Eating Regulation Responses and Eating Disorders

Eating Regulation Responses and Eating Disorders

Gail W. Stuart

Food is essential to life. It supplies needed nutrients and sources of energy. Eating is a crucial self-regulatory activity. However, it also can assume importance and meaning beyond that of nutrition and can become a problem and a maladaptive coping response.

Continuum of Eating Regulation Responses

Properly controlled eating contributes to psychological, biological, and sociocultural health and well-being. Adaptive eating responses are characterized by balanced eating patterns, appropriate caloric intake, and body weight that is appropriate for height.

Although everyone eats, society has difficulty understanding the idea of unregulated eating. Everyone has at times overeaten, skipped one or more meals, or seen adolescent boys consume large amounts of food at a single meal. Many women have premenstrual cravings for salty, sweet, or other types of foods. These eating behaviors are not viewed as problematic.

However, food also can be used to satisfy unmet emotional needs, to moderate stress, and to provide rewards or


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.

Case Background

She was a medical student and a horse jockey. She was passionate about each and threw herself into both aspects of her life. But she also was depressed. Her boyfriend was threatening to break up with her. He felt she had no room in her life for him and he didn’t feel like he could get close to her. He didn’t understand it but knew that he was tired of fighting for her time and attention.

She stood just about 5 feet tall, trim and athletic. She came to all of her appointments but seemed unable to really engage. She felt her mother had unrealistic expectations of excellence for her and that they never really had a close relationship. This seemed to be a theme in her life. One evening her boyfriend arrived unexpectedly at her apartment and walked in as she was purging her dinner. He was shocked and insisted that she get treatment.

She admitted that from her early teens she had been bingeing and purging to control her weight. She thought she was fat. She said she thought her mother was anorexic because she would cook food and always serve the family but not sit down and eat herself. The patient also admitted bingeing and purging on alcohol. She said she hated herself, and she blamed her mother.

punishments. People can have unrealistic images of their ideal body size and desired body weight.

Research has shown that most people think they should weigh less than they do, and this can result in behaviors that range from fasting fads to severe dieting. The inability to regulate eating habits and the frequent tendency to overuse or underuse food interfere with biological, psychological, and sociocultural integrity.

Illnesses associated with maladaptive eating regulation responses include anorexia nervosa, bulimia nervosa, binge eating disorder, and night eating syndrome (Figure 24-1). They are potentially fatal (Crow et al, 2009).

Eating disorders occur across the life span. They are more commonly seen among females, with a male/female ratio ranging from 1:6 to 1:10. This gender difference in the prevalence of eating disorders may result from biological, sociocultural, or psychodynamic factors or from a greater reluctance on the part of men to seek treatment.

Among young women in the United States, eating disorders appear to be about as common in Hispanics as in whites, more common in Native Americans, and less common in African Americans and Asian Americans. African-American women are more likely to develop bulimia nervosa than anorexia nervosa, and they are more likely to purge with laxatives than by vomiting.

Obsessions about eating can cause psychological problems that include depression, isolation, and emotional lability. Sociocultural ideals concerning body size can lead to an eating disorder by influencing people to perceive their body size as being larger or smaller than it actually is. This distorted body image may lead to an attempt to attain an unrealistic body size.

Before working with patients with maladaptive eating regulation responses, nurses must closely examine their own feelings and prejudices about weight and body size. It may be helpful for nurses to think about the following questions:

Nurses who suspect that they have an eating disorder may not be able to provide care for patients who cannot regulate their eating responses (Hicks et al, 2008). These nurses should seek professional help for themselves before attempting to care for others.

Prevalence of Eating Disorders

Anorexia Nervosa

Anorexia nervosa is a serious mental illness that is characterized in part by intense and irrational beliefs about one’s shape and weight, including fear of gaining weight. It occurs in approximately 0.9% of females and 0.3% of males.

Its onset usually occurs between 13 and 20 years of age, but the illness can occur in any age-group, including elderly people and prepubertal children. Anorexia nervosa is also seen in males, who are thought to make up 5% to 10% of the anorexic population. The mortality rate from anorexia nervosa is estimated to be approximately 5% of those with the disorder.

Many patients with anorexia nervosa recover within 5 years. However, for some, anorexia nervosa is a chronic illness. Vomiting, binge eating, purging, obsessive-compulsive personality symptoms, and alcohol use are associated with the least favorable prognosis.

Bulimia Nervosa

Bulimia nervosa is an eating disorder that is characterized by eating binges typically followed by efforts to purge calories. It is more common than anorexia, with an estimated occurrence of 1.5% in women and 0.5% in men; among female high school and college students, the prevalence rates are 4% and 15%, respectively. The age at onset is typically 15 to 18 years. The male/female ratio for bulimia nervosa is about 1:11, but males and females with this eating disorder have similar clinical features.

An early response to treatment is a good predictor of a successful outcome in bulimia nervosa. A good outcome also is associated with a shorter duration between onset of symptoms and the first treatment intervention (Steinhausen and Weber, 2009). Therefore, early identification of bulimia nervosa is important in preventing a chronic eating disorder.

Bulimia and anorexia may be present in the same patient. As many as 50% of individuals with anorexia develop bulimic symptoms, and some people with bulimia develop anorexic symptoms. Bulimia usually occurs in people of normal weight, but it also may occur in those who are obese or thin.

Night Eating Syndrome

Night eating syndrome is a severe eating problem that is under consideration for future inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a separate eating disorder. Individuals with night eating syndrome have symptoms of morning anorexia, difficulty staying asleep, and depression occurring mostly in the evening.

Night eaters average two awakenings per night, and these awakenings are associated with food intake. The prevalence of night eating syndrome has been estimated to be 1.5% in the general population, 8.3% in the obese population, and 27% among severely obese people seeking surgical treatment.

The overlapping relationships among the various maladaptive eating responses are depicted in Figure 24-2.


Patients with maladaptive eating regulation responses need to receive a comprehensive nursing assessment that includes complete biological, psychological, and sociocultural evaluations (Himmerich et al, 2010).

Specific attention should focus on the assessment of eating regulation responses. Several questionnaires and rating scales have been developed to screen for the presence of eating disorders. However, asking only the following two questions may be as effective as using more extensive questionnaires in identifying individuals with eating disorders:

These two questions can be easily incorporated into the nursing assessment of all patients.

If a patient is being evaluated for an eating disorder, additional information should be obtained, including the following:

It also is helpful to ask the patient how the illness developed and what impact it has had on school, work, and social relationships so that a holistic view of the patient’s world can be obtained.


Binge Eating

Binge eating involves the rapid consumption of large quantities of food in a discrete period of time. There is no agreement on exactly how many calories constitute a binge. Patients with anorexia who binge may describe a binge of several hundred calories. Patients with bulimia who are not also anorexic may ingest several thousand calories at a sitting.

An emphasis on the patient’s perception of loss of control and perceived excessive caloric intake is more important to the nursing assessment than the total number of calories consumed during a binge. Therefore, it is important that the nurse carefully assess exactly what each patient means by a binge.

People usually binge secretively, whether during the day or in the middle of the night. Considerable shame is often associated with their bingeing behavior. A person with bulimia typically is of average weight or slightly overweight and has a history of unsuccessful dieting. The severity of the bingeing can vary greatly, ranging from several times per week, to more than 10 times per day, to only occasional binges related to stressful situations.

Fasting or Restricting

People with anorexia often consume less than 500 to 700 calories daily and may ingest as few as 200 calories daily, yet they see their intake as adequate for their energy needs. They may follow an unbalanced vegetarian diet, eliminating all meat, poultry, fish, and dairy products without substituting nonanimal sources of protein and other important nutrients.

They may be obsessive-compulsive about their eating habits and food choices, such as eating the same foods repeatedly, eating foods in a predetermined order, or eating at the same time every day. They may have bizarre food preferences, avoid foods that are considered fattening, or fast for days at a time.

Despite these restrictions, many people with anorexia are preoccupied or obsessed with food. They may do much of the family cooking or be employed in a food-related occupation. The following clinical example describes the fasting behavior seen in people with anorexia.


A variety of purging behaviors may be used by people with maladaptive eating regulation responses to prevent weight gain. Purging includes excessive exercise, forced vomiting, and abuse of over-the-counter or prescription diuretics, diet pills, laxatives, or steroids.

Laxatives are commonly abused by people with eating disorders, yet they are one of the most inefficient ways to lose calories. Laxative abuse often begins gradually but can increase to 60 doses per week in some people. Less well-known substances used to counteract weight gain include insulin, cocaine, heroin, thyroid replacements, nicotine, hallucinogens, analgesics, benzodiazepines, antidepressants, ipecac, and sorbitol. Many patients engage in more than one purging behavior.

For these patients, exercising often becomes a grueling, time-consuming affair. Running or participating in high-impact aerobics for 2 to 3 hours each day is typical of the compulsive exerciser. Many patients with an eating disorder exercise so much that they sustain major skeletal injuries, but this still does not deter them from continuing this maladaptive behavior. Such behavior is seen in the following clinical example.

Medical Complications

People with a maladaptive eating regulation response usually have some type of associated physical problem. The various complications associated with eating disorders are listed in Box 24-1.

An assessment of the patient’s physical status can reveal the seriousness of the eating problem. For example, patients who are 20% below or 40% above their ideal body weight demonstrate more physical abnormalities than those who are closer to their ideal weight.

In anorexia nervosa, metabolic and endocrine abnormalities result from the reaction of the body to the malnutrition associated with starvation. All body systems are affected. Most commonly seen are amenorrhea, osteoporosis, and hypometabolic symptoms, such as cold intolerance and bradycardia (Smith and Wolfe, 2008). Starvation may cause hypotension, constipation, and acid-base and fluid-electrolyte disturbances, including pedal edema.

In bulimia nervosa, potassium depletion and hypokalemia often are seen as a result of vomiting or laxative or diuretic abuse. Symptoms of potassium depletion include muscle weakness, cardiac arrhythmias, conduction abnormalities, hypotension, and other problems associated with electrolyte imbalance. Gastric, esophageal, and bowel abnormalities are common complaints in patients with bulimia. Those who vomit are subject to erosion of the dental enamel and enlargement of the parotid glands.

Serious health problems caused by excess weight or prior health problems exacerbated by increased weight are common for individuals with binge eating disorder and concurrent morbid obesity. Excess weight is associated with hypertension, cardiac problems, sleep apnea, difficulties with mobility, and diabetes mellitus. Some of the medical consequences of eating disorders are seen in the following clinical example.


Audrey is a 25-year-old African-American female with a 4-year history of restrictive intake and a 3-year history of binge eating and laxative abuse. Audrey has been concerned about her weight since high school, when she was a star basketball player, a competitive swimmer, and a participant in track, volleyball, and tennis. She bypassed her senior year in high school. She began to diet at 20 years of age, and her severe restriction of food at 21 years led to a 20-pound (9-kg) weight loss and amenorrhea. At 22 years old, she began to binge and use laxatives. Since that time she has binged two or three times each week and uses an average of 30 to 60 laxatives each week.

Audrey is constantly preoccupied with food and her weight and has periods of mood lability, sadness, lack of energy, social isolation, anxiety, irritability, and difficulty concentrating. Audrey also reports chronic constipation; bloating; edema of the hands, feet, legs, and face; and lightheadedness. She recently consulted a gastroenterologist for her severe constipation and was advised that her large intestine is grossly oversized. Audrey became very frightened by the report and immediately called a local eating disorder program for help.

Psychiatric Complications

Many patients seeking treatment for eating disorders show evidence of other psychiatric disorders, most particularly depression, anxiety disorders, and substance abuse. Co-morbid major depression or dysthymia has been reported in 50% to 75% of people with anorexia or bulimia, and obsessive-compulsive disorder may be found in as many as 25% of patients with anorexia nervosa.

Patients with bulimia have increased rates of anxiety disorders, posttraumatic stress disorder, substance abuse, and mood disorders (Hirth et al, 2011). People with antisocial personality disorders are six to seven times more likely to have bulimia than the general population.

Binge eating disorder has been found to be associated with higher rates of major depression, panic disorder, bulimia nervosa, borderline personality disorder, and avoidant personality disorder. Night eating syndrome is associated with increased rates of mood disorders characterized by a circadian pattern.

Predisposing Factors

Biological, psychological, and sociocultural factors may predispose a person to the development of an eating disorder (Roman and Reay, 2009). These factors are involved in the regulation and control of food intake and reflect a combination of genetic, neurochemical, developmental, personality, social, cultural, and familial elements (Figure 24-3).


Both anorexia nervosa and bulimia nervosa are familial. The risk for eating disorders is higher in first-degree female relatives of people with eating disorders than in the general population. The concordance rates for eating disorders are 52% in monozygotic twins and 11% in dizygotic twins.

The risks for other eating disorders, depression, and substance abuse also are higher in first-degree relatives of people with eating disorders. Current genetic studies are exploring the chromosomal locations of the genes responsible for contributing to the development of eating disorders. In time, these findings may lead to better prevention programs for eating disorders.

Biological models of the etiology of eating disorders focus on the appetite regulation center in the hypothalamus, which controls specific neurochemical mechanisms for feeding and satiety. It has been hypothesized that the neurotransmitters, neuromodulators, and hormones that control feeding and satiety are dysregulated in patients with eating disorders.

Reduced serotonin is associated with reduced satiety, increased food intake, and dysphoric mood. When dietary tryptophan (the amino acid necessary for the brain to manufacture serotonin) is reduced, women with bulimia show a marked increase in eating behavior and mood changes, such as irritability, lability, and fatigue; this suggests a disturbance of serotonin activity. Single-photon emission computed tomography (SPECT) studies support the role of serotonin dysregulation in eating disorders.

Norepinephrine is reduced in eating disorders, and reduced dopamine has been found in obese individuals with binge eating disorder, suggesting a role for these neurotransmitters as well. It is hypothesized that decreases in dopamine receptors in this subset of eating disorder patients perpetuate pathological eating as a way to compensate for the decreased activation of reward circuits that are modulated by dopamine. Leptin, a protein that inhibits food intake, and the hormone, ghrelin, also may have a role in the neurobiology of eating disorders.

Finally, gray matter loss in the anterior cingulated cortex of the brain has been found to be related to the severity of anorexia nervosa, indicating an important role of this area in the pathophysiology of the disorder (Fladung et al, 2010). Ongoing research promises to shed more light on the biological factors that may predispose a person to maladaptive eating regulation responses (Brewerton, 2011; Marsh et al, 2011).


A variety of environmental factors may predispose a person to develop an eating disorder. Early histories of patients with eating disorders are often complicated by medical and surgical illnesses, separations, and family deaths. Women with bulimia also describe growing up in a detached family environment and experiencing more behavioral disturbances such as drug abuse, suicide attempts, truancy, and other emotional problems.

Sexual abuse has been reported in 20% to 50% of patients with bulimia and anorexia. This rate is higher than in the general population.

Parents who overemphasize athletics, reward slimness, or express disapproval of overweight people are placing their children at risk for development of eating disorders. Parents who continually skip meals, eat when distressed, and otherwise role model poor nutritional habits are not teaching children about the appropriate value of food as nourishment. An important preventive nursing intervention involves educating the parents of young children regarding healthy eating behaviors (Table 24-1).

TABLE 24-1

Preventing Childhood Eating Problems

Describe self-demand feeding and its importance in healthy eating behaviors. Explore parents’ current feeding practices and understanding of healthy eating.
Provide information to enhance knowledge of healthy eating behaviors.
Parents will identify healthy eating behaviors and self-demand feeding and begin to explore how their relationship with food influences their children’s eating.
Describe the physiological and psychological signs of hunger and satiety, as well as the meaning and difference of both types of signs. Explore parents’ own signs of hunger and satiety, and have parents describe children’s signs. Parents will keep a hunger diary to record physical and psychological signs of hunger and satiety for themselves and their children.
Describe the danger of psychological hunger. Explain the use of a hunger diary, which is a daily journal regarding signs of hunger. Parents will be able to distinguish between psychological and physical hunger.
Explore myths about feeding, such as “cleaning the plate” and “eating because other children are starving.” Describe the importance of allowing children to determine their feeding needs and the relationship of healthy eating to children’s ability to differentiate between physical and psychological signs of hunger and satiety.
Give a homework assignment for each parent to interview three other adults about their current eating practices and memories of eating.
Parents will complete homework assignment, discuss interview experiences, and describe how perpetuating myths about feeding can harm their children.
Implement self-demand feeding at particular developmental stages of children. Review the eating stages children experience and the potential problems they may have at each stage. Parents will discuss the developmental stages of their children and plan to implement self-demand feeding.
Discuss parental experiences related to implementing self-demand feeding. Review parents’ expectations and experiences with implementing self-demand feeding. Parents will relate any problem with implementing self-demand feeding.
Nurse will evaluate family for further education and plan for follow-up if necessary.

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Eating Regulation Responses and Eating Disorders

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