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How to manage it

1. EATING DISORDERS

2. CONTENT INTRODUCTION DEFINITION AETIOLOGY CLASSIFICATION MOST PREVALENT EATING DISORDERS ASSESSMENT TREATMENT .

3. INTRODUCTION An eating disorder is suspected when a person experiences severe disturbances in eating behavior, such as extreme reduction of food intake or overeating, or feelings of intense distress or concern about body weight or shape. Society , today promote the ideals of a slim body and models are often taken as role models of success. conversely they may be underweight to look perfect on televisions and magazines. In order to look good they practice abnormal pattern of eating. Socioeconomic- cultural changes and westernization could result of eating disorders.

4. DEFINITION Eating disorders are psychological illnesses defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. These are mental disorders characterized by severe disturbances in eating behaviors.

5. ETIOLOGY OF EATING DISORDERS   GENETIC  FACTORS Both disorders (Anorexia and Bulimia) tend to run in families, and twin studies support the role of genetics in the actual disorders . BIOCHEMICAL FACTORS Research findings on the role of serotonin in anorexia are mixed. Serotonin may play a role in bulimia, with studies finding a decrease in serotonin metabolites, smaller responses to serotonin agonists, and an increase in cognitions related to eating disorders, such as feeling fat, among formerly bulimic individuals who had their serotonin levels reduced. Newer research suggests dopamine may play a role in restrained eating

6. ETIOLOGY OF EATING DISORDERS SOCIAL AND CULTURAL STANDARDS As sociocultural standards changed to favor a thinner shape as the ideal for women, the frequency of eating disorders increased . Occupational stress Physical and psychiatric condition ( Depression , body dimorphic disorder)

7. WHY WE SHOULD KNOW ABOUT EATING DISORDERS Eating disorders involves self-starvation and over eating. The body is denied the essential nutrients which needs to function normally, so it is forced to slow down all of its processes to consume energy and other nutrient. This slowing down can have serious medical consequences The prevalence of eating appears to be increasing significantly

8. CLASSIFICATION OF EATING DISORDERS Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge eating disorder (BED) Other Specified Eating Disorder (OSED) Food Craving Pica Other Prevalent Eating Disorders Currently not recognized in medical manual Currently recognized in medical manual

9. ANOREXIA NERVOSA The  term anorexia nervosa was first formulated in 1873 by Sir William Gul . The term is Greek origin which means : A lack of desire to eat . anorexia  - refers to loss of appetite and nervosa - indicates that the loss is due to emotional reasons It is characterised by self-induced weight loss of at least 15% below the expected weight.

10. definition Anorexia nervosa is defined as a restriction of energy intake sufficient to cause significantly low body weight, and occurring in the presence of an intense fear of gaining weight or becoming fat (or persistent behavior that interferes with weight gain) and a disturbance in the perception of his or her body shape

11. ANOREXIA NERVOSA The term is something of a misnomer because most individuals with anorexia nervosa actually do not lose their appetite or interest in food. On the contrary, while starving themselves, most individuals with the disorder become preoccupied with food; they may read cookbooks constantly and prepare gourmet meals for their families.

12.   PREVALENCE The lifetime prevalence of Anorexia Nervosa among females is approximately 0.5%. It is at least 10 times more frequent in women than in men. The incidence of Anorexia Nervosa appears to have increased in recent decades.

13. COURSE Anorexia Nervosa typically begins in mid- to late adolescence (age 14-18 years). The onset of this disorder rarely occurs in females over age 40 years . Hospitalization may be required to restore weight and to address fluid and electrolyte imbalances. Death most commonly results from starvation, suicide, or electrolyte imbalance.

14. Two Types of Anorexia Nervosa   Restricting Type : during the current episode of Anorexia Nervosa, the person has NOT regularly engaged in binge-eating or purging behavior ( i .e., self-induced vomiting or the misuse of laxatives, diuretic;, or enemas) Binge-Eating/Purging Type : during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

15. Severity based on the BMI Mild: BMI ≥17 kg/m2 Moderate: BMI 16–16.99 kg/m2 Severe: BMI 15–15.99 kg/m2 Extreme: BMI<15 kg/m2

16. CLINICAL FEATURES Psychological Emotional liability Low self esteem Social isolation Depression Obsessive compulsive acts Fear of gaining weight Poor thinking and concentration Preoccupied with food, calories and exercise Physical features Severe weight loss Constipation Lethargy Amenorrhea Poor skin conditions Dehydration Bloating of abdomen Behavoral Frequent weighing Excessive talking about food Receive and read recipes Enjoy cooking for others Lying that they have eaten Secrete hiding of food Drinks a lot of water Moving food around the plate

17. DIAGNOSTIC CRITERIA-ANOREXIA NERVOSA   Refusal or inability to maintain body weight over a minimum normal weight. Intense fear of gaining weight despite being underweight. Disturbance in perception of body shape. Absence of three consecutive menstrual cycles .

18. ASSESSMENT Full physical examination & appropriate medical investigations is required for proper treatment. Assess patients height & weight If any of the following features are present in patient then treatment is indicated: Wt < 70% of that expected Or BMI < 15 Acute rapid weight loss Marked dehydration Electrolyte imbalance Convulsions Uncontrolled vomiting Self - injurious behaviour Severe depression, suicide risk

19. TREATMENT Restore the body weight by consulting the nutritionist. Chemotherapy : Antidepressants i.e. fluoxetine - Manage the underlying psychiatric condition I.e. depression give antidepressants Manage any complication Psychotherapy Cognitive behavioral therapy Family counselling Group therapy

20. PROGNOSIS About 70% of patients with anorexia eventually recover. Recovery often takes 6 or 7 years, and relapses are common Anorexia nervosa is a life-threatening illness Death rates are 10 times higher among individuals with the disorder than among the general population and twice as high as among individuals with other psychological disorders. Death most often results from physical complications of the illness – for example, congestive heart failure – and from suicide

21. BULIMIA NERVOSA Bulimia  is from a Greek word meaning “ox hunger.” This disorder involves episodes of rapid consumption of a large amount of food(binge eating), followed by compensatory behavior, such as vomiting, fasting, or excessive exercise to prevent weight gain . The DSM defines a BINGE as eating an excessive amount of food within less than 2 hours

22. PREVALENCE The lifetime prevalence of Bulimia Nervosa among women is approximately 1 %-3%; the rate of occurrence of this disorder in males is approximately one- tenth of that in females.  COURSE Bulimia Nervosa usually begins in late adolescence or early adult life. The binge eating frequently begins during or after an episode of dieting. The course may be chronic or intermittent

23. Two types of Bulimia Nervosa Purging Type : during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas Nonpurging Type : during the current episode of Bulimia Nervosa, 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

24. SIGNS AND SYMPTOMS  Chronic gastric reflux after eating Dehydration and hypokalemia caused by frequent vomiting Oral trauma, in which repetitive insertion of fingers or other objects causes lacerations to the lining of the mouth or throat Gastroparesis or delayed emptying Constipation Infertility

25. CONT…. Inflammation of the esophagus Peptic ulcers Electrolyte imbalance, which can lead to cardiac arrest and even death. Russell's sign :scarring of the knuckles from placing fingers down the throat to induce vomiting . Swelling of the parotid gland due to excessive vomiting.

26. Cont … In  bulimia, binges typically occur in secret; they may be triggered by stress and the negative emotions it arouses, and continue until the person is uncomfortably full

27. Cont … After the binge is over, disgust, feelings of discomfort, and fear of weight gain lead to the second step of bulimia nervosa – purging to attempt to undo the caloric effects of the binge. Individuals  with bulimia most often stick fingers down their throats to cause gagging, but after a time many can induce vomiting at will without gagging themselves. Laxatives and diuretic abuse as well as fasting and excessive exercise are also used to prevent weight gain

28. DIAGNOSTIC CRITERIA Minimum  of 2 binge-eating episodes weekly for 3 months/recurrent binge eating. A feeling of lack of control over binge-eating behavior. Regular use of self-induced vomiting, laxatives, diuretics, or vigorous exercise to prevent weight gain. Disturbance of body shape perception .

29. TREATMENT Restore the body weight by consulting the nutritionist. Chemotherapy : Antidepressants i.e. fluoxetine - Manage the underlying psychiatric condition I.e. depression give antidepressants Manage any complication Psychotherapy Cognitive behavioral therapy (stand therapy) Family counselling Group therapy

30. PSYCHOLOGICAL TREATMENT OF BULIMIA  NERVOSA The overall goal of treatment in bulimia nervosa is to develop normal eating patterns . Patients need to learn to eat 3 meals a day and even some snacks in between meals without sliding back into binging or purging. Cognitive behavior therapy (CBT) is the best validated and most current standard for the treatment. Cognitive behavioral treatment for bulimia focuses on questioning society’s standard for physical attractiveness, challenging beliefs that encourage severe food restriction, and developing normal eating patterns .

31. Cont … One intervention that is sometimes used in the cognitive behavioral treatment approach asks the patient to bring small amounts of forbidden food to eat in the session. Relaxation is employed to control the urge to induce vomiting. To improve on CBT, some investigators are examining one important aspect –exposure and ritual prevention (ERP – aspect of CBT of obsessive-compulsive disorder). This ERP component involves discouraging the patient from purging after eating foods that usually elicit an urge to vomit. Patients with bulimia nervosa are also taught assertiveness skills to help them cope with unreasonable demands placed on them by others.

32. .  PROGNOSIS Long-term follow-ups of individuals with bulimia nervosa reveal that about 70% recover, although about 10% remain fully symptomatic Individuals with bulimia nervosa who binge and vomit more, and have comorbid substance abuse or a history of depression, have a poorer prognosis than patients without these factors

33. IMPORTANT DIFFERENCE One striking difference between anorexia and bulimia is weight loss; individuals with anorexia nervosa lose a tremendous amount of weight whereas individuals with bulimia nervosa do not .

34. BINGE EATING DISORDER(BED) Binge  eating disorder is characterized by consuming large quantities of food in a very short period of time until the individual is uncomfortably full. Binge eating disorder is much like bulimia except the individuals do not use any form of purging (i.e. vomiting, laxatives, fasting, etc.) following a binge. Individuals usually feel out of control during a binge episode, followed by feelings of guilt and shame. Many individuals who suffer with binge eating disorder use food as a way to cope with or block out feelings and emotions they do not want to feel. Individuals can also use food as a way to numb themselves, to cope with daily life stressors, to provide comfort to themselves. Like all eating disorders, binge eating is a serious problem but can be overcome through proper treatment .

35. SIGNS & SYMPTOMS Significant  weight gain Digestive problems Breathlessness Periodically does not exercise control over consumption of food. Eats an unusually large amount of food at one time, far more than an average person would eat in the same amount of time. Eats much more quickly during binge episodes than during normal eating episodes. Eats until physically uncomfortable and nauseated due to the amount of food just consumed.

36. CONT… Eats large amounts of food even when not really hungry. Usually eats alone during binge eating episodes, in order to avoid discovery of the disorder. Often eats alone during periods of normal eating, owing to feelings of embarrassment about food. Feels disgusted, depressed, or guilty after binge eating. Rapid weight gain, and/or sudden onset of obesity.

37. FOOD CRAVING Food Craving is an intense desire to consume a specific food and is different from normal hunger. It may or may not be related to specific hunger . CRAVING SPECIFIC IN MALE & FEMALE Male typically crave protein, fat and sodium : Roast beef, burgers, fries, steak, pizza and chips etc. Female are more likely to crave sweet, high-carbohydrate and high-fat foods : Chocolate, cookies, ice cream, pasta, and bread etc.

38. PICA   Comes from the Latin word magpie - a bird which eat anything. An eating disorder in which non-nutritional objects are eaten. Characterized by a compulsive craving for eating, chewing or licking non-food items or foods containing no nutrition. MOST PREVALENT IN: Children ages 1-6 Pregnant women Certain cultures Mentally deficient

39. POSSIBLE CAUSES Nutrient  deficiencies- especially iron and zinc Stress OCD- Obsessive Compulsive Disorder Developmental disorders Mental disorders

40. TREATMENT Treatment varies according to type and severity of eating disorder and usually more than one treatment option is utilized . NUTRITIONAL INTERVENTION: Goals of Nutrition Intervention To normalise the relationship with food. To gain an understanding of nutrient needs for growth, development, tissue maintenance, wt control, appropriate body weight. To provide an increased/ adequate energy intake (macronutrient) to promote weight gain (initially 800-1200kcal/d and gradually increased to achieve goal weight gain of 0.5 to 1 kg/ wk ) OR weight stabilisation . Adequate vit & min intake ( Ca , Mg, K, Zn, Fe, B- vits )

41. COGNITIVE BEHAVIOURAL THERAPY Cognitive behavioural therapy (CBT) : which postulates that an individual's feelings and behaviours are caused by their own thoughts instead of external stimuli such as other people, situations or events, the idea is to change how a person thinks and reacts to a situation even if the situation itself does not change. Teach the patient to recognize the cognitions around eating and to confront the maladaptive cognitions. Introduce “forbidden foods” and regular diet and help the him/her confront irrational cognitions about these.