Bulimia Nervosa and Binge Eating , , Kathrin Spoeck, MA, RD October 29, 2013 CFS 453

Transcription

1 Bulimia Nervosa and Binge Eating , , Kathrin Spoeck, MA, RD October 29, 2013 CFS 453

2 ( ) This research looks at the eating disorder Bulimia Nervosa (BN) and Binge Eating Disorder (BED) in adolescents. Adolescents are a major population that are affected by eating disorders. This paper explains the characteristics of BN and BED, what studies have contributed to the disorders, analysis of such studies and why BN and BED are of concern. Although many studies have been done to progress identification and treatment of BN and BED, more research in the adolescent age group needs to be done. Eating disorders are common in adolescents and often go untreated. Treatment for an eating disorder requires a multidisciplinary clinical team approach to help the patient have normalize eating behaviors. This research will provide valuable information regarding the impact of eating disorders in adolescents. ( ) There are three major types of eating disorders anorexia nervosa, bulimia nervosa, and non-specific eating disorders. Anorexia nervosa was the first known eating disorder. Anorexia nervosa (AN) is an eating disorder categorized by food restriction and an irrational fear of gaining weight. Bulimia nervosa (BN) is characterized by eating large amounts of food in one sitting followed by a forced excretion of the food consumed. Food exertion is done by self-induced vomiting, overuse of diuretics, excessive amounts of exercise, and laxatives. BN is the second most common eating disorder affecting women (Heaner & Walsh, 2013). Binge Eating Disorder (BED) is defined by recurrent episodes of unregulated eating either by eating too much or too little at least twice a week for at least six months. BED is under the category of eating disorders not otherwise specified (EDNOS) which pertains to disorders of eating that do not meet the criteria for any specific eating disorder (Nelms, Sucher, & Lacey, 2011). BN is often associated with BED, but the difference is that bulimic people will rid themselves of the food consumed. 10% to 50% of women not diagnosed with an eating disorder have admitted to binging on more than one occasion (Johns Hopkins Medicine Health Library, 2010).

3 People with BN seek to gain control of their diet and weight through eating habits, therefore it is common to see bulimics following a strict diet. However, extreme dieting causes improper nutrition and lack of satiety leading to tension, cravings, and starvation. At this stage control is lost and a binge session occurs. Feelings of disgust and shame occur after a binge which, motivates the bulimic to purge the food consumed. This allows the individual to feel as if control has been gained once again, but in reality this is a continuous cycle (Smith & Segal, 2013). People who suffer from BN are cautious to keep their condition hidden. The first sign of BN is the inability to stop eating to the point where one feels discomfort and abdominal pain followed by purging. The second sign is having private eating patterns and behaviors to the point where a person will only eat in solitude. The third sign is eating an enormous amount of food but never gaining a significant amount of weight. The fourth sign is the recurring disappearance of food or the discovery of a large amounts of empty food containers in the trash. The last sign that characterizes BN is eating an obscenely large amount of food followed by purging or eating nothing at all because of fear of not wanting to waste energy on purging a small amount of food. More noticeable signs of BN are when a person takes frequent bathroom trips after every meal to purge, often with the water running to mask the noise. A person with BN may also abuse laxatives, diuretics, and participate in strenuous exercise for long periods of time right after a meal. The diagnosis of eating disorders includes a physical and psychological evaluation. A medical doctor conducts a physical examination looking for signs of

4 cardiomyopathy, cardiac arrhythmias, esophageal tearing, and calluses on the back of the hand among other symptoms. Laboratory tests are also done to check electrolytes and protein levels, as well as liver, kidney, and thyroid function. A qualified mental health provider will also need to make a diagnosis based on the strict criteria stated in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Some patients will not meet the criteria of the DSM, but still will need professional help to overcome and manage unhealthy eating habits (Mayo Clinic Staff, 2012). According to the National Comorbidity Survey-Adolescent Supplement (NCS-A) 2.7% of adolescents from the age of 13 to 17 suffer from an eating disorder such as BN and BED. Females have a higher prevalence rate of 3.8 compared to 1.5 in boys. In addition the prevalence of eating disorders increases in both adolescent boys and girls as they get older. Adolescents between the ages of 13 and 14 have a prevalence rate of 2.4 while adolescents ages 17 and 18 have a 3.0 prevalence rate (National Institute of Health, 2013). Consequently, disordered eating habits are reported by over one half of teenage girls and nearly one third of boys. On the other hand of the known cases of eating disorders 95% of these cases are between the ages of 12 and 25.8 (National Association of Anorexia Nervosa and Associated Disorders, 2013). BN is very important because it affects adolescents and young adults. This age is a critical time when adequate nutrient intake is essential for growth. Nutritional complications of BN include, but are not limited to, high blood pressure, seizures, stomach ulcers, fatigue, loss of teeth, esophageal damage, osteoporosis, kidney failure and infertility (Johns Hopkins Medicine Health Library, 2010). Most of these stem from

5 malnutrition leading to certain body organs breaking down gradually rather than the system as a whole. Eventually, if no intervention has taken place, it can lead to heart failure due to the constant loss of vitamins, minerals, and electrolyte imbalance. The exact causes of BN are not entirely known as with all eating disorders. Disordered eating patterns are caused by a combination of genetic, psychological, cultural or social factors. In adolescents, social factors play a key role in developing psychological risks that increase the likelihood of developing an eating disorder. Many adolescents have symptoms of disordered eating but are untreated because they cannot be fully diagnosed with a disorder (Grave, 2011). For this reason knowing the risk factors that can lead to eating disorders in adolescents is of importance in order to help diagnose, treat, and most importantly prevent eating disorders. This can help adolescents overcome eating disorders early on in life to allow them to become healthy adults. ( ) Research studies have allowed medical professionals better understanding of the specific characteristics of different eating disorders to aid in diagnosis. In the early 1980 s when BN was first recognized it was not well understood. A critical question that stood was what defined a binge session in BN? Did people suffering from BN really overeat or was it simply a reflection of anxiety? A series of studies that took 25 individuals with BN and 18 non-bulimic individuals as a control group and asked them to binge eat in a laboratory setting. Subjects were asked to eat from a multi item buffet as much as they desired to replicate a binge at home. It was found that individuals with BN consumed significantly more calories in a binge meal, almost 4000 kcal than did

6 controls.. The same study then took a step further to see how individuals with BN ate during times they were not binging. The same individuals were asked to eat according to a non-binge meal. It was then found that individuals with BN ate significantly less compared to their binging meal and also fewer calories than the controls (Heaner & Walsh, 2013). Research has also allowed for a better understanding of BED. As stated earlier, BED is a period of unregulated eating of too much or too little food (Nelms et. al, 2011). Like individuals with BN, it was not clear what defines their eating patterns. The following study has been done to understand what qualifies as binge eating. Heaner & Walsh (2013) found that individuals with BED when asked to binge eat in a laboratory setting they consumed kcal more than the controls without BED. After individuals with BED were asked to eat a meal that they were comfortable with which resulted in them eating kcal more than the control groups. Although the results of various studies have allowed the identification of the characteristics of BN and BED it is still difficult to identify individuals suffering from such conditions. When exploring susceptibility of genders to eating disorders it was found that eating disorders are more common in female adolescents. However, eating disorder symptoms are prevalent in both genders. A study done to determine a correlation between eating disorders and gender asked students of both sexes, in a school setting, to answer a questionnaire that would identify behaviors associated with eating disorders. In addition to better understand prevalence differences, if any, between genders health-risk factors were also considered. These included: biological factors such as relative weight to

7 peers; psychological factors which included depressiveness, anxiety, dissatisfaction with appearance and weight, and perceived stress; behavioral characteristics including use of tobacco, alcohol, and skipping meals; social factors including teasing, loneliness, and poor communication with parents. Results showed that there were significant gender differences in the incidence of these health-risk factors. More girls reported gaining weight by more than 10% since the seventh grade, depression, anxiety, dissatisfaction with their appearance, feeling stress, and loneliness. On the other hand, being teased was the only factor boys reported more consistently. Furthermore, adolescents who were dissatisfied with their appearance, dissatisfied with their weight, had used tobacco, had eaten meals irregularly, or had poor family communication were found more likely to have an eating disorder compared to their peers without these factors. Although there are various factors that affect the likelihood of males and females developing an eating disorder, these results showed that there were no gender differences in susceptibility to health-risk factors that led to eating disorders (Hautala et. al., 2008). In some adolescents, eating disorders can have a brief duration and can outgrow such behaviors, but in some situations treatment is needed. Eating disorders have both psychiatric and medical complications therefore it is important to have an interdisciplinary team of healthcare professionals to help patients overcome such conditions. It has been demonstrated that patients with BN benefit from cognitive behavioral therapy (Nelms et. al 2011). Nutrition therapy has also been shown to be effective in helping patients with BN and BED to treat dietary and nutritional complications. Therefore nutrition professionals most importantly registered dietitians are

8 an integral part in the recovery of BN and BED. The main goal of a nutrition therapy is to help patients make healthy food choices and form healthy eating habits. Nutrition professionals can assess patients disordered eating habits and correct misconceptions that patients might have to allow education to reach goals that will help in recovery. With help patients can reach and maintain a healthy body weight, normalize their eating patterns, regulate hunger and satiety perceptions, and correct malnutrition-affected biological and psychological functions (Reiter & Graves, 2010). Research on eating disorders is neither extensive nor conclusive. Eating disorders are caused by complex combination of genetic, biological, psychological, social and behavioral factors. Studies up to this point in time have allowed enough understanding of these conditions to diagnose and help treat individuals. But many questions still stand unanswered. Studies have offered a standardized way to view eating disorders to allow for easy understanding and diagnosis. Proof of this is how BED is now included as its own diagnostic category in the updated DSM-V this year. (National Association of Anorexia Nervosa and Associated Disorders, 2013) Although this can be an advancement to bring awareness to BED and help in its diagnosis, this promotes strict criteria in the diagnosis of eating disorders. In order for a mental health professional to diagnose a person with anorexia, BN, or BED the patient must present specific symptoms according to the DSM-V. The downside to this fact is that it creates a small spectrum of symptoms to diagnose eating disorders, which can leave a high amount of teens undiagnosed and treated. A broader range of systems can allow teens that begin to show symptoms of

9 disordered eating to be diagnosed and treated to prevent full progression of AN, BN, or BED. In addition, the understanding of risk factors would further allow early treatment to prevent eating disorders. In hope of better understanding risk factors and biological indicators studies about behavior, genetics and brain function are ongoing. Adolescents are a population that is most affected by eating disorders and it is at an early on stage where eating disorders can be diagnosed, treated, and even prevented. However, only a small amount of research has been done to try and identify who is at risk of falling into disordered eating. As mentioned before Hautala et. al., (2008) attempted to initiate a hypothesis of who among the adolescents had an increased risk of having eating disorders. It was found that females have a greater incidence of eating disorders, but both males and females have the same prevalence to the symptoms of eating disorders. Both genders are exposed and suffer from healthy-risk factors that can lead to eating disorders. Factors such as being teased, poor communication at home, being teased, and tobacco usage were seen in adolescents with disordered eating habits. The least amount of research has been done on treating BN and BED. Lack of research is especially seen in the younger population which requires an age appropriate treatment versus an adult. Nelms et. al (2011) recognized the necessity of having an interdisciplinary team. Reiter & Graves, (2010) also emphasized the responsibilities of a registered dietitian and their importance t in implementing a healthy diet, eating habits, and in treating any underlying nutritional/physical implications. However, most studies and information about eating disorders is preliminary and not definitive. The available

10 studies usually recognize the shortcomings in the field and believe that more studies need to be done in order to support their findings or find more conclusive information. Furthermore, not any registered dietitian can attend the needs of a patient with an eating disorder like BN and BED. It is important for RDs that become part of the team helping patients with BN and BED to learn what approach works best. RDs should be trained in nutrition therapy to have the ability to counsel patients with eating disorders and be aware of their boundaries as nutrition specialists. However, to be able to do this research needs to be done so accurate and effective methods are utilized. More research needs to be done focusing on the adolescent population. It is not yet know if the treatment for BN and BED found is effective in an adolescent population. ( ) BN and BED are important eating disorders that affect adolescents. It is estimated that about 3 percent of U.S. adolescents have an eating disorder but do not receive treatment for their condition. Studies have found that the presence of an eating disorder is associated with other psychiatric disorders and suicidal thinking, making it a public health concern (National Institutes of Mental Health, 2011). Early recognition of eating disorders and better accessibility of treatments can help with prevention. Therefore research that helps to diagnose and treat eating disorders can be of great value to decrease the cases of BN, BED, and all eating disorders. A dietitian plays a key role in rehabilitation of a patient with BN and BED. A dietitian cannot diagnose an eating disorder, but can contribute to the assessment of a disorder. Treatment for a patient with an eating disorder involves working with a team of

11 multidisciplinary clinical professionals. A dietitian's role is not only involved in normalizing eating habits. Understanding all aspects of a patient s treatment include medical monitoring, medications and medical nutrition therapy. A dietitian working with patients with eating disorders needs to be specialized in the field to be able to have the skills to implement evidence-based practice (Graves and Reiter, 2010). Nutritional therapy for a patient with BN and BED includes maintaining a healthy body weight, normalizing eating patterns, regulating hunger and satiety, as well as the correction of malnutrition complications. Perception is a main component involved in a patients eating behavior. As a nutrition therapist, assessing attitudes, knowledge and beliefs about the patient s behavior is key. Treatments that a dietitian can make with this knowledge include helping the patient create a normalized eating schedule, understand physical activity and help change their relationship with his or her body. Patients should be comfortable eating from all the food groups to meet nutritional needs as well as eating in a social setting (Graves and Reiter, 2010). To achieve nutritional goals dieticians are directly involved in the patients psychosocial treatments. Specialized dietitians understand that a patient with an eating disorder is going to have complex interpersonal and psychological problems. Nutrition counselors need to empathize with the clients struggle to build a relationship of trust. The use of motivational interviewing has been shown to be effective when working with eating disorders. Motivational interviewing works to increase self-efficacy by having the client understand their needs to change and come up with his or her own goal for change (Graves and Reiter, 2010).

12 Patients are often given medications to reduce disturbed eating and treat depression, anxiety or obsessive disorders, like binge eating. SSRI fluoxetine or Prozac is the only medication approved by the United States Food and Drug Administration for BN however; other drugs are also used to treat symptoms of BN. It is important for a dietician to be aware of medications to prevent drug-nutrient interactions (Franco, 2013). Although a multitude of professionals are involved in the rehabilitation of a patient with BN treatment should also include social support from friends and family. Research has shown that incorporating more time for family meals and social settings at meal times helps create a positive environment and structured meals to maintain a healthy weight in adolescents (Neumark-Sztainer, Story and Fulkerson, 2004). In addition common recommendations given by registered dietitians for BN patients is to eat three meals a day with snacks to begin a regimen that will help patients break from disorder eating habits, such as binging. Patients should begin by eating sufficient amounts they feel comfortable with and allow them not to feel hungry which can be a trigger to binge episodes (Nelms et. al 2011). It takes a team effort to treat a person with an eating disorder. Eating disorders tend to begin in the years of adolescence. Therefore research that helps to diagnose and treat eating disorders can be of great value to decrease the cases of BN, BED, and all eating disorders.

13 References Grave, Riccardo D. (2011). Eating disorders: Progress and challenges. European Journal of Internal Medicine, 22(2), Franco, K., N. (2013). Eating Disorders. Cleveland Clinic-Center For Continuing Education. Retrieved October 29, 2013, from Hautala, L., Junnila, J., Helenius, H., Väänänen, A., Liuksila, P., et al. (2008). Towards understanding gender differences in disordered eating among adolescents. Journal of Clinical Nursing, 17(13), Heaner, M. K., & Walsh, T. B. (2013). A history of the identification of the characteristic eating disturbances of bulimia nervosa, binge eating disorder and anorexia nervosa. Science Direct, 65, Retrieved from Johns Hopkins Medicine Health Library. (n.d.). Eating Disorders. Johns Hopkins Medicine. Retrieved October 29, 2013, from bulimia_nervosa_85,p00751/ Lewis-McCormick, I. (2004). understanding the female athlete triad. Retrieved from Mayo Clinic Staff. (2012, February 8). Eating disorders: Tests and diagnosis. Mayo Clinic. Retrieved October 29, 2013, from National Association of Anorexia Nervosa and Associated Disorders. (2013). Binge Eating Disorder. National Association of Anorexia Nervosa and Associated Disorders. Retrieved October 29, 2013, from National Institute of Mental Health. (n.d.). Eating Disorders Among Children. National Institute of Mental Health. Retrieved October 29, 2013, from National Institute of Mental Health. (March 7, 2012). Most Teens with Eating Disorders Go Without Treatment. Retrieved October 29, 2013, from Nelms, M. N., Sucher K., Lacey K., Roth S. L. (2011). Nutrition Therapy & Pathophysiology 2/e. Belmont, CA: Brooks/Cole Cengage Learning. Neumark-Sztainer, D., Wall, M., Story, M., & Fulkerson, J. A. (2004). Are family meal patterns associated with disordered eating behaviors among adolescents? Journal of Adolescent Health, 35(5), doi: /j.jadohealth Reiter, MS, RD, CSSD, C. S., & Graves, RD,LD, FAED, L. (2010). Nutrition Therapy for Eating Disorders. Nutrition in Clinical Practice, 25(2), Smith, M., & Segal, J. (2013, July). Bulimia nervosa. Retrieved from