MNT in Eating Disorders

1. MNT in Eating Disorders

2. The Ideal Body Image • Media promotion • Social acceptance • Influence and stress on young individuals

3. Food: More Than Just Nutrients • Linked to personal emotions • Comfort • Release of natural opioids • Reward

4. Eating Disorders (APA Diagnoses) • Anorexia nervosa • Bulimia nervosa • Eating disorder not otherwise specified (EDNOS) • Binge eating disorder (BED) Schebendach in Krause, 12th ed., p. 564)

5. Genetic Link? • Identical twins have a higher chance of eating disorders • Fraternal twins are less likely

6. Profile of Anorexia • Usually occurs between the ages of 12-18 • Typically white female • Lifetime prevalence among women is .3 to 3.7%, depending on criteria used • 5%-10% are male • Middle-upper socioeconomic class • Often coexists with other psychiatric disorders: major depression or dysthymia (50-75%), anxiety disorders, OCD (40%) • 5-20% mortality rate, mostly from heart failure or arrhythmias Schebendach in Krause, 12th Ed, p 564

7. Anorexia Nervosa: Psychological Features • Perfectionism • Harm avoidance • Feelings of ineffectiveness • Inflexible thinking • Overly restrained emotional expression • Limited social spontaneity Schebendach in Krause, 12th Ed., p. 564

8. Anorexia Nervosa • Food rituals • Cuts food in small pieces • Rearranges food on plate • Eliminates foods gradually • 300-600 calories a day • Diet pop, sugarless gum • Prolonged exercise • Preoccupation with food • Cooks for others • Hungry, but refuses to eat

9. Diagnostic Criteria • American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria are the standard

10. AN APA Diagnostic Criteria • Weight <85% standard • Intense fear weight gain/fat although underweight • Distorted body image • Women: amenorrhea: absence of 3 consecutive periods • Restricting type • Not regularly engaged in binge eating-purging behavior • Binge eating/purging type • Regularly engaged in binge eating and purging behavior

11. AN Diagnostic Criteria • Weight deficit is necessary (<85% of expected) • If AN develops in childhood or early adolescence, failure to make expected weight gains instead of weight loss may occur • Stunting possible in prepubertal children • Growth charts are essential • Amenorrhea may not be useful in younger patients as menarche may be delayed

12. Related Psych Disorders in AN • Depression: May be due, in part, to the psychological stress of starvation • Obsessive-compulsive disorder: may be exacerbated by malnutrition • Comorbid personality disorders: poor impulse control, substance abuse, mood swings, and suicide tendencies

13. Prevalence of AN • More prevalent in industrialized countries that idealize a thin body type although expected to become more widely distributed • Lifetime prevalence among women is .5% to 3.7%, depending on criteria used • Prevalence among men is one tenth of that among women Schebendach in Krause, 12th edition, p. 564

14. Risk Periods for Anorexia Nervosa • Age 14 – puberty, high school • Age 18 – college, full time jobs

15. Pathophysiology of AN • Physical and psychological consequences of malnutrition

16. Pathophysiology of AN • Depleted fat stores; muscle wasting • Amenorrhea • Cheilosis • Postural hypotension; dehydration or edema • Bradycardia; hypothermia • Sleep disturbances

17. Pathophysiology of AN: Osteopenia • Reduced bone mineral density • May result in vertebral compression, fractures • Caused by estrogen deficiency, elevated glucocorticoid levels, malnutrition, reduced body mass • Affects males and females

18. Pathophysiology of AN • Low body temperature/cold intolerance • Lower metabolism: low thyroid hormone • Bone marrow hypoplasia (50% of AN patients) results in leukopenia, anemia, thrombocytopenia

19. Pathophysiology of AN: Cardiovascular • Decreased heart rate <60 bpm • Fatigue, fainting • Decreased blood pressure <70 mm/Hg systolic; orthostatic hypotension • Reduction in heart mass • Mitral valve prolapse related to hypovolemia or cardiomyopathy • Death from CHF

20. Pathophysiology of AN • Iron deficiency anemia • Increased infections • Dry skin, hair • Yellow skin due to hypercarotenemia • Desquamation, hair loss, alopecia • Hirsutism • Lanugo: fine body hairs

21. Pathophysiology of AN: GI • Bloating, abnormal fullness after eating • Constipation • Digestive enzymes low

22. Pathophysiology of AN • Electrolyte imbalance → heart failure, death • Low intake potassium • Loss in vomiting, diuretics • Refeeding syndrome: electrolyte imbalances caused by too-rapid refeeding

23. Bulimia Nervosa An illness characterized by repeated episodes of binge eating followed by inappropriate compensatory methods • Purging, including self-induced vomiting or misuse of laxatives, diuretics, or enemas • Non-purging including fasting or engaging in excessive exercise

24. Bulimia Nervosa APA Criteria • Characterized by recurrent episodes of binge/purge eating • Average ≥ 2 binges/purge cycles/week • Uncontrollable eating during binge • Purge regularly: vomiting, laxatives, diuretics, strict dieting, fasting, vigorous exercise • Continues at least 2x/wk for ≥ 3 months American Psychological Association. DSM-IV-TR, ed 4, Washington DC, 2000

25. Bulimia Nervosa Prevalence • Lifetime prevalence of BN among young adult women is 1% to 3% • Rate of occurrence in males is 10% of that in females • Rarely seen in childhood Schebenbach, in Krause, 12th edition, p. 565

26. Bulimia Nervosa Prevalence • 5% of college women • 20% of college women exhibit symptoms (Sx) • 50% of those with anorexia nervosa develop bulimia nervosa • Gorging and purging/vomiting • Susceptible populations—athletes, actors, dancers, wrestlers, runners

27. Profile of Bulimia • Young (usually female) adults (college students) • May be predisposed to becoming overweight • Usually at or slightly above normal weight • Tried frequent weight-reduction diets as a teen • Impulsive • Often goes undiagnosed

28. Profile of Bulimia Nervosa • Other psychological disorders, including major depression, dysthymia, anxiety disorders, personality disorders, substance abuse • Low self esteem • Guilt • Preoccupied with food • Recognize behavior is abnormal

29. Binge Definition • Eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most people would eat under similar circumstances • A sense of lack of control over eating during the episode

30. Binge • Relieves stress • Common binge foods: • High carbohydrate, high fat • Convenience foods • Cakes, cookies, ice cream • Soft, easier to purge • High food bills

31. Purge • Laxatives, enemas • Act on large intestine • 90% of calories are absorbed in small intestine • Damages large intestine → constipation

32. Vomiting • Most commonly used compensatory behavior (80%-90% of BN) • 33-75% of calories still absorbed • Fingers down throat • Damaged knuckles • Syrup of Ipecac • Toxic to heart, liver, kidneys • Poison if taken repeatedly

33. Vomiting • Teeth • Stomach acid erodes enamel • Pain, decay

34. Diuretics • Water loss • Electrolyte loss • NO fat loss!

35. Hypergymnasia: Excessive Exercise • Compulsive exercise: that which significantly interferes with life activities • Occurs at inappropriate times or in inappropriate settings • Continues despite injury or other medical complications

36. Symptoms of BN • Usually normal weight and secretive in behavior • Scarring of the dorsum of the hand used to stimulate the gag reflex, known as Russell’s Sign • Parotid gland enlargement • Erosion of dental enamel with increased dental caries resulting from gastric acid in the mouth

37. Pathophysiology of BN: Vomiting • Dehydration • Alkalosis • Hypokalemia • Sore throat, esophagitis, mild hematemesis • Abdominal pain

38. Pathophysiology of BN: Vomiting • Subconjunctival hemorrhage • Mallory-Weiss esophageal tears • Esophageal ruptures (rare) • Acute gastric dilatation or rupture • Salivary gland infections

39. Pathophysiology of BN: Laxative Abuse • Dehydration • Elevation of serum aldosterone and vasopressin levels • Rectal bleeding • Intestinal atony • Abdominal cramps

40. Pathophysiology of BN: Diuretic Abuse • Dehydration • Hypokalemia

41. Pathophysiology of BN • Cardiac arrhythmias related to electrolyte and acid-base imbalance caused by vomiting, laxative, and diuretic abuse • Ipecac may cause irreversible myocardial damage and sudden death • Menstrual irregularities

42. Vicious Cycle of Bulimia

43. Eating Disorder Not Otherwise Specified (EDNOS) • A diagnostic category for eating disorders that fail to meet full criteria for either anorexia nervosa or bulimia nervosa • May have partial symptoms of either AN or BN • For example, all criteria for AN may be met except patient has regular menses • OR significant weight loss but wt still in normal range

44. Physical Manifestations of Eating Disorders

45. Treatment of Eating Disorders

46. AN: Treatment Nutrition • Increase food intake to raise the BMR • Prevent further weight loss • Restore appropriate food habits • Ultimately weight gain • Some weight restoration and treatment of malnutrition may make psychotherapy more effective

47. AN: Treatment Psychological • Cognitive behavior therapy • Determine underlying emotional problems • Reject the sense of accomplishment associated with weight loss • Family therapy, support group

48. Nutrition Assessment in Eating Disorders

49. Assessment of Intake in Eating Disorders • Calories compared with DRI • Evaluate macronutrient mix (carbohydrate, protein, fat) • Evaluate micronutrient intake compared with DRI • Estimate fluids and compare with needs • Evaluate alcohol, caffeine, drugs, dietary supplements

50. Dietary Intake in AN • Generally inadequate caloric intake, <1000 kcals/day • Tend to avoid fat • Many follow a vegetarian lifestyle • Identify whether vegetarian lifestyle coincided with onset of disease