EATING DISORDERS

Nutrition department
Medical school
University of Sumatera Utara
 Psychiatric condition
Characterized by abnormal eating patterns and
cognitive distortions related to food and body
weight, which adversely affect nutritional
status and lead to medical complications and
impaired health status and function
3rd most common chronic illness in adolescent
females
 ANOREXIA NERVOSA (AN)
BULIMIA NERVOSA (BN)
EATING DISORDER NOT OTHERWISE
SPECIFIED (EDNOS)
 ANOREXIA NERVOSA

Voluntary self-starvation and emaciation

Weight loss is viewed as a sign of extraordinary
achievement and self-discipline
Weight gain is perceived as an unacceptable
loss of self-control
 1-2% of young adult women
85% during adolescent
Increased risk occurs with conditions in which
dietary restraint or control of body weight is
considered important (e.g. athletes, DM)
American Psychiatric Association
Diagnostic Criteria for AN

A. Refusal to maintain body weight at or above a

minimally normal weight for age and height
(e.g. weight loss leading to maintenance of
body weight less than 85% of that expected;
or failure to make expected weight gain
during period of growth, leading to the body
weight less than 85% of that expected
B. Intense fear of gaining weight or becoming
fat, even though underweight
C. Disturbance in the way in which ones body
weight or shape is experienced; undue
influence of body weight or shape on self-
evaluation; or denial of the seriousness of the
current low body weight
D. Amenorrhea in postmenarcheal females, i.e.,
the absence of at least three consecutive
menstrual cycles
Specific type :
Restricting type : during the current of AN,
the person has not regularly engaged in
binge eating or purging behavior
Binge eating/purging type : during the
current episode of AN, the person has
regularly engaged in binge eating and purging
behavior
 Body image distortion feel fat despite their
often cachectic state
Symptom depression (+) due to the
psychological stress of starvation
Obsessive compulsive features (+)
particularly with regard to food
Typically reject treatment
Body Image= How you see your body
and the way you feel about it.
 APA recommends that in AN :
1. depressive symptoms should be reassessed
after partial or complete weight restoration
2. patients exhibiting non-food related
obsessive compulsive behaviors should be
evaluated for a co morbid diagnosis of obs-
com disorders
 Characteristics
Determined food avoidance
Weight loss or failure to gain weight during the period
of preadolescent growth (10-14 yr) in the absence of
any physical or mental illness
Any two or more of the following :
- preoccupation with body weight
- preoccupation with energy intake
- distorted body image
- fear of fatness
- self induced vomiting
- extensive exercising
- laxative abuse
 Etiology

Multifactorial, with biologic, genetic, familial,

sociocultural precipitans
Typically introverted, obsessional, and
perfectionistic in nature
Family pathology : overprotectiveness, rigidity
Comorbid anxiety disorders, depressive
disorders, personality disorders
Physical features
Weight < 85% expected BMI < 17,5
Lanugo hair on face & trunk, brittle listless
hair
Cyanosis on hands & feet, dry skin
CV changes bradycardia, hypotension
Orthostatic hypotension
GI changes delayed gastric emptying, gut
motility , severe constipation
 Medical & nutritional management
Goals : - nutritional rehabilitation
- weight restoration
- cessation of weight reduction behavior
- improvement eating behavior
- improvement in psychological and
emotional state
Forcing weight gain without psychological support
and counseling is contraindicated
 Nutrition counseling targeted helping the
patients understand nutritional needs, make
wise food choices by increasing variety in the
diet, practice appropriate food behavior
Individualized guidance and meal plan that
provides a framework for meal & snacks and
food choices helpful for most patients
During early refeeding monitored closely for
sign of refeeding syndrome
 BULIMIA NERVOSA (BN)
Characterized by recurring episodes of binge
eating followed by one or more inappropriate
compensatory behaviors to prevent weight
gain
Self induced vomiting, laxative abuse, diuretic
abuse, excessive fasting, compulsive exercise
The binge eating behavior that is central to
the diagnosis
 Typically within the normal weight range,
some may be under or overweight
Binge : consumption of an unusually large
amount of food in a discrete period (usually
2 hours)
Self-induced vomiting the most commonly
used (80-90%)
Stimulate the gag reflex with a finger or
instrument
Syrup ipecac cardiomyopathies & sudden
death
Etiology

Addictive
Family
Sociocultural
Cognitive-behavioral
psychodynamic
American Psychiatric Association
Diagnostic Criteria for BN

A. Recurrent episodes of binge eating. An episodes

of binge eating is characterized by both of the
following :
1. 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 during a similar
period of time and under similar circumstances.
2. A sense of lack of control over eating during the
episode (e.g feeling that one cannot stop eating or
control what or how much one is eating)
B. Recurrent inappropriate compensatory behavior in
order to prevent weight gain, such as self-induced
vomiting, misuse of laxatives, diuretics, enemas, or
other medications; fasting; or excessive exercise
C. The binge eating and inappropriate compensatory
behaviors both occur, on average, at least twice a
week for 3 months
D. Self-evaluation is unduly influenced by body shape and
weight
E. The disturbance does not occur exclusively during
episode of AN
Specific type :
1. Purging type : during the current episode of BN,
the person has regularly engaged in self-induced
vomiting or the misuse of laxatives, diuretics or
enemas
2. Nonpurging type : during the current episode of
BN, the person has used other inappropriate
compensatory behaviors, such as fasting or
excessive exercise, but has not regularly
engaged in self-induced vomiting or the misuse
of laxatives, diuretics or enemas
Complication BN
Vomiting
scarring of the dorsum of the hand used to

stimulate the gag reflex Russells sign

parotid gland enlargement

erotion of dental enamel with increased dental

caries resulting from the frequent presence of
gastric acid in the mouth
dehydration, alkalosis, hypokalemia

Mallory-Weiss esophageal tears

Laxative abuse
Dehydration
Elevation of serum aldosterone & vasopressin
Rectal bleeding
Intestinal atony
Abdominal cramps

Diuretics abuse
Dehydration & hypokalemia

Ipecac irreversible myocardial damage &

sudden death
Medical & nutritional management
Interdisciplinary team management
Main goal help the patients develop normal
eating habits
Patients often believe that controlled intake is
healthy and is the only way to lose/maintain
weight need to met with clear guidelines
 EDNOS
50% of ED
Do not meet the diagnostic criteria for either
AN or BN
If the disordered behaviors continue, they may
progress to frank BN or AN
Treatment modality depend on the severity of
impairment & symptoms
American Psychiatric Association
Diagnostic Criteria for EDNOS
1. For females, all of the criteria for AN are met
except that the individual has regular menses
2. All of the criteria for AN are met except that,
despite significant weight loss, the individuals
current weight is in the normal range
3. All of the criteria for BN are met except that the
binge eating and inappropriate compensatory
mechanisms occur at a frequency of less than
twice a week or for a duration of less than 3
months
4. The regular use of inappropriate compensatory
behavior by an individual of normal body weight
after eating small amount of food
5. Repeatedly chewing and spitting out, but not
swallowing, large amounts of food
6. Binge Eating Disorder (BED) : recurrent episodes
of binge eating in the absence of the regular use
of inappropriate compensatory behaviors
characteristic of BN
 BED bingeing behavior without the
compensatory purging seen in BN
1-2% of the population, late adolescent or
early twenties
Binge episodes must occur at least twice a
week and have occurred for at least 6 months
Most patients are overweight & suffer the
same medical problems
Significant emotional distress (+) feeling
disgust, guilt, depression
BINGE EATING DISORDER
Bingeing behavior without the compensatory purging
seen in BN
1-2% of the population, late adolescent or early
twenties
Binge episodes must occur at least twice a week and
have occurred for at least 6 months
Most patients are overweight & suffer the same
medical problems by obese population
Significant emotional distress (+) feeling disgust,
guilt, depression
American Psychiatric Association
Diagnostic Criteria

A. Recurrent episodes of binge eating. An episode

of binge eating is characterized by both of the
following :
1. 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 during a similar period of time and under
similar circumstances.
2. a sense of lack of control over eating during the episode (e.g
feeling that one cannot stop eating or control what or how much
one is eating)
B. The binge eating episodes are associated with three or
more of following :
1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling
physically hungry
4. Eating alone because of embarrassment over how
much one is eating
5. Feeling disgusted with oneself, depressed, or very
guilty after overeating
C. Marked distress regarding binge eating is
present
D. The binge eating occurs, on average, at least
2 days a week for 6 months
E. The binge eating is not associated with the
regular use of inappropriate compensatory
behavior (e.g. purging, fasting, excessive
exercise) and does not occur exclusively
during the course of AN or BN
 Malnutrition
PEM results when the bodys need for protein
and energy fuels are not satisfied by the diet
Its clinical manifestations depends on :
- Duration and degree of shortfall in dietary
intake
- The quality of the diet
- Host factors such as age
- Interplay with infection
 Origin
Primary inadequate food intake

Secondary other diseases that lead to :

- low food ingestion
- inadequate nutrient absorbtion or
utilization
- increased nutritional requirements
- increased nutrient losses
Binge Eating
 What are the Causes of Malnutrition?

Two Views
Nutritionists
Economists
Not enough
Slow GDP
calories or protein
growth
Poor nutrition
Low incomes
knowledge
Micronutrient
deficiencies
Infections
The problems of PEM
The main health problem
primadonna of nutritional diseases
Influencing morbidity and mortality among
underfives
Early detection and proper management are
very important
Severe malnutrition should be hospitalized
Poor quality of life
MARASMUS

Result from prolonged starvation

Predominant energy deficit
Because of chronic or recurring infections with
marginal food inatake (secondary marasmus)
most common form of PEM before 1 yr of age
KWASHIORKOR
Usually affect children after 18 mo of age
Predominant protein deficiency and varying
degrees of energy deficit
Main sign is oedema so children look fat
Others :
- hair changes : loss of pigmentation, easy
pluckability
- skin lesions and depigmentation
- apathetic
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