FEEDING AND EATING DISORDERS
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Define eating disorders
2. Discuss the history and epidemiology of eating disorders
3. Identify the different eating disorders
4. Distinguish among the diagnostic criteria for eating disorders
5. Discuss possible theories related to the etiology of eating disorders, differentiating the biological, sociocultural, and familial influences, as well as psychological and individual risk factors associated with these disorders
6. Explain various treatment options for persons experiencing eating disorders
7. Apply the nursing process from an interpersonal perspective to the care of patients with eating disorders
Avoidant/restrictive food intake disorder
Binge eating disorder
FEEDING and EATING DISORDERS are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. Eating disorders include PICA, RUMINATION DISORDER, AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER, ANOREXIA NERVOSA (refusal or inability to maintain a minimally normal body weight), BULIMIA NERVOSA (repeated episodes of binge eating followed by compensatory behaviors), and BINGE EATING DISORDER (characterized by episodes of binge eating, i.e., eating in a discrete period of time an amount of food that is larger than most other people would eat in a similar period under comparable circumstances). The most common eating disorders include anorexia nervosa, bulimia nervosa, and binge eating disorder; therefore, these disorders will be the primary focus of this chapter.
The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder (American Psychiatric Association [APA], 2013). Obesity (a body mass index [BMI] greater than or equal to 30) is not included in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; APA, 2013) as a mental disorder. Obesity (excess body fat) results from the long-term excess of energy intake relative to energy expenditure. A range of genetic, physiological, behavioral, and environmental factors that vary across individuals contributes to the development of obesity; thus, obesity is not considered a mental disorder. However, there are robust associations between obesity and a number of mental disorders (e.g., binge eating disorder, depressive and bipolar disorders, schizophrenia; APA, 2013). Feeding and eating disorders have become increasingly prevalent and of great concern to mental health professionals.
To understand eating disorders, it is important to understand the concept of eating. Human eating serves many functions in addition to nutrition. Normal healthy eating is not only about what a person eats but also how and why a person eats, and the attitudes and beliefs held in relation to food and eating. How a person eats differs from individual to individual, and is dependent on many factors such as:
Physical needs (biological)
Cultural needs (cultural)
Emotional needs (psychological)
Healthy eating behaviors are characterized by balanced eating patterns, appropriate calorie intake, and body weight appropriate for gender, height, age, and level of activity. Nurses need to be aware of the various factors pertaining to the functions of eating and food to provide appropriate care for recovery to those who are experiencing eating disorders.
This chapter addresses the historical perspectives and epidemiology of eating disorders, followed by a detailed description of eating disorders and the development of a greater phenomenological understanding of eating disorders through collaborative case conceptualization (Kuyken, Padesky, & Dudley, 2011). Biological, sociocultural, familial, and psychological factors that may potentially contribute to eating disorders are described along with common treatment options, including pharmacotherapy, psychoanalytical approaches, cognitive and behavioral treatments, group and family therapy, supportive therapy, and nutritional therapies. Application of the nursing process from an interpersonal perspective is presented, including a plan of care for a patient with an eating disorder.
Numerous factors affect an individual’s eating patterns. Eating provides nutrition but also other functions.
In the past 30 years, eating disorders have become more clearly defined. In Western culture, society and, in particular, the media offer contrasting messages about food and eating (Abraham & Llewellyn-Jones, 2005; Hausenbias et al., 2013). The first message is that a slim woman is a successful, attractive, healthy, happy, fit, and popular person. Most teenagers believe that being slim will help them secure a good job, find a boyfriend, be popular with their peers, be and look fit and healthy, and get on well with their family. The second message is that eating is pleasurable.
Today’s society is communicating mixed messages. For example, in nearly every issue of women’s magazines, there are new diets to ensure thinness followed by photographs of luscious cakes. Furthermore, the provision of food in our society is viewed as a sign of caring. The cultural imperatives place a burden on parents to provide abundant quantities of food for their children. Therefore, it is not surprising that in the face of two contradictory messages, most young women diet, with some of them developing eating disorders.
The wider societal influences of the media and popular culture have recently received much scrutiny and criticism for their negative aspects in relation to body size and its importance (Ringwood, 2010). Thinness is highly prized. People who can remain slender, lose weight, or are seen to be in control of their appetites are praised and rewarded. Celebrity culture is fixated on issues of weight and shape—the final domain where personal comments are unchallenged and not taboo. Issues such as sexual orientation, religion, race, and even age are no longer acceptable topics for derogatory remarks; however, weight and shape continue to be (Ringwood, 2010). As with families, the media itself does not cause eating disorders. However, it can contribute to the continuation of the myth and condition. Surrounded by hyperperfect images of celebrated thinness, individuals reinforce their strongly held belief that their weight and shape are the most important aspects of their being (Ringwood, 2010).
Eating disorders are relatively rare among the general population. The overall incidence rate has remained stable over the past decades; however, there has been an increase in the high-risk group of 15- to 19-year-old girls (Smink, van Hoeken, & Hoek, 2012). Eating disorders have long been perceived to occur primarily in women; few disorders in general medicine or psychiatry exhibit such a skew in gender distribution (Rhys Jones & Morgan, 2010). Recent research has focused on the assumption and stereotype that eating disorders in men are associated with homosexuality. Feldman and Meyer (2007) demonstrated a much higher prevalence for eating disorders among gay and bisexual men than their heterosexual counterparts, with more than 15% of gay or bisexual men suffering from anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified. It has been suggested that gay men may be under more pressure to conform to being thin, are more dissatisfied with their bodies, and tend to diet more. This may be related to the fact that values and norms place a heightened focus on physical appearance to which men may feel pressured to conform, ultimately influencing self-esteem and body image satisfaction. However, Morgan and Arcelus (2009) found widespread body image dissatisfaction among younger men, regardless of sexual orientation. Media and peer group influences appeared particularly relevant among gay men, but there were more similarities than differences between gay and heterosexual men, with both groups exposed to pressures to manipulate body shape and both aware of such pressures sufficient to resist them. Male beauty ideals differed from that of women in that they appeared compatible and consistent with healthy physiology, and health appeared less divorced from the aesthetic ideal for men than women.
In the late 1960s, anorexia nervosa became a much more prevalent disorder in Western societies. Young females from middle- and upper-class families were beginning to deprive themselves of food. The following decade saw the emergence of bulimia nervosa, where young women alternated self-starvation with binging, usually followed by purging. Although the number of men experiencing eating disorders is increasing, the majority of people who experience eating disorders are young women in late adolescence or early adulthood. The group at highest risk is young women between the ages of 15 and 30 years. Anorexia nervosa appears to strike at a younger age, with bulimia nervosa being more prevalent in the older group. Anorexia nervosa occurs in about 1% of the world population, being more prevalent among White females younger than 25 years of age from middle to upper social classes in Western cultures (Abraham & Llewellyn-Jones, 2005). Men represent 10% to 20% of cases of anorexia nervosa (Rhys Jones & Morgan, 2010). The age of onset for females is around 16 years of age; for males, it tends to be younger. About one third of people experiencing anorexia nervosa become chronically ill. The mortality rate for anorexia from a recent meta-analysis of 35 published studies was 5.1% per decade or 0.51% per year. One in five individuals with anorexia dies by suicide. The overall mortalist rate of anorexia is falling due to the introduction of specialized units to care for those experiencing anorexia (Smink et al., 2012).
Bulimia nervosa is one of the most common eating disorders, affecting 1% to 3% of adolescents and young females. Men account for 10% to 20% of the cases (Rhys Jones & Morgan, 2010). Before being diagnosed with bulimia nervosa, nearly all sufferers, when they were between 15 and 24 years of age, had periods of severely restricting food or extreme fasting that led to episodes of binge eating. Over time, the frequency and severity of the binge eating increased and bulimia nervosa developed. It is also believed that many people with bulimia nervosa will have met the criteria for anorexia nervosa at some time in their lives. Although anorexia nervosa is more prevalent among the middle and upper socioeconomic groups, bulimia is prevalent among all groups equally. Both conditions are less common in ethnic minority groups.
The World Health Organization (WHO) defines overweight as a BMI less than or equal to 25 (kg/m2) and obesity as a BMI greater than or equal to 30.0 (kg/m2). Obesity is a global public health problem affecting both developed and developing countries. Worldwide, the proportion of adults with a BMI greater than 25 kg/m2 increased between 1980 and 2013 from 28.8% to 36.9% in men and from 29.8% to 38% in women (Ny, Fleming, Robinson, Thompson, & Graetz, 2014). The prevalence in children and adolescents has increased substantially in developed countries; 23.8% of boys and 22.6% of girls were overweight or obese in 2013. The prevalence in children and adolescents has also increased in developing countries; 12.9% of boys and 13.4% of girls were overweight or obese in 2013 (Ny et al., 2014). According to the U.S. Department of Health and Human Services (2015) in their Health Report, 69% of adults aged 20 years and older are overweight or obese. More specifically, 71% of men and 65% of women are overweight or obese (Ogden et al., 2006). In addition, prevalence rates for conditions such as diabetes, cardiovascular disease, hypertension, and cancer are higher among those who are obese. Other adverse health conditions associated with obesity include musculoskeletal problems such as arthritis, chronic respiratory diseases, and reproductive problems such as infertility and impotence (Cawley & Meyerhoefer, 2012).
The populations affected by anorexia nervosa and bulimia nervosa are different from those affected by binge eating disorders. The prevalence rate for binge eating disorder varies between 0.7% and 6.6% for the general population and 30% for persons applying for weight loss treatment (Grucza, Przybeck, & Cloninger, 2007). Anorexia nervosa and bulimia nervosa primarily affect women and rarely affect men. In contrast, the male-to-female ratio among individuals with binge eating disorder is 2:3. This disorder also occurs across ethnically diverse samples, whereas most individuals with anorexia nervosa and bulimia nervosa are Caucasians.
Anorexia is more commonly found in females than in males, occurring more in adolescents and young adults.
DIAGNOSTIC CRITERIA/CASE CONCEPTUALIZATION
Case conceptualization involves clinicians staying attuned to the patient’s unique experiences while also understanding the scientific theories and research related to eating disorders (Kuyken et al., 2011). In other words the nurse aims to gain a comprehensive understanding of the patient’s idiographic (individual) phenomenological (lived) experience and incorporates the scientific theories to help both the patient and the nurse develop a deeper contextualized understanding of their experience. This is known as collaborative case conceptualization. Eating disorder is characterized by severe disturbances in eating behavior (APA, 2013). It includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa (refusal or inability to maintain a minimally normal body weight), bulimia nervosa (repeated episodes of binge eating followed by compensatory behaviors), and binge eating disorder. Each disorder has a specific set of defining characteristics that a patient must meet for diagnosis. Box 19-1 highlights the defining characteristics of each eating disorder.
Pica, the persistent mouthing or eating of nonnutritive substances, is an eating behavior that occurs most commonly in young children, individuals with intellectual and developmental disabilities, and pregnant women (Williams, Kirkpatrick-Sanchez, Enzinna, Dunn, & Borden-Karasack, 2009). Prevalence rates of pica in the general population are unclear, though estimates have ranged from 25% to 50% in high-risk groups. Ingestion of nonnutritive substances such as paper, foam, and powders can result in serious health complications, including abdominal pain, intestinal obstruction, lead poisoning and cognitive dysfunction, and gastric bezoars, which are solid masses of indigestible material that accumulate in the digestive tract. Although the etiology of pica is not well understood, pica has been associated with iron, zinc, and other mineral and nutritional deficiencies (Khan & Tisman, 2010), as well as anxiety and psychosocial stressors (O’Callaghan & Gold, 2012).
The essential feature of rumination disorder is the repeated regurgitation of food occurring after feeding or eating over a period of at least 1 month. Previously swallowed food that may be partially digested is brought up into the mouth without apparent nausea, involuntary retching, or disgust. The food may be re-chewed and then ejected from the mouth or re-swallowed. The behavior is not better explained by an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis) and does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge eating disorder, or avoidant/restrictive food intake disorder. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], neurodevelopmental disorder), they must be sufficiently severe to warrant additional clinical attention and should represent a primary aspect of the individual’s presentation requiring intervention. The disorder may be diagnosed across the life span, particularly in individuals who also have intellectual disability. Many individuals with rumination disorder can be directly observed engaging in the behavior by the clinician. In other instances, diagnosis can be made on the basis of self-report or corroborative information from parents or caregivers. Individuals may describe the behavior as habitual or outside of their control (APA, 2013). Prevalence data for rumination disorder are inconclusive, but the disorder is commonly reported to be higher in certain groups, such as individuals with intellectual disability.
BOX 19-1: DIAGNOSTIC CRITERIA
• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
• Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
• Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
• Recurrent episodes of binge eating as characterized by both of the following:
• 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 under similar circumstances
• A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
• Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise
• The binge eating and inappropriate compensatory behavior both occurring, on average, at least twice a week for 3 months
• Self-evaluation unduly influenced by body shape and weight
• The disturbance not occurring exclusively during episodes of anorexia nervosa
BINGE EATING DISORDERa
• Recurrent episodes of binge eating, with episodes characterized by both of the following:
• Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food definitely larger than most people would eat in a similar period of time under similar circumstances.
• A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
• The binge eating episodes associated with three or more of the following:
• Eating much more rapidly than normally
• Eating until feeling uncomfortably full
• Eating large amounts of food when not physically hungry
• Eating alone because of being embarrassed by how much one is eating
• Feeling disgusted with oneself, feeling depressed, or very guilty after eating
• Marked distress related to binge eating present
• The binge eating occurs, on average at least 2 days a week for 6 months.
• The binge eating is not associated with the regular use of inappropriate compensatory behaviors as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright © 2013, American Psychiatric Association.
Avoidant/Restrictive Food Intake Disorder
Avoidant/restrictive food intake disorder replaces and extends the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; APA, 2013) diagnosis of feeding disorder of infancy or early childhood. The main diagnostic feature is avoidance or restriction of food intake manifested by clinically significant failure to meet requirements for nutrition or insufficient energy intake through oral intake of food. One or more of the following key features must be present: significant weight loss, significant nutritional deficiency (or related health impact), dependence on enteral feeding or oral nutritional supplements, or marked interference with psychosocial functioning. In severe cases, particularly in infants, malnutrition can be life threatening. “Dependence” on enteral feeding or oral nutritional supplements means that supplementary feeding is required to sustain adequate intake. Examples of individuals requiring supplementary feeding include infants with failure to thrive who require nasogastric tube feeding, children with neurodevelopmental disorders who are dependent on nutritionally complete supplements, and individuals who rely on gastrostomy tube feeding or complete oral nutrition supplements in the absence of an underlying medical condition. Inability to participate in normal social activities, such as eating with others, or to sustain relationships as a result of the disturbance would inculcate marked interference with psychosocial functioning. Avoidant/restrictive food intake disorder does not include avoidance or restriction of food intake related to lack of availability of food or to cultural practices (e.g., religious fasting or normal dieting) nor does it include developmentally normal behaviors (e.g., picky eating in toddlers, reduced intake in older adults; APA, 2013).
Anorexia nervosa is characterized by the maintenance of low body weight, fear of weight gain, and indifference to the seriousness of the illness (Kanye, Bulik, Plotnicov, & Thornton, 2008). It involves an intense fear of becoming obese. Therefore, the person experiencing anorexia nervosa will not eat sufficient food to maintain a normal body weight. Anorexia can occur in two forms: the restricting type, in which the person has not participated in binge eating or purging behavior, and binge eating/purging type, in which the person has engaged in behaviors such as self-induced vomiting or misuse of laxatives, diuretics, or enemas. Although many individuals with anorexia nervosa engage in compulsive exercising, individuals with restrictive-type anorexia nervosa are distinguished by their refusal to eat (much).
Anorexia is characterized by a low body weight (less than 85% of minimally normal weight for age and height), intense fear of gaining weight or becoming fat, disturbed perception of the body, and amenorrhea for at least three consecutive menstrual cycles.
Bulimia nervosa is characterized by recurrent episodes of binge eating in combination with some form of inappropriate compensatory behavior (Berkman, Lohr, & Bulik, 2007), such as frequent vomiting or diuretic and/or laxative misuse. It is important to highlight the difference between binge eating/purging type of anorexia nervosa and bulimia nervosa. Individuals with bulimia nervosa may not be able to suppress their weight less than the 85% cut off and thus fail to display amenorrhea.
Bulimia is characterized by binge eating in combination with an inappropriate means to compensate for the binge eating, such as self-induced vomiting; misuse of laxatives, diuretics, or enemas; fasting; or excessive exercise.
Binge Eating Disorder
Binge eating disorder is associated with overweight and obesity. However, not all obese people have this disorder. Obese people with binge eating disorder display more chaotic eating habits, exhibit higher levels of eating disinhibition (i.e., eating in response to emotional states), and show substantially higher rates of psychiatric comorbidity. Individuals with binge eating disorder, like those with anorexia nervosa and bulimia nervosa, are preoccupied with shape and weight concerns, with self-worth strongly influenced. However, the characteristics of binges among individuals with binge eating disorder differ from those with bulimia nervosa. Individuals with bulimia nervosa consume more calories during a binge meal but their caloric intake is less during non-binge meals than those with binge eating disorder. Furthermore, unlike individuals with bulimia nervosa, whose binge eating takes place against a background of extreme dietary restraint, binge eating is part of a pattern of chaotic eating and general overeating for those with binge eating disorder.
The exact etiology of eating disorders is not fully known. Numerous research studies have attempted to address the underlying causes but without a consensus. However, various factors have been identified as contributing to the development of eating disorders.
There is evidence for the genetic transmission of eating disorders, although such evidence is not conclusive. It is argued that a hereditary predisposition to eating disorders exists in families. For example, anorexia nervosa has been found to be more common among sisters and mothers of those with the disorder than among the general population.
In addition, it has been hypothesized that a dysfunction in the hypothalamus, the “seat” of appetite, may be a factor in the development of eating disorders. Although tests of hormonal functioning and evidence of hormonal aberrations in anorexia nervosa are both prevalent, the fact is that refeeding alone, leading to consistent weight gain and balanced nutrition, reverses the endocrine changes observed in anorexia nervosa. The opinion is that these aberrations are not a cause of the disorder.
It is argued that an obsession with slimness, a core feature in eating disorders, is concentrated in cultures in which food is abundant. This ideal of slimness and derogation of fatness in cultures of abundance is more intense for females than males and may account for the higher incidence of eating disorders among females than males. This ideal of slimness is often portrayed in the media. However, not all individuals who are exposed to this ideal develop an eating disorder, indicating that other factors contribute to the development of eating disorders. Peer influence is also considered to be an important factor in the development of eating disorders. Adolescent girls learn certain attitudes and behaviors, such as dieting and purging, from their peers. These, in turn, may contribute to the development of an eating disorder.
Family dynamics have been implicated in the development and perpetuation of eating disorders. Studies show that individuals with eating disorders have families that tend to be enmeshed, intrusive, hostile, and negative to the individual’s emotional needs or are overly concerned with parenting. Also, abnormal attachment processes and insecure attachment are recognized as common in individuals with eating disorders. Generally, individuals with eating disorders describe a critical family environment, featuring coercive parental control and a high value placed on perfectionism. The individual feels that he or she must satisfy these standards. Thus, the issue of control becomes the overriding factor in the family of the individual with an eating disorder (Townsend, 2004).
Familial factors associated with eating disorders commonly involve the issue of control due to enmeshment, overly concerned parenting, abnormal attachment processes, and insecure attachments.
Psychological and Individual Factors
Many factors specific to the individual may contribute to the development of an eating disorder. These include personality traits, self-esteem deficits, and environmental factors. Interpersonal factors that have been most frequently linked to the development of eating disorders include abuse, trauma, and teasing. Individuals experiencing eating disorders commonly report more life stresses. These stresses occur jointly with affective deficiencies such as low self-esteem, depressed mood, generalized anxiety, and irritability. This combination may be particularly significant for the development of bulimia nervosa. More recent theorists concur that an extreme need to control both eating and other aspects of behavior is a central feature of eating disorders (Palmer, 2008; Read & Morris, 2008). Gaining a sense of control and pride in one’s ability to control one’s eating combats the feeling of being taken over by thoughts of food or of lacking control of one’s thoughts, eating, and weight.
Other individual factors contributing to the development of eating disorders may include:
Low self-esteem, which reflects how others react to an individual. Perceived rejection may cause lower self-esteem and maladaptive behaviors contributing to eating disorders. Dieting often results in overeating, further lowering self-esteem.
Body dissatisfaction, which occurs when negative affect and negative feelings about one’s self are channeled in eating disorders, promoting further negative feelings about the body.
Cognitive factors such as cognitive aberrations, including obsessive thoughts, inaccurate judgments, and rigid thinking patterns.
Perfectionism, which relates to the belief that one must be perfect, contributes to eating disorders by making normal shortcomings more traumatic or by making a normal body a sign of imperfection.