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Chapter 18 Eating Disorders

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Chapter 18 Eating Disorders

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Eating disorders can be viewed on a continuum: the anorexic eats too little or is starving, the bulimic eats in a chaotic way, and the obese person eats too much. There is much overlap among the eating disorders: 50% of clients with anorexia exhibit bulimic behavior and 35% of normal-weight clients with bulimia have a history of anorexia. More than 90% of cases of anorexia nervosa and bulimia occur in females.
anorexia nervosa
Anorexia Nervosa

Life-threatening eating disorder characterized by:

  • Client’s refusal or inability to maintain a minimally normal body weight
  • Intense fear of gaining weight or becoming fat
  • Significantly disturbed perception of the shape or size of the body-most difficult to resolve successfully
  • Steadfast refusal by client to acknowledge the problem is severe or that there is even a problem at all
85% of expected body weight or less
  • Amenorrhea—at least 3 consecutive cycles-nurse to suspect anorexia-esp if weight loss is an issue
  • Total absorption in quest for thinness and weight loss
Onset and Clinical Course
  • Anorexia typically begins between 14 and 18 years of age. Unrealistic perception of body size.
  • Ability to control weight give pleasure to the client.
  • Client may feel empty emotionally and be unable to identify or express emotional feelings.
  • As illness progresses, depression and labile moods are common.
Client is socially isolated, mistrustful of others; may believe that others are trying to make her fat and ugly
  • Long-term studies show that after 21 years, 50% had fully recovered,
  • 25% had intermediate outcomes, 10% still met criteria for anorexia, and 15% had died from causes related to anorexia
bulimia nervosa
Bulimia Nervosa
  • Characterized by recurrent episodes of binge eating(uncontrollable craving for food), inappropriate compensatory behaviors to avoid weight gain (purging: self-induced vomiting, use of laxatives, diuretics, enemas, emetics, fasting, excessive exercise).
  • Binge eating is done in secret and the client recognizes the eating behavior as pathologic, causing feelings of guilt, shame, remorse, or contempt. Clients with bulimia are usually in normal weight range but may be underweight or overweight.
Dentists may be the first to discover bulimia due to loss of tooth enamel, caries, chipped or ragged teeth.
Onset and Clinical Course
  • Begins about age 18 or 19
  • Binge eating begins after an episode of dieting.
  • Between binges, eating may be restrictive.
  • Food is hidden in the car, desk at work, and secret locations around the house.
  • Behavior may continue for years before it is discovered.
About 50% of clients recover completely, 20% continue to meet all criteria for bulimia, 30% have episodic bouts of bulimia. One third of fully recovered clients have a relapse. Death rate for bulimia is estimated at 0% to 3%.

Specific etiology for eating disorders is unknown, but initially dieting may be the stimulus that leads to the eating disorder.

Biologic Factors
  • Genetic vulnerability
  • Disruptions in the nuclei of the hypothalamus relating to hunger and satiety (satisfaction of appetite)
  • Neurochemical changes are seen, but it is not known if these changes cause the disorders or are a result of eating disorders
developmental factors anorexia nervosa
Developmental Factors: Anorexia Nervosa
  • Struggle to develop autonomy and identity (lack of control, fear of growing up and maturing)
  • Overprotective or enmeshed families that lack clear roles and boundaries
  • Body image disturbance and body image dissatisfaction
developmental factors bulimia nervosa
Developmental Factors: Bulimia Nervosa
  • Separation-individuation difficulties (excessive anxiety over growing up, leaving home and becoming independent).
  • Body image dissatisfaction.
family influences
Family Influences
  • Families of anorexic clients are often rigid and overprotective; avoid interpersonal conflict by ignoring it; stifle the client’s attempts at autonomy and identity formation
  • Families of bulimic clients are chaotic, lack clear boundaries, are achievement-oriented; client feels pressure to be successful, to please others, to maintain harmony
sociocultural factors
Sociocultural Factors
  • Image of ideal woman as thin and perfectly toned in U.S. and westernized countries
  • Books, magazines, TV promote this thin image as well as numerous “beauty” industries (weight loss, plastic surgery, body-building, etc.)
  • Being overweight is often equated with being lazy, lacking willpower, being “bad” or unsuccessful.
  • Pressure from peers, parents, and coaches may also contribute to the development of eating disorders.
cultural considerations
Cultural Considerations
  • Eating disorders are more prevalent in countries where food is prevalent and beauty is linked to being thin.
  • Immigrants from cultures where eating disorders are rare may develop eating disorders as they assimilate the thin ideal body image.
  • Eating disorders are equally common among Hispanic and white women but are less common among African American and Asian women.
treatment anorexia nervosa
Treatment: Anorexia Nervosa
  • Setting depends on severity of illness. More medically compromised clients require inpatient care; risk of suicide is significant.
  • Outpatient therapy is more likely to be effective for those who have been ill less than 6 months, who are not bingeing and purging, and who have parents who participate in family therapy.
  • Medical management focuses on weight restoration, nutritional rehabilitation, rehydration, correction of electrolyte imbalances.
treatment anorexia nervosa21
Treatment: Anorexia Nervosa
  • Generally client is supervised during meals to ensure eating and after meals while using bathroom to prevent purging. Up 2 hours after closely watched. Nurse will sit quietly with client while he or she eats.
  • Weight gain and adequate intake are often criteria for judging treatment effectiveness.
  • Many drugs have been studied and tried, but few show success. Fluozetine (Prozac) may help prevent relapse but only when weight has been gained because it can cause weight loss due to appetite suppressant.
  • Family therapy- resolve family conflicts-restoring control issues
treatment bulimia nervosa
Treatment: Bulimia Nervosa
  • Most clients are treated on outpatient basis; inpatient only if bingeing and purging behavior is out of control or medical status is compromised
  • Cognitive-behavioral therapy has been effective; designed to change client’s thinking and actions about food, eating, weight, body image, and self-concept-Have client write about all feelings and experience related to food-self- monitoring.
  • Medications are marginally effective; antidepressants do improve mood, reduce preoccupation with shape and weight, reduce bingeing and purging behaviors
application of the nursing process eating disorders
Application of the Nursing Process: Eating Disorders


  • Many assessment tools have been developed to identify eating disorders and measure progress toward achieving outcomes.
  • History: Client with anorexia is described by parents as a model child, no trouble, dependable, before onset of anorexia. Clients with bulimia are eager to please and conform, avoid conflict, but may have history of impulsive behavior. Self imposed dieting-leading to severe weight loss.
Assessment (cont’d)
  • General appearance and motor behavior: Clients with anorexia are slow, lethargic, even emaciated; slow to respond to questions, difficulty deciding what to say, reluctant to answer questions fully; often wear baggy clothes or layers to hide weight or keep warm; limited eye contact; unwilling to discuss problems or enter treatment. Clients with bulimia generally have a normal appearance, are open and talkative.
application of the nursing process eating disorders25
Application of the Nursing Process: Eating Disorders
  • Mood and affect: Moods are labile, corresponding to eating or dieting behavior. Clients with anorexia may look sad and anxious and seldom smile or laugh. Clients with bulimia are initially cheerful but express intense emotions of guilt, shame, and embarrassment when discussing bingeing and purging behaviors.
application of the nursing process eating disorders cont d
Application of the Nursing Process: Eating Disorders (cont’d)
  • Ask clients with eating disorders about suicidal ideas and self-harm urges; both are common.
  • Thought processes and content: Clients spend most of their time thinking about food, dieting, food-related issues. Body image disturbance can be almost delusional. Clients with anorexia may have paranoid ideas about their family and health care professionals being the “enemy,” trying to make them fat.
application of the nursing process eating disorders cont d27
Application of the Nursing Process: Eating Disorders (cont’d)
  • Sensorium and intellectual processes: generally alert, oriented, intact; exception is the severely malnourished client with anorexia, who may have mild confusion, slowed mental processes, and difficulty with concentration and attention.
application of the nursing process eating disorders cont d28
Application of the Nursing Process: Eating Disorders (cont’d)
  • Judgment and insight: Clients with anorexia have very limited insight and poor judgment about health status. Giving factual information has no effect. Restrictive dieting continues despite failing health and malnutrition. Clients with bulimia have insight into the pathologic nature of their eating behavior but feel out of control and unable to change that behavior.
application of the nursing process eating disorders cont d29
Application of the Nursing Process: Eating Disorders (cont’d)
  • Self-concept: Low self-esteem is prominent in clients with eating disorders; they see themselves only in(anorexic’s) terms of their ability to control food intake and weight and judge themselves harshly and see themselves as “bad” if they eat certain foods or fail to lose weight. Other personal characteristics are overlooked or ignored. Clients see themselves as powerless, helpless, and ineffective.
Roles and relationships: Eating disorders interfere with clients’ abilities to fulfill roles and have satisfying relationships. The client with anorexia may have failing grades in school, in sharp contrast to previous high-level performance. She withdraws from her peers, believing others will not understand. The client with bulimia is ashamed of bingeing and purging and hides it from others. The amount of time spent buying and consuming food can interfere with role performance at work and home.
application of the nursing process eating disorders31
Application of the Nursing Process: Eating Disorders
  • Physiologic and self-care considerations: Client’s health status is directly related to severity of self-starvation and purging behavior. Excessive exercise may lead to exhaustion. Many clients have trouble sleeping. Frequent vomiting causes sores in the mouth and dental problems.( need good oral hygiene) Thorough medical evaluation is essential.
Data Analysis
  • Nursing diagnoses may include:
  • Imbalanced Nutrition: Less Than/More Than Body Requirements
  • Ineffective Coping
  • Disturbed Body Image –initial goal for treating the severely malnourished client
  • Other diagnoses such as Deficient Fluid Volume, Constipation, Fatigue, and Activity Intolerance may be indicated.

The client will:

  • Establish adequate nutritional eating patterns
  • Eliminate use of compensatory behaviors such as laxatives, enemas, diuretics and excessive exercise
  • Demonstrate non-food-related coping mechanisms
  • Verbalize feelings of guilt, anger, anxiety, or excessive need for control
  • Verbalize acceptance of body image with stable body weight
  • Establishing nutritional eating patterns
  • Helping client identify emotions and develop coping strategies
  • Dealing with body image issues
  • Client and family education
  • Evaluation may involve use of an assessment tool to measure progress.
  • Body weight within 5% to 10% of normal
  • No medical complications from starvation or purging
  • Positive progress-the client identifies healthy ways of coping with anxiety
community based care
Community-Based Care
  • In addition to outpatient treatment, includes individual or group therapy and self-help groups
  • Prevention and early detection are essential.
  • Nurses play a key role in educating parents, children, and young people on issues of unrealistic “ideal” images in the media: realistic ideas about body size and shape, resisting peer pressure to diet, improving self-esteem, coping strategies for dealing with emotions and life issues
Routine screening for eating disorders in high school and colleges and universities might prove useful.
self awareness issues
Self-Awareness Issues
  • Feelings of frustration when client rejects help
  • Being seen as “the enemy” if you must ensure the client eats
  • Dealing with own issues about body image and dieting