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Course: Mental Health Nursing

Topic: Eating Disorders Part I

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Module Goals

Learners will be able to:

Define eating disorder.
Describe the types of eating disorders.
Identify the signs and symptoms.
Identify the clinical manifestations.
Discuss the evidence-based management.
Identify the appropriate nursing interventions.

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What is an Eating Disorder?

Serious and often fatal illness, associated with severe disturbances in an individual’s eating behaviors and related thoughts and emotions.

Disruption in eating behavior with excessive concern about body weight that impairs physical health or psychosocial functioning.

Associated with high rates of morbidity and mortality.

National Institute of Mental Health [NIMH], 2016

Balasundaram & Santhanam, 2021

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Risk Factors for Eating Disorders

Psychological:

Perfectionism
Anxiety
Depression
Difficulty regulating emotions
Obsessive-compulsive behaviors
Rigid thinking style (only one right way to do things, etc.)

National Eating Disorders Association, n.d.

Sociocultural:

Cultural promotion of the thin ideal
Size and weight prejudice
Emphasis on dieting
“Ideal bodies” include only a narrow range of shapes and sizes.

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Risk Factors for Eating Disorders

Biological:

Family member with an eating disorder
Family history of depression, anxiety, and/or addiction
Personal history of depression, anxiety, and/or addiction
Presence of food allergies that contribute to picky or restrictive eating (e.g. celiac disease)
Presence of Type 1 Diabetes

National Eating Disorders Association, n.d.

JDRF, n.d.

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Types of Eating Disorders

Feeding and Eating Disorders per DSM-5:

Anorexia nervosa
Bulimia nervosa
Binge eating disorder
Avoidant or restrictive food intake disorder
Pica
Rumination
Unspecified feeding and eating disorders
Other specified feeding and eating disorders:

Purging disorder
Night eating syndrome
Atypical anorexia nervosa
Subthreshold bulimia nervosa and binge eating disorder
Orthorexia

Balasundaram & Santhanam, 2021

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Critical Thinking Question:

Which of the following statements are true about eating disorders? (Select all that apply)

It is caused by negative lifestyle choices
Can stem from excessive concern about body weight and image
A severe psychiatric illness with high morbidity and mortality
Children who are ‘fussy eaters’ when they are young

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Anorexia Nervosa

Severe restriction of food or eating very small quantities leading to dangerously low body weight.
Perceives self as overweight even when dangerously underweight.
May weigh themselves repeatedly.
Two subtypes:

Restrictive subtype: Severely limits amount and type of food consumed.
Binge-purge subtype: Restrict amount and type of food consumed. May eat large amounts of food in a short time followed by purging to prevent absorption.

NIMH, 2021

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Anorexia Nervosa: Sign/Symptoms

Characteristics features include:

Extremely underweight
Intense fear of gaining weight
Preoccupation with food and weight
Amenorrhoea
Exercises compulsively for extended periods of time.
Distorted body image, denial of being seriously underweight.
Persistent compensatory behaviors to avoid gaining weight, despite being underweight.
May have obsessive-compulsive symptoms like using the same cutlery or breaking the food into small pieces.

Balasundaram & Santhanam, 2021

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Anorexia Nervosa: Complications

Anorexia Nervosa can lead to many health consequences:

NIMH, 2021

Slowed breathing and pulse
Damage to the structure and function of the heart
Drop in internal body temperature, causing a feeling of being chilled all the time
Lethargy, sluggishness, fatigue
Infertility
Brain damage
Multiple organ failure

Decreased bone density (Osteopenia/Osteoporosis)
Mild anemia
Muscle wasting/weakness
Brittle hair and nails
Dry and yellowish skin
Growth of fine hair all over the body (lanugo)
Severe constipation
Low blood pressure

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Anorexia Nervosa

May be fatal

High mortality rate from medical complications associated with starvation.
Suicide is the second leading cause of death for individuals diagnosed with anorexia nervosa.

Has extremely high mortality rate compared to other mental disorders.

NIMH, 2021

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DSM-5 Criteria for Anorexia Nervosa

Restriction of energy intake relative to requirements causing significantly low body weight.

Intense fear of gaining weight or of becoming fat, persistent behavior interfering with weight gain despite having significantly low weight.

Distorted body image,i.e negative perception about body image, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Substance Abuse and Mental Health Services Administration, 2016a

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DSM-5 Diagnostic Criteria for Anorexia Nervosa

Criterias for subtype:

Restricting type: During last 3 months, lack recurrent episodes of binge eating or purging behavior; weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
Binge-eating/purging type: During last 3 months, evidence of recurrent episodes of binge eating or purging behavior.

Substance Abuse and Mental Health Services Administration, 2016a

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DSM-5 Diagnostic Criteria for Anorexia Nervosa

In partial remission: Has history of anorexia nervosa, but does not have low BMI for a sustained period, and has either intense fear of gaining weight/becoming fat/behavior that interferes with weight gain, or disturbances in self-perception of weight and shape.

In full remission: Has a history of anorexia nervosa but has not met the criteria for anorexia nervosa diagnosis for sustained period.

Severity of weight loss: Mild: BMI 15-17 kg/m²; Moderate: BMI 16–16.99 kg/m²; Severe: BMI 15–15.99 kg/m²; Extreme: BMI < 15 kg/m².

Substance Abuse and Mental Health Services Administration, 2016a

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Anorexia Nervosa: Diagnostic Evaluation

Comprehensive review of systems, family and social history, medications including non-prescribed, past medical and psychiatric history.
Head to toe exam, body mass index, and signs of complications.
Basic laboratory tests:

Coagulation panel, complete blood count, complete metabolic profile, 25-hydroxyvitamin D, testosterone (males), thyroid-stimulating hormone, and urine testing (beta-hCG [females] and drugs, either illicit or prescription), electrocardiogram.

Moore & Bokor, 2021

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Anorexia Nervosa: Evidence-Based Management

First priority: identify emergency medical conditions that require hospitalization and stabilization.

Indications for hospitalization:

Significant electrolyte abnormalities.
Arrhythmias or severe bradycardia.
Rapid persistent weight loss in spite of outpatient therapy.
Serious comorbid medical/psychiatric conditions, suicidal ideation.

(Harrington et al., 2015)

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Anorexia Nervosa: Evidence-Based Management

Outpatient management:

Psychotherapy foundation for successful treatment

Family based treatment (Maudsley method)
Reduction of distorted body image and dysfunctional eating habits, return to social engagement, and resume full physical activities.

Nutritional Intervention and Weight Restoration

Initial target for weight: Restore 90% of the average weight expected for the client's age, height, and sex.
Resumption of menses- important biologic health marker in females.

Harrington et al., 2015

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Anorexia Nervosa: Outpatient Management (continued)

Nutritional Intervention and Weight Restoration:

A multivitamin, vitamin D and calcium supplements.
Strenuous physical activity and sports should be restricted.

Medications:

Antidepressants, including selective serotonin reuptake inhibitors (SSRIs), may help mitigate symptoms of depression and suicidal ideation.
Not proven beneficial in facilitating weight restoration or preventing relapse.

Harrington et al., 2015

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Anorexia Nervosa: Evidence-Based Management

Inpatient management:

Client stabilization, initial treatment target is restoring nutritional health.
Feeding tubes may be placed in severe cases with high resistance to eating.
Daily monitoring of key markers: weight, heart rate, temperature, hydration, and serum phosphorus level to prevent refeeding syndrome.

Harrington et al., 2015

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Case Study:

Cindy is 16 years old. She has been eating less at meal times and refusing dessert. Additionally, she has begun an exercise program where she runs several miles every day and then engages in two long aerobic exercise sessions.

Cindy’s mother noticed that her clothes are too big for her. Cindy has been reading several glamor magazines and told her mother that she wants to go into modelling as a career.

What are the signs that Cindy could be at risk for anorexia nervosa?

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Bulimia Nervosa

Defined as uncontrolled eating of an abnormally large amount of food in a short period, followed by compensatory behaviors, such as self-induced vomiting, laxative abuse, or excessive exercise.
Unlike those with anorexia nervosa, people with bulimia nervosa may maintain a normal weight or be overweight.

Harrington et al., 2015

NIMH, 2021

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Bulimia Nervosa:

Sign/symptoms:

Chronically inflamed and sore throat
Swollen salivary glands
Worn tooth enamel, sensitive/decaying teeth from stomach acid
Acid reflux disorder and other gastrointestinal problems
Intestinal distress/irritation from laxative abuse
Severe dehydration from purging
Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium, and other minerals), may cause stroke or heart attack.

Harrington et al., 2015

NIMH, 2021

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DSM-5 Diagnostic Criteria for Bulimia Nervosa

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Substance Abuse and Mental Health Services Administration, 2016b

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DSM-5 Diagnostic Criteria for Bulimia Nervosa

Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of anorexia nervosa.

Substance Abuse and Mental Health Services Administration, 2016b

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DSM-5 Diagnostic Criteria for Bulimia Nervosa (Continued):

Identification criteria for remission of the disorder:

In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.

In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time.

Substance Abuse and Mental Health Services Administration, 2016b

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DSM-5 Diagnostic Criteria for Bulimia Nervosa (Continued):

Criteria for Severity of the case:

Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.

Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week.

Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week.

Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Substance Abuse and Mental Health Services Administration, 2016b

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Bulimia Nervosa: Diagnostic Evaluation

Comprehensive review of systems, family and social history, medications including non-prescribed, past medical and psychiatric history, prior abuse.
Physical exam, body mass index, and signs of complications.
Laboratory tests:

Comprehensive metabolic panel, including electrolytes, liver function tests, blood urea nitrogen, serum creatinine, and calcium
Complete blood count with differential, vitamin B12 level
Urinalysis

Harrington et al., 2015

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Bulimia Nervosa: Diagnostic Evaluation (Continued)

Serum magnesium and phosphorous, & electrocardiogram for severe cases.
For Female: pregnancy test, luteinizing hormone, prolactin, beta-HCG, and a follicle-stimulating hormone to assess other potential contributors to amenorrhea.
Test for stool or urine bisacodyl, emodin, aloe-emodin, and rhein for presence of laxatives.
Laboratory abnormalities: hypokalemia (including hypokalemic hypochloremic metabolic alkalosis), hyponatremia, and transaminitis.

Jain & Yilanli, 2021

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Bulimia Nervosa: Management

First priority is evaluation for emergency medical conditions that require hospitalization and stabilization.
Nutritional intervention, restore healthy eating.
Evidence-based self-help program.
Adults with bulimia are offered a trial of an antidepressant drug therapy.
Cognitive behaviour therapy (CBT) programs of 16-20 sessions over four or five months.

Walsh, 2007

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Nurse’s Role in Care of Clients with Anorexia/Bulimia

Knowledgeable about assessment, identification, and evidence-based management.
Build therapeutic relationship.
Ensure clients with Type 1 Diabetes are screened for eating ‘disorders’.
Special considerations:

Weigh client in underwear and hospital gown
Have client face away from scale while weighing
Record orthostatic blood pressures and pulses
Observe for potential suicide risk

Queensland Mind Essentials, 2010

JDRF, n.d.

Harrington et al., 2015

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Nurse’s Role in Care of Clients with Anorexia/Bulimia

Ensure adequate nutrition and electrolyte balance
Monitor:

Weight and elimination pattern on regular basis
Activity levels
Skin integrity
Oral hygiene

Provide client and family education:
Importance of balanced nutrition, directions for healthy diet
Detrimental effect of unhealthy body weight, persistent vomiting and use of laxatives
Maintaining oral and dental hygiene
Medication education and importance of adherence

Walsh, 2007

Queensland Mind Essentials, 2010

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Nurse’s Role in Care of Clients with Anorexia/Bulimia

Counsel family to:

Supervise clients during and after mealtimes to prevent purging.
Set time limits for each meal to set realistic expectations.
Encourage relaxed atmosphere at mealtimes to reduce stress and anxiety.

Assist in appropriate referral to specialist and resources available in the community.

Queensland Mind Essentials, 2021

Harrington et al., 2015

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What Would the Nurse Do?

A client on an in-patient unit with diagnosed bulimia tells the nurse that they are going to the bathroom and will be right back.

Which response by the nurse is most appropriate?

“Let me know when you get back to the day room.”
“Thank you for letting me know.”
“ I will stand outside your door to give you privacy.”
“I will accompany you to the bathroom.”

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Answer: D

The response, “I will accompany you to the bathroom,” is appropriate. Any client suspected of self-induced vomiting should be accompanied to the bathroom for the nurse to be able to deter this behavior.

The response, “Thanks you for letting me know,” does not address the nurse’s responsibility to deter the self-induced vomiting done by clients diagnosed with bulimia nervosa. The nurse should accompany the client to the bathroom.

The response, “Let me know when you get back to the day room,” does not address the nurse’s responsibility to deter the self-induced vomiting done by clients diagnosed with bulimia nervosa. The nurse should accompany the client to the bathroom.

The response, “I’ll stand outside your door to give you privacy,” does not address the nurse’s responsibility to deter the self-induced vomiting done by clients diagnosed with bulimia nervosa. The nurse should accompany the client to the bathroom. Providing privacy is secondary to preventing further nutritional deficits.

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Red Flags

Extremely underweight
Extreme fear of weight gain
Excessive exercising
Extreme fasting
Persistent vomiting
Misuse of laxatives
Social isolation

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Reference:

American Psychological Association (n.d.). APA Dictionary of Psychology: Self-help. https://dictionary.apa.org/self-help

Agency for Healthcare Research and Quality. (2013, January). Preventing Falls in Hospitals: Tool 3F: Orthostatic Vital Sign Measurement. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html

Balasundaram, P. & Santhanam, P. (2021, June 29). Eating Disorders. In: StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK567717/

Harrington, B.C., Jimerson, M., Haxton, C., & Jimerson, D.C. (2015). Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa. American Family Physician, 91(1):46-52. https://www.aafp.org/afp/2015/0101/p46.html

Contact info: info@nursesinternational.org

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Reference:

Jain, A. & Yilanli, M. (2021, August 4). Bulimia Nervosa. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562178/

JDRF. (n.d.). Type 1 Diabetes and Eating Disorders. https://www.jdrf.org/t1d-resources/living-with-t1d/food-and-diet/eating-disorders/

Mental Health, Addiction and Intellectual Disability Services [MHAIDS]. (2018, March 1). Maudsley Family Therapy. https://www.mhaids.health.nz/our-services/central-region-eating-disorder-services-creds/maudsley-family-therapy/

Moore, C.A. & Bokor, B.R. (2021, September 1).Anorexia Nervosa. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459148/

Contact info: info@nursesinternational.org

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Reference:

National Eating Disorders Association. (n.d.). Risk factors for eating disorders. Retrieved on November 8, 2021 from https://www.nationaleatingdisorders.org/toolkit/parent-toolkit/risk-factors

National Institute of Mental Health. (2016, February). Eating Disorders. https://www.nimh.nih.gov/health/topics/eating-disorders#part_2267

National Institute of Mental Health. (2021). Eating disorders: About more than foods. https://www.nimh.nih.gov/health/publications/eating-disorders#part_6160

NHS UK. (2018, August 28). Self-help therapies. https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/self-help-therapies/

Queensland Mind Essentials. (2010). Queensland Government. https://www.health.qld.gov.au/__data/assets/pdf_file/0029/444773/mindessentialsfinal.pdf

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Reference:

Substance Abuse and Mental Health Services Administration. (2016a). DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t15/

Substance Abuse and Mental Health Services Administration. (2016b). DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t16/#:~:text=A.,how%20much%20one%20is%20eating

Walsh, L. (2007, September 7). Caring for patients who have eating disorders. Nursing Times, 103 (28), 28. https://www.nursingtimes.net/clinical-archive/nutrition/caring-for-patients-who-have-eating-disorders-10-09-2007/

Zieve, D. (2020, May 13). Diet for rapid weight loss. [Review of article Diet for rapid weight loss, updated by B.Wisse]. MedlinePlus. https://medlineplus.gov/ency/patientinstructions/000885.htm#:~:text=Rapid%20weight%20loss%20diet%20is,you%20eat%20very%20few%20calories

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