At the conclusion of this exercise, the learner will be prepared to:
- Identify the appropriate terms and definitions related to eating disorders.
- Consider the impact of eating disorders on healthcare in the US.
- Identify possible risk factors that influence the development of eating disorders.
- Review the pathophysiology of eating disorders.
- Reference appropriate tests and evaluations used to diagnose eating disorders.
- Discuss treatment interventions for individuals diagnosed with eating disorders.
Most individuals worry about maintaining a healthy weight at some point during their life; however, there are many who worry about their weight on an ongoing basis and take their worry to extremes. The Eating Disorders Coalition (EDC, 2016), notes that over 30 million people in the US suffer from an eating disorders sometime during their life. One person dies every hour due to complications of an eating disorder. The most common eating disorders are anorexia nervosa, typically known as anorexia, bulimia nervosa, typically known as bulimia, and binge eating disorder (BED). Females suffer from eating disorders at a much higher rate than men, but all socioeconomic groups are affected, including military personnel. Eating disorders are NOT a personal choice and are legitimate illnesses. Nurses and healthcare professionals can help educate patients and their families on the dangers of these disorders including the potential for death (EDC, 2016). This module will explore the incidence and prevalence, risk factors, and current treatment recommendations for eating disorders.
Eating Disorder Terms and Definitions
Anorexia nervosa is a condition where an individual believes they are overweight even when they are dangerously thin, as they often have skeletal frames. The affected person limits their food intake and may restrict eating to the point of starvation. They may engage in excessive exercise to burn more calories. (American Psychological Association [APA], 2020).
Bulimia nervosa is a condition in which the individual consumes abnormally large amounts of food (known as binging), and then purges the intake through vomiting or the use of laxatives. The affected person typically has feelings of shame, depression, and self-condemnation after a binge episode, and they are characteristically a normal weight or slightly overweight (APA, 2020).
Those affected by binge eating disorder also eat abnormally large quantities of food; however, they do not purge through vomiting or laxative use. Food is consumed in private, and the affected individual often reports being embarrassed by their intake. They are typically depressed, guilty, and disgusted with themselves after the binge (APA, 2020).
Impact of Eating Disorders on Healthcare in the US
The National Institute of Mental Health (NIMH, 2017) notes that the prevalence of anorexia is 0.6% over the lifetime of an adult with a three-fold increase in risk among women as compared to men. Bulimia is reported to have a prevalence of 0.3% over the lifetime of an adult and women have five-fold the risk of men. The overall prevalence of BED is 2.8% over the lifetime of an adult and is twice more likely in women than men. The typical onset of an eating disorder is 21 years of age for BED and 18 years of age for anorexia and bulimia. Anorexia may be seen in adolescence, particularly with females, as body changes start to occur. Eating disorders are frequently associated with other mental health disorders as shown in Table 1 (NIMH, 2017).
Based on this data, over half of the patients identified with an eating disorder also had a mental health disorder, as identified by the DSM-V. All the eating disorders had the highest comorbidity with anxiety disorders (NIMH, 2017). While costs related to eating disorders are difficult to define, a study by Samnalieve and colleagues (2015) found that annual healthcare costs for a patient with an eating disorder is approximately $1900 higher in comparison to someone without an eating disorder in similar health otherwise. In addition to the healthcare costs, eating disorders increase the cost of food purchases to accommodate the binges that are associated with bulimia, laxative or diet pill purchases, gym memberships, and even clothes of varying sizes as the patient's weight fluctuates. Lost workdays increase with eating disorders, particularly with anorexia, and inpatient treatment facilities can cost up to $20,000 per month, adding to the overall cost (Samnalieve et al., 2015). Males are less likely to get an accurate diagnosis since many people, including healthcare providers, see eating disorders as a female-only issue and fail to recognize the problem (National Eating Disorders Association [NEDA], 2016). Males and females have different concerns regarding their body image. Most females are concerned with being thin and losing weight, while many males focus on gaining muscle mass. Males are more likely to use steroids to increase their muscle mass or to "bulk up" for sports (Malcore, 2016).
Miscellaneous statistics related to eating disorders include the following:
- As much as 55% of men and women in the US are dieting at any given time.
- Up to 80% of females surveyed report being dissatisfied with their appearance.
- By the first year of college, 5-19% of women and 0.4% of men report a history of bulimia.
- Studies indicate that 35% of those engaging in "normal" dieting progress to pathological dieting, and 20-25% progress to full-blown eating disorders (Tracy, 2016).
Risk Factors for Eating Disorders
As recognized in Table 1, mental health disorders commonly coexist with eating disorders and can also be risk factors for the development of eating disorders. Many people who have eating disorders suffer from low self-esteem, self-dissatisfaction with their appearance, and often voice feelings of helplessness. Eating disorders habitually begin as methods to cope with daily living. Consistent with each of the eating disorders is the risk related to family discord, parental substance abuse, sexual and physical abuse, and parental mood disorder. Additionally, each eating disorder has its own individual risk factors (APA, 2011; Stoppler, 2019).
Risk factors for anorexia include being a female adolescent, a perfectionist, having controlling parents, participation in weight-conscious sports or activities such as gymnastics/dance, and ongoing exposure through social media to models, actors, and role models that are excessively thin. Particularly young females may feel pressured to be thin due to societal expectations and feel unattractive otherwise. Obsessive-compulsive disorder, depression, and anxiety are associated with the development of anorexia. Studies also show that patients with anorexia often have abnormally low levels of serotonin and norepinephrine and higher than normal levels of cortisol and vasopressin (APA, 2011; GoodTherapy, 2015).
Individuals suffering from bulimia are often impulsive, and negative emotions can be a trigger for binge eating and purging. Genetics are a risk factor for bulimia, and patients with a first-degree relative such as a parent or a sibling with a history of an eating disorder are more likely to develop an eating disorder. Childhood obesity or teen obesity, psychological or emotional issues, including depression, anxiety disorders, or substance abuse disorders, are all triggers for bulimia. Additionally, those who diet are at a higher risk of developing bulimia many will severely restrict calories between binge episodes (Mayo Clinic, 2018c).
BED was formally recognized as a distinct disorder in the DSM-5 in 2013; it was formerly thought to be about personal choices and not a true disorder. Rigid eating habits, previous anorexia, and previous diets can trigger BED. Traumatic events, physical abuse, perceived risk of abuse, stress, body criticism, history of childhood obesity, negative comments from others about their weight, low self-esteem, sexual abuse history, or potentially a genetic component can be associated with the development of BED (Mayo Clinic, 2018b).
Pathophysiology of Eating Disorders
The pathophysiology of each eating disorder is unique. Anorexia essentially leads to a state of severe starvation. Although bulimia does not lead to near starvation, the patient can still have serious pathophysiological effects. The pathophysiology and complications of BED are due to the effects of obesity (Mayo Clinic, 2018a, 2018b, 2018c).
The lack of nutritional intake and availability with anorexia leads to a variety of pathophysiological alterations. As weight loss occurs, fat storage is depleted, and muscle mass is further lost. Since there is little to no body fat, intolerance to cold and a lowered body temperature ensues. As the alterations in body temperature and metabolic changes occur, further metabolic changes take place. The clinical manifestations include:
- Hypothyroidism-since the thyroid does not have adequate nutrition to create hormones, the patient may develop fatigue, dry skin, thinning hair, mental health issues, difficulty remembering things, muscle weakness, pain infertility, and cardiac implications.
- Mental health issues-secondary to thyroid dysfunction, depression may develop early in the disease process and continue worsening as hypothyroidism worsens.
- Infertility-with lower levels of thyroid hormones, ovulation and the menstrual cycle will be altered.
- Cardiac implications- secondary to thyroid dysfunction, subsequent cardiac issues arise including bradycardia, chest pain (angina), heart failure (HF), enlargement of the heart, decreased cardiac output (due to the HF), and an increase in bad cholesterol (low-density lipoproteins [LDL]) (Halter, 2017).
The patient’s hypothyroidism is noted by low total thyroxine (T4) and low triiodothyronine (T3). Thyroid-stimulating hormone (TSH) is typically in the normal range, similar to that of euthyroid sick syndrome (ESS). ESS is characterized by abnormal thyroid function tests occurring outside of pre-existing thyroid gland dysfunction. After recovery of the causative process (in this case, anorexia), the abnormalities should be reversible (Aytug, 2018; Halter, 2017).
In addition to those mentioned above, further cardiac problems may include a loss of cardiac muscle mass, arrhythmias, hypotension, and even cardiac arrest, particularly as the disease progresses. With progression, the QT interval will be prolonged which can lead to torsade de pointes, a life-threatening ventricular arrhythmia that may further progresses to ventricular fibrillation and cardiac arrest (Halter, 2017; Mayo Clinic, 2018d).
Metabolic disturbances due to the lack of nutritional intake by those with anorexia include hypokalemia (serum potassium level less than 3.5 mEq/L); hypochloremia (serum chloride level less than 98 mEq/L); hypomagnesemia (serum magnesium level less than 1.5 mEq/L); hypocalcemia (serum calcium level less than 8.9 mg/dl); and hyponatremia (serum sodium level less than 135 mEq/L). See Table 2 for signs and symptoms related to these conditions.
Gastrointestinal (GI) disorders associated with anorexia include abdominal pain, delayed gastric emptying, and an enlarged or inflamed pancreas that leads to other symptoms discussed later. The GI symptoms are caused by the anorexia and not a separate pathology from the condition (Halter, 2017).
Dermatologic issues related to anorexia include dry, cracked skin, loss of skin turgor, edema, lanugo (downy fine hair over the body due to heat loss), and acrocyanosis (bluish discoloration of the hands and feet due to poor circulation) (Halter, 2017).
Reproductive system concerns include a decrease in estrogen, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). This leads to failure to ovulate, infertility and amenorrhea (Halter, 2017).
Even though bulimia does not lead to starvation as previously discussed, serious fluid and electrolyte imbalances can result from the binging and purging of food. Major imbalances include hypokalemia, hyponatremia, or hypochloremia resulting in symptoms as listed in Table 2. Additionally, metabolic alkalosis can result from the elevated bicarbonate levels in the blood. This is evidenced by a blood pH above 7.45 and a bicarbonate level above 26 mEq/L caused by the excessive loss of acid in the GI tract from vomiting. Diuretic use can also promote metabolic alkalosis. Thiazide diuretics such as hydrochlorothiazide (HCTZ, Hydrodiuril) or loop diuretics such as furosemide (Lasix) cause fluid loss along with the loss of potassium, hydrogen, and chloride through the kidneys. The low serum potassium levels cause the kidneys to excrete hydrogen ions in an attempt to conserve potassium. The potassium moves out of the cells, allowing hydrogen to move into the cells, resulting in alkalosis. Metabolic alkalosis can result in slow, shallow respirations that lead to hypoxemia (a low level of oxygen in the blood) in the early stages; then, as the condition progresses, respirations may increase in an attempt to correct the hypoxemia (Halter, 2017; Thomas, 2018).
Long-term bulimia can lead to overall poor health outcomes such as hypertension, arrhythmias, severe tooth decay, gum disease, esophageal erosion and bleeding, gastric rupture due to repeated vomiting episodes, irregular periods, and mental health disorders such as anxiety, depression, personality disorders, substance abuse, or suicidal tendencies. If severe dehydration develops, it can lead to renal failure (Halter, 2017; Mayo Clinic, 2018c).
The pathophysiology of BED is mostly related to weight gain and subsequent obesity. The increased weight leads to hypertension, elevated cholesterol and triglycerides leading to cardiovascular disease, type 2 diabetes, gallbladder disease, sleeping disorders such as obstructive sleep apnea, dental problems due to the foods that are chosen during binges such as high-fat, high-carbohydrate foods, and coronary artery disease (CAD). Mental health concerns include depression and suicidality due to the weight gain and the self-disgust associated with binge eating (Eating Disorder Hope, 2019; Halter, 2017). For more on obesity complications, see the Bariatric Surgery NursingCE module.
Diagnosing Eating Disorders
Anyone can suffer from an eating disorder, and families are often unaware that there is a problem. The person is aware that their behavior is not normal and may isolate themselves socially, deny that they have an issue when confronted, or hide their eating habits from others. Research indicates that many people with eating disorders will go untreated; less than 13% of those with an eating disorder during adolescence are actually diagnosed and treated. The failure to treat can lead to death, particularly with anorexia. The body can be devastated by eating disorders. Anorexia can lead to anemia, osteoporosis, heart damage, or even brain damage, while bulimia can lead to acid reflux, worn tooth-enamel, or heart attack. BED is associated with hypertension, cardiovascular disease, diabetes, and all the other complications of obesity (APA, 2011; Stoppler, 2019).
While there can be non-distinct manifestations of eating disorders such as weight fluctuation, others are more recognizable. Symptoms of anorexia, bulimia, and BED can be seen in Table 3.
For suspected eating disorders, the healthcare provider should obtain a patient history that focuses on eating patterns, attitudes towards eating, exercise, and appearance. A family history of obesity, eating disorders, and psychiatric disorders such as depression, anxiety, or substance abuse disorders should be completed as well (NEDA, 2018). The medical examination should include:
- Physical examination-weight, height, body mass index (BMI), growth chart assessment for children or adolescents, skin condition, hair distribution or loss, evidence of self-abuse/injury, and cardiovascular/peripheral vascular function.
- Body temperature
- Orthostatic blood pressure
- Oral examination (with a focus on dental condition if vomiting is suspected)
- Laboratory test
- Complete blood count (CBC)
- Comprehensive metabolic profile (CMP)
- Blood glucose
- Blood urea nitrogen (BUN)
- Liver enzymes (ALT, AST, ALP)
- Total bilirubin
- Serum magnesium and phosphate
- Urine specific gravity
- Thyroid screen
- TSH (NEDA, 2018).
If there is an uncertain diagnosis, further testing might include an estradiol level (lowered estrogen levels are expected with anorexia), erythrocyte sedimentation rate (ESR), and radiographic studies of the brain, upper GI, or lower GI series. For extremely underweight females with sustained amenorrhea, a dual energy X-ray absorptiometry (DEXA) scan for bone density measurement should be done. Urine pregnancy, LH, FSH, and prolactin testing should be completed in those without a menstrual period for more than six months (Halter, 2017; NEDA, 2018).
Screening for mental health disorders is typically completed by the primary healthcare provider, and referral to a mental health professional may be indicated (Mayo Clinic, 2018a)
Treatment Interventions for Eating Disorders
Treatment for all eating disorders begins with an accurate diagnosis and recognizing the mitigating circumstances that may have led to the disorder, such as an underlying mental health disorder. With all eating disorders, mental health can be a risk factor for the development or can be a result of the disorder itself. So, a clear diagnosis and prompt treatment of the mental health aspects of eating disorders is vital. A team approach is taken for eating disorders, but especially with anorexia. The complexity of the disease and its effects on multiple body systems necessitates a multidisciplinary approach to fully meet the needs of the patient. Ongoing psychotherapy, nutritional counseling, and monitoring of physiological needs are required with each. A closer look at the treatment for each disorder is below (Halter, 2017; Mayo Clinic, 2018a; NEDA, 2018).
Hospitalization is often required to meet the immediate needs of the anorexic patient. They are often brought into the emergency room with heart arrhythmias, dehydration, electrolyte imbalances, or even a psychiatric emergency. If the patient refuses to eat upon hospitalization, they may be admitted for severe psychiatric problems and/or malnutrition. Patients may be placed in a treatment facility specializing in eating disorders that offers intensive treatment over a longer period of time. Medical care is focused on immediate threats to health, including electrolyte imbalances, acid-base imbalances, rehydration, and in more severe cases, the patient may require a feeding tube (Mayo Clinic, 2018a).
The primary goal of treatment is to get to a healthy weight. Most aspects of anorexia can be corrected by getting to a healthy weight and maintaining good nutrition. The primary healthcare provider, mental health professional, dietician or nutritional expert, and family or friends will all be involved in the healing process for patients with anorexia. Individual and family-based psychotherapy is recommended for these patients. Because the family is often a primary risk factor for anorexia, therapy for the entire family may be needed. Teenagers, in particular, need family-based therapy to assist them in making good choices for their health, and engaging the family in their recovery is important. Therapy helps the parents learn to communicate therapeutically with the teen with anorexia and aids in promoting weight restoration. The secondary goal of treatment for anorexia is to help change the patient’s beliefs and thoughts that led to the restrictive eating in the first place. Individual psychotherapy is used to this end, and while teens benefit as well, adult patients seem to respond best to individual cognitive-behavioral therapy (Mayo Clinic, 2018a).
Medications are not typically used in the treatment of anorexia; however, antidepressants or other psychiatric medications may be useful in treating underlying or subsequent mental health disorders. One of the greatest barriers to treating anorexia is the patient’s perception that they do not need treatment; they may see their weight as a lifestyle choice or have an unrealistic fear of gaining weight. Due to these firmly held beliefs, relapses are common, particularly during times of stress. Ongoing monitoring for the mental and physical indications of anorexia are needed to ensure lifetime success and optimal patient outcomes (Halter, 2017; Mayo Clinic, 2018a).
The team approach to treating bulimia has been proven effective. The use of psychotherapy and antidepressants is noted as highly effective in overcoming the disorder. A dietician that is experienced in eating disorders can be a useful team member along with a primary care provider and mental health professional. Psychotherapy is generally focused on individual cognitive-behavioral therapy. Interpersonal psychotherapy may also be helpful in teaching communication and problem-solving skills with personal relationships, including family and friends. The patient needs support to normalize their eating patterns and address the underlying feelings that led to the disorder initially. These behaviors need to be replaced by healthy and positive behaviors that can support a healthy weight and nutritional intake (Halter, 2017; Mayo Clinic, 2018c).
Teenagers suffering from bulimia may benefit from family therapy to support the parents in recognizing unhealthy behaviors and guiding them to healthier habits and behaviors. The entire family is often involved in the underlying issues that led to the bulimia and should understand the implications for the teen's future health and how to support the development of healthy behaviors (Mayo Clinic, 2018c).
The antidepressant most often used in patients with bulimia is fluoxetine (Prozac). The selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac) may help the bulimia patient, even where depression is not present. It is the only medication approved by the Food and Drug Administration (FDA) for the treatment of bulimia (Mayo Clinic, 2018c).
Nutritional education will be focused on a healthy eating plan that helps to decrease hunger and cravings. Consuming small nutritious meals and snacks throughout the day helps to keep the patient satisfied and feels less restrictive than three meals that are restrictive in caloric content and quantity of food. Bulimia is not usually treated in the hospital and is not usually found in an emergency visit. Rather, programs that offer day treatments or outpatient therapy are preferred. Treatment challenges can include periods of binging and purging that are often triggered by stress or life events. Lifestyle changes and home remedies to incorporate into the treatment plan include being cautious with exercise, sticking to the treatment plan developed by the healthcare team, empowerment through education, getting the right nutrition daily, nurturing caring relationships that can support the journey of recovery, and resisting urges to fall back into unhealthy habits like daily weights or looking in the mirror frequently. Dietary supplements and herbal products are tempting but can be part of the unhealthy weight loss cycle. The use of any of these products should be discussed with the healthcare team to determine if it should be part of the treatment plan (Mayo Clinic, 2018b).
Parents of patients with bulimia may blame themselves for their child's disorder. A focus on helping the patient is most important during recovery, and they should be taught communication strategies to support optimal outcomes. Suggestions include asking the teen to participate in family activities after eating to reduce the temptation to purge, listening to their child and allowing them to express their feelings, planning regular mealtimes as a family, and communicating about concerns without placing blame. Eating disorders affect the entire family, and learning to communicate is very important. Finally, relapse is possible, and the patient should be aware of this. When a patient finds themselves falling back into the binge-purge cycle, a visit to the primary healthcare provider, mental health professional, and/or dietician can help to stop the cycle and get back on the road to recovery. If relapse occurs, rather than feel guilty, it is important to be empowered to seek the help that is needed (Halter, 2017; Mayo Clinic, 2018c).
The primary goals for the treatment of BED are to reduce the binges, gain control of eating habits, and ensure proper nutrition. Since BED may be interwoven with mental health disorders such as depression and anxiety, treatment must address these issues if they are present. Psychotherapy may be done individually or in a group setting. Cognitive-behavioral therapy, interpersonal therapy, and dialectical behavioral therapy have all been identified as useful components of management for BED. Cognitive-behavioral therapy can aid in the development of coping mechanisms to avoid binge eating, while interpersonal psychotherapy focuses on relationships with other people that may trigger the binge episodes. Dialectical behavior therapy can help the patient learn skills to better tolerate stress and regulate emotions, thus lowering the desire to binge (Mayo Clinic, 2018b).
Medications are a vital part of BED management. Lisdexamfetamine dimesylate (Vyvanse), which was approved for attention-deficit hyperactivity disorder originally, was approved by the FDA to treat moderate to severe BED in adults. Lisdexamfetamine dimesylate (Vyvanse) is a stimulant and can be habit-forming or abused. Common side-effects include insomnia and a dry mouth; more serious side effects include tachycardia, elevated blood pressure, and palpitations. Central nervous system (CNS) side effects can include irritability, anxiety, jitteriness, emotional liability, nightmares, or tic disorders. Erectile dysfunction, urinary tract infection, dyspnea, fever, GI disturbances, and hyperhidrosis can occur. Cardiovascular events have occurred, including sudden death, stroke, and MI. Many drug-drug interactions occur with lisdexamfetamine dimesylate (Vyvanse), including acebrophylline (Adbrophyll), Iobenguane I-123 (AdreView), monoamine oxidate inhibitors such as selegiline (Zelapar), isocarboxiazid (Marplan), tranylcypromine (Parnate), and phenelzine (Nardil). These drugs are contraindicated with lisdexamfetamine dimesylate (Vyvanse) and should not be administered simultaneously (Fookes, 2019). Other medications that may reduce the symptoms of BED include topiramate (Topamax), which is an anticonvulsant that decreases binges associated with BED. Side effects of topiramate (Topamax) include dizziness, drowsiness, difficulty concentrating, and nervousness. Other antidepressants, including SSRIs, may be used to reduce binge-eating episodes. While it is not clear how these reduce the binges, it is thought to be linked to brain chemicals that affect mood (Mayo Clinic, 2018b).
Weight loss programs are not typically indicated with BED until the disorder is treated. Dieting can trigger further episodes of binge eating and/or further eating disorder development, such as anorexia or bulimia. Weight-loss programs should be done under medical supervision of the entire healthcare team. Lifestyle or home remedies for BED should be done only after a treatment plan has been developed. Focus should be on the maintenance of the treatment plan. Dieting should be avoided, and eating plans developed by the dietician should be followed meticulously. Foods in the home should be limited to healthy choices that are allowed in the eating plan; junk foods, or high-fat, high-carbohydrate snacks should be kept out of the home. Getting active is an important component of recovery from BED. While exercise plans should be approved by the healthcare team, they can help reduce stress and improve overall mood. A strong support team that is aware of the treatment plan and goals for health can improve compliance. Dietary supplements and herbals may be misused by people with eating disorders, and any use should be discussed with the primary healthcare provider. Living with BED can be challenging and requires a strong support system. The person suffering from BED should avoid self-criticism, identify situations that trigger binges and avoid them, find positive role models in their life, develop strong relationships with trusted friend and family members, and find healthy ways to self-nurture such as yoga, walks, meditation, or massages. Journaling has proven to be another helpful tool toward insight into feelings and how to recognize stressors (Halter, 2017; Mayo Clinic, 2018b).
Other Eating Disorders
Other eating disorders that may be found in clinical practice include avoidant/restrictive food intake disorder that develops in infancy or early childhood. These children do not grow as expected and may be diagnosed with failure to thrive. They will have significant nutritional deficiencies and may require enteral or oral nutritional supplements (American Psychiatric Association, 2013). The DSM-5 further identifies the following eating or feeding disorders:
- Atypical anorexia nervosa - the individual displays all the criteria needed to diagnose anorexia but remains in or above their normal weight range for height.
- Bulimia nervosa of low frequency or low duration- exists when all criteria for bulimia are met with the exception of frequency (more than once per week for more than three months).
- Being-eating disorder of low frequency or limited duration- all symptoms for BED are present except the required criterion of frequency (more than once a week for more than three months).
- Night eating syndrome- characterized by ongoing episodes of eating large amounts of food after going to sleep and waking. This person is aware they are waking up and binging but have no other symptoms of BED or substance abuse (American Psychiatric Association, 2013).
Future Opportunities for Those with Eating Disorders
The Mayo Clinic currently has a clinical trial underway for former adolescents and their parents to develop an eating disorder assessment and management protocol for primary care providers (Mayo Clinic, n.d.).