EATING DISORDERS

Eating disorders are serious medical illnesses characterized by abnormal eating behaviors, maladaptive efforts to control body shape or weight, and disturbances in perceived body shape or size. These disorders can affect a person’s physical and mental health and can even be life-threatening.

Common types of eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder. Eating disorders are among the deadliest mental illnesses—second only to opioid overdose—due to medical conditions and complications. Suicide is the second leading cause of death for people diagnosed with these disorders (ANAD, 2021; NIMH, 2021).

Signs and Symptoms Eating Disorders

Anorexia nervosa involves avoiding food, severely restricting food, or eating very small quantities of only certain foods. Even when people are dangerously underweight, they see themselves as overweight. There are two subtypes of anorexia nervosa:

  • Restrictive: Severe restrictions on the amount and type of food consumed
  • Binge-purge: Severe restrictions on the amount and type of food consumed together with binge eating and purging behaviors (e.g., vomiting, laxative and diuretic use)
    (NIMH, 2021)

Common signs and symptoms of anorexia that develop over time include:

  • Muscle wasting and weakness
  • Dry skin
  • Hypercarotenemia (yellowish skin)
  • Lanugo (fine downy hair over the body to help retain body heat)
  • Amenorrhea
  • Bradycardia
  • Bradypnea
  • Hypotension
  • Enlarged salivary glands and eroded dental enamel resulting from purging
  • Dehydration and electrolyte imbalance
  • Severe constipation
  • Lowered internal body temperature resulting in feeling cold
  • Lethargy, sluggishness
    (NIMH, 2021)

Bulimia nervosa is characterized by recurrent episodes of binge-eating unusually large amounts of food accompanied by the feeling of lack of control. People with bulimia nervosa, unlike those with anorexia nervosa, may maintain a normal weight or be overweight.

Common signs and symptoms of bulimia nervosa include:

  • Chronically inflamed and sore throat
  • Swollen salivary glands of the neck and jaw
  • Worn tooth enamel with increasingly sensitive and decaying teeth related to stomach acid exposure from vomiting
  • Scarring or calluses of the knuckles from using fingers to induce vomiting
  • Esophagitis and other GI problems
  • Intestinal discomfort and irritation from laxative abuse
  • Severe dehydration
  • Electrolyte imbalance
    (NIMH, 2021)

People with binge eating disorder lose control over their eating but do not purge, exercise excessively, or fast. As a result, they are most often overweight or obese. Binge-eating disorder is the most common eating disorder in the United States.

It is extremely difficult to detect binge-eating disorder, as most signs and symptoms do not present to others. Although these patients eat large amounts of food and eat rapidly, they eat normally when around others. They are often of normal weight or obese and may go on diets to try to lose weight.

Persons with binge-disorder who are obese often present with the following:

  • Hypertension
  • Hyperlipidemia, particularly elevated triglyceride and cholesterol levels
  • Hyperglycemia
  • Osteoarthritis due to trauma to weight-bearing joints
  • Angina or respiratory insufficiency related to increased workload
    (NIMH, 2021)

Other eating disorders include:

  • Avoidant/restrictive food intake disorder (ARFID): Limiting the amount or types of foods consumed and failing to meet nutritional or energy needs; without distress about body shape, size, or fatness; more than just a “picky eater”
  • Diabulimia: Deliberate insulin restriction in people with type 1 diabetes for purposes of controlling weight; increases the risks for retinopathy, neuropathy, and diabetic ketoacidosis, thereby increasing the mortality risk threefold
  • Pica: Repeated eating of nonfood substances
  • Rumination disorder: Repeated regurgitation to rechew, reswallow, or spit out what has been eaten
SCREENING FOR EATING DISORDERS

A number of screening instruments have been developed to identify patients with eating disorders. Some are long and not ideally suited for screening in a primary care setting, but shorter instruments have been developed that may help identify patients who need further evaluation.

SCOFF is a clinician-administered 5-question screening that asks:

  1. Do you make yourself sick because you feel uncomfortably full?
  2. Do you worry you have lost control over how much you eat?
  3. Have you recently lost more than one stone (14 pounds) in a three-month period?
  4. Do you believe yourself to be fat when others say you are too thin?
  5. Would you say that food dominates your life?

(Feltner et al., 2022)

Treatment Modalities for Eating Disorders

The foundation for the treatment of eating disorders includes:

  • Adequate nutrition
  • Reducing excessive exercise
  • Discontinuing purging behaviors

Treatment and therapy may include:

  • Medical care and monitoring
  • Individual, family, or group psychotherapy
  • Nutritional counseling
  • Weight restoration and monitoring
  • Medications, including antidepressants, antipsychotics, mood stabilizers
    (NIMH, 2021)

Inpatient hospitalization is required for medical instability. Some patients may require medical refeeding, which carries the risk of developing “refeeding syndrome.” This syndrome can occur when patients that have been starved begin to eat again, causing changes in metabolism and dangerous shift in fluids and electrolytes in the body, resulting in compromised cardiovascular status, respiratory failure, seizures, and even death (ACUTE, 2020).

Responding to and Caring for the Patient with Signs and Symptoms of an Eating Disorder

A patient with an eating disorder may not be easy to identify, and patients may not be forthcoming because of the secrecy and shame that go hand-in-hand with eating disorders. The stereotype of an underweight person makes it easier to identify an eating disorder, but it must be remembered that patients of normal weight or those who are obese also may have an eating disorder.

Many medical conditions can mimic eating disorders, including:

  • Chronic infectious disease
  • Malabsorptive disorders
  • Malignant conditions
  • Immune deficiency
  • Endocrine disorders
    (StatPearls, 2021)

Patients in primary care often are not diagnosed with eating disorders most probably due to the fact that they present with apparently unrelated physical or psychiatric complaints. It is important for healthcare providers in outpatient and inpatient settings to know the signs and symptoms of the disorders, as early intervention produces the best outcomes. The following are factors to keep in mind when working with patients with eating disorders:

  • Be nonjudgmental. Because there is stigma surrounding eating disorders, patients are often reluctant to discuss them; they are embarrassed and ashamed and are very successful at hiding their behaviors.
  • Develop a therapeutic relationship, allowing the patient to verbalize feelings related to food and weight gain.
  • Promote constructive self-talk, such as complimenting the patient on other positive qualities unrelated to appearance or highlighting features they say they like about themselves.
  • Monitor for changes in vital signs, height, and weight.
  • If hospitalized, monitor meals and snacks and record amounts eaten.
  • Refer to a dietitian for meal planning to promote weight restoration or maintenance, considering the patient’s specific eating disorder history and what behaviors they engage in, such as purging.
  • Monitor nutritional status, electrolyte balance, and activity.
  • Be watchful for diuretic/laxative use.
  • Determine anxiety level when discussing food and weight, and how willing the patient is to follow a nutritional regimen.
  • Provide education related to normal growth of the body and the role of fat in the protection of the body.
  • Establish patient-centered or patient-driven goals together with the patient to ensure the patient maintains awareness, practices healthy coping techniques, and adopts a positive body image.
  • Remain vigilant regarding suicidal ideation.
  • If the patient is hospitalized for medical refeeding, monitor closely for signs and symptoms of refeeding syndrome.
    (Dugan 2022; Quann, 2022)
CASE

A Patient with an Eating Disorder

Grace is a 20-year-old female college student who has come to the clinic with the chief complaint of abdominal pain and constant constipation. She says she has been using over-the-counter laxatives, but they “don’t work.” While taking her health history, the intake nurse, Helen, notes that Grace looks thin, pale, and tired, and she reports being a bit moody.

Helen: “You look a bit tired.”

Grace: “Oh, yes. I am. I’m so stressed out. I have my college finals next week.”

Helen: “I see. What else is concerning you, Grace?”

Grace: “My periods have been a bit erratic lately.”

Helen: “Erratic?”

Grace: “Yeah. Some months I miss my period. I get scared I might be pregnant.”

Helen: “Have you lost any weight lately, Grace?”

Grace: “Yeah, I’ve lost a couple of pounds, but I think that’s because of the stress of my finals.”

Helen: “Do you think your diet might have anything to do with your constipation?”

Grace: “Oh, I don’t think so. I’m very careful with my diet. I have allergies to meat and dairy, so now I only eat organic vegetables.”

Helen: “Grace, does how much you weigh affect how you think and feel about yourself?”

Grace: “Well, of course. Nobody wants to be fat and ugly. I’d die if I was fat.”

Helen: “Do you feel fat and ugly?”

Grace: “Well, I am, aren’t I?”

Helen: “So, are you happy with how you eat and with what you eat?”

Grace: “I try to watch what I eat very carefully. I’m quite picky and don’t like a lot of stuff.”

Using Grace’s complaint of erratic menstrual periods, along with the two questions “Have you lost any weight lately?” and “Does how much you weigh affect how you think and feel about yourself?”, Helen has validated that Grace may have an eating disorder. She will discuss this with the physician, and further screening and treatment recommendations should follow.

Discussion

Helen was alerted to the possibility of an eating disorder by Grace’s appearance, her complaints of abdominal pain and constant constipation, her use of over-the-counter laxatives that “don’t work,” and her complaints of being under stress. A big red flag went up when Grace talked about her erratic menstrual cycles and her recent weight loss.

As Helen continued to interview Grace, she understood that patients with eating disorders often complain of many food allergies and restrict their eating to one food group (in this case, only vegetables). To further clarify her suspicion that Grace has an eating disorder, Helen asked questions that involved Grace’s perceptions about weight, her self-image, and her approach to eating. Helen is now in a position to refer Grace for further assessment and intervention. Throughout the interaction, Helen used active listening skills, encouraged description of perception, and restatement.