to recur any time the patient thinks about their “weight problem.”
  5. the edema of the salivary glands is caused by irritation of the gland lumen by the repeated vomiting. If you suspect Bulimia nervosa, based on signs, you should palpitate the submaxillary salivary glands for the edema symptom. If you are unclear where to palpitate, you can try this on yourself. Locate the submaxillary lymph gland (the ones normally swollen during mumps, or tooth infections), then move anteriorly along the maxilla to the vicinity of the premolars and canines to find another palpable gland. If you are on the salivary gland, palpating it will express saliva into the mouth. This is the gland which will exhibit edema as a symptom of bulimia, and charting this edema will support the nursing diagnosis of possible Bulimia nervosa.
  6. "may be suicidal" WARNING, Will Robinson! ALL evidences of suicidal ideations require charting and referral. Too many suicidal ideations become suicide attempts, and in the current world, too many first suicide attempts are successful.

treatment of anorexia and bulimia

The treatment of Anorexia nervosa and Bulimia nervosa require a team of qualified professionals, including, but not limited to, the physician of record, the nursing staff, a trained dietician [specialized in eating disorders], and the pyschological therapy team. Many “…individuals with self-harm behaviors, such as self-cutting, suicide thoughts, urges to suicide, and suicide attempts … meet criteria for a disorder called borderline personality (BPD). It is not unusual for individuals diagnosed with BPD to also struggle with other problems -- depression, bipolar disorder, post-traumatic stress disorder (PTSD), anxiety, eating disorders [emphasis added], or alcohol and drug problems” (quoted by a student [responding to a quiz question for this course] from Behavioral Tech, LLC, 1996-2009). Beyond the psychological treatment to resolve the underlying psychological issue(s), the goals of the intervention are, at the least:
  (1) to encourage adequate food intake to restore weight to subclinical underweight (or if possible, low normal range; but not all the way to “normal”). Secondary to increasing total food intake is to shift the diet to a nutritionally sound balanced diet (even if it doesn't provide RDAs yet).
  (2) to encourage reduction in exercise intensity and duration, due to the risks of muscle tears and stress fractures. Secondary to decreasing exercise, is to reduce calorie demands.

    Because of the low effacacy (50%) and high relapse rates (30 to 50%), the treatments are being continually revised. Thus, you should research the disorders any time you encounter possible cases to make sure you are working with the most current thinking about these disorders.

binge-eating disorder

Originally binge-eating disorder was described in Nutrition texts as “binge without purge,” which was considered to be synonymous with “compulsive [over] eating.” With the observation that 30% to 50% of persons in organized weight control programs have episodes of binge eating, as a self-awarded reward for meeting a weight loss goal, some authors began suggesting that this should not be recognized as a disorder, but as an occasional lapse in compliance with the weight control program. Further investigation has now shown that often the binge leads to feelings of guilt over the binge [especially when the weight loss appears to have reversed]. The guilty feelings may be transient, but in some personality types the guilt leads to implusive actions to compensate for the appearance of weight gain [although in all but the most severe binges, this observed weight gain is not significant]. After this becomes cyclic behavior: compliance with the program, bingeing as reward for success, guilt, renewed “dedication” to the program, bingeing as reward for success, … , it may become so close to full-blown bulimia that it would take a psychologist specializing in bulimia to distinquish between binge eating disorder and bulimia.
    For now, we must recognize that binge eating disorder may be a precursor to Bulimia nervosa for some patients, and treat it as an eating disorder requiring formal diagnosis to determine the severity of the disordered eating pattern, the prognosis for return to normal, and design of intervention as needed.

Pica

Pica is defined as “the eating of non-food substances.” The oldest references to the eating of non-food substances predate written records. I have yet to do any research on this disorder, so you will have to read the text and determine for yourself how to interpret the signs and symptoms.

other ...

female athlete triad

female athlete triad, and the un-named male equivalent, affect primarily youth involved in the appearance-based sports (such as gymnastics and figure skating), where the panel of judges awards scores based on the appearance of the performance [which also translates way too often into the appearance of the participant], and youth involved in endurance sports (such as track, skiing, and swimming). These patients exhibit disordered eating patterns, which may lead to technical starvation with respect to some nutrients (some vitamins and/or some minerals). This obviously has the potential to develop deficiency symptoms if the disordered eating patterns persist for a long time. The most severe symptom reported [in Nutrition texts] is early onset osteoporosis as young as 18 years. The females exhibit delayed onset of puberty, with irregular or no menstral periods. This may be caused by the eating patterns (as currently suggested) or by competition between anabolic steroid production and estrogen production with limited cholesterol due to a lack of red meat fatty acids intake (as previously hypothesized). For males, there is delayed onset of puberty, with reduced semen and sperm count, again which has been hypothesized to be attribuable to competition between anabolic steroid production and testosterone production with limited cholesterol due to a lack of red meat fatty acids intake. This disordered eating behavior comes with a high risk of becoming diagnosable Bulimia nervosa; and I suspect it may be a sub-clinical version of bulimia.

baryophobia

When I first encountered a discussion of this disordered eating behavior [in a Nutrition text sent to me for possible adoption as the text for this course], my initial reaction was that the author was making up new eating disorders. Then I remembered the consequences of parents [Yuppie generation] putting their young children on the then popular low cholesterol diets for reduction in heart disease risks; which was to produce the first generation of young adults who were not taller than their parents [later determined to be stunted in growth, since cholesterol is the precursor of Human juvenile growth hormone].
    The primary ‘symptom’ is a “fear of becoming heavy.” The discussion of baryophobia contained three statements that lead me to infer that it may be another instance of parental diagnosis and parental care plan for treatment: (1) the condition may be triggered by placing young children on adult low-fat, low-calorie diet; (2) the affected children seem to have been repeatedly cautioned to eat less to avoid becoming over-weight; and (3) nearly all affected children have parents who are clearly over-weight. If a young child presents with signs and symptoms of baryophobia, I suspect it is the parents who need to be referred for possible diagnosis of abnormal thinking leading to potentially treatable behaviors.

other ... reported disordered eating behaviors will undoubtedly continue to appear, particularly in the popular media. This is the “Wiki-generation” which seems to believe that expertise about any subject is conferred by access to electronic communication: the internet allows anyone to author articles on Wikipedia as an expert; text messaging allows anyone to judge the merits of musical performances without having any training in music composition nor performance. There is no reason to believe that diagnosable hypochondriacs won't engage in electronically distributed “reality medicine.”



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revised: 21 Oct 2009