Eating Disorders

July 2013, 1 hour
Eating Disorders
Statistics
Eating Disorders Defined
An eating disorder is defined as an unhealthy relationship with food and
weight that interferes with many areas of a person’s life. These areas
include, but are not limited to: work, school, sports activities and social
events, and relationships with family and friends. An eating disorder
can affect anyone, and there have been many well-known people who
have struggled with eating disorders, including: Karen Carpenter,
Paula Abdul, Elton John, Jane Fonda, Princess Diana, and Joan
Rivers.
Americans with eating disorders:
 13 million binge eat
 10 million women battle anorexia or bulimia
 1 million men battle anorexia or bulimia
 The more time adolescent girls spend on social
media, the more likely they are to develop an
eating disorder
Children:
 80% of all 10-year-olds are afraid of being fat
 42% of all 1st - 3rd grade girls want to be thinner
Eating disorder related hospitalizations increased
from 1999 to 2006 by:
 18% overall
 37% for men
 119% for children under 12
Some Statistics
An estimated eight million Americans have an eating disorder, there is only a 50% chance of being cured.
disorder. One in 200 women suffers from Anorexia
The most frightening statistic of all: eating disorders
Nervosa. Two-to-three in 100 women suffer from
have the highest mortality rate of any mental illness.
Bulimia Nervosa. It is estimated that
Twenty percent of the people suffering
“...eating disorders have the
individuals with eating disorders need 3-6
from Anorexia will prematurely die from
months of inpatient care. Treatment costs
highest mortality rate of any
complications related to their eating
range from $500.00-$2,000.00 per day in
disorder, including heart problems and
mental illness.”
the United States, and since many health
suicide. Suicide is the major cause of
insurance companies do not cover the cost of treatdeath in people with Anorexia Nervosa. This is a very
ment for eating disorders, many afflicted individuals do
serious problem.
not receive treatment. Once someone has an eating
Eating Disorders vs. Feeding Disorders
Eating disorders are different from feeding disorders.
Feeding disorders are found primarily in children, and
occur much more commonly in developmentally delayed children. Often feeding disorders can have
underlying organic causes, but psycho-social factors
are thought to play a significant role. There are three
main feeding disorders.
intellectually disabled individuals, the onset may occur
later in life.
Feeding Disorder of Infancy or Early Childhood
begins anywhere from 0-3 years, characterized by the
failure to ingest enough food to gain weight. Often these
children appear withdrawn and without energy, and may
be shorter and lighter in adolescence than their peers.
Pica involves eating non-nutritive substances (paint, In some cases, parents can contribute to the problem
plastic, hair, string, feces, etc.), and is frequently by inappropriately presenting food or responding to the
associated with Intellectual Disability or Pervasive child’s refusal to eat as an act of aggression.
Developmental Disorder. Usually it lasts for several
Conversely, eating disorders tend to develop during
months and then stops. Occasionally it continues into
adolescence, are thought to be primarily psychological
adolescence and less frequently, into adulthood.
and related to self-image, and tend to last longer than
Rumination Disorder occurs when partially digested feeding disorders do. We shall discuss four types of
food is brought up into the mouth without any apparent eating disorders: Anorexia Nervosa, Bulimia Nervosa,
disgust, nausea or gastrointestinal condition, and then Binge-Eating Disorder, and Eating Disorders Not
is chewed and re-swallowed or ejected from the mouth. Otherwise Specified (EDNOS).
The onset is between three and 12 months, but in
Since 1969, Milestone Centers, Inc. has provided programs and services to people with developmental and behavioral health cha llenges.
Eating Disorders | Page 2
Introduction
Anorexia Nervosa
HCQU Northwest
Anorexia Nervosa means “without appetite”. The word “anorexia” is actually a misnomer, since it is rare that individuals
with this disorder lack an appetite; in fact, quite the opposite is true. During adolescence, appetites tend to increase for
boys and girls. It is just that the desire to be thin (or the fear of getting fat) is so strong that it overrides the basic drive to
eat. Anorexia occurs most often during the teen years, typically in early- to mid-adolescence, occasionally in prepubescence, and rarely, over forty. Over 90% of the cases diagnosed occur in females.
Diagnosis
The diagnosis of Anorexia Nervosa is made when the following criteria are met: refusal to maintain minimally normal
weight; an intense fear of gaining weight, even though the individual is underweight; a disturbance in one’s perception of
weight or shape; the denial of the seriousness of low body weight; and the absence of at least three consecutive menstrual periods in females or the loss of morning erections and nocturnal emissions in males.
Psychological Factors
People with Anorexia tend to be perfectionistic and have a
need for control; spontaneity and flexibility are not easy for
them. Self-esteem is often lacking and thus there may be
a strong need to please others and to be liked. There may
be a history of being teased about bodyweight or shape.
Depression, anxiety and irritability may be evident.
One or both parents may be dieting. Parental
expectations of the child can be high, while at the
same time, the child can often be afraid to grow up
and leave home. Compounding these pressures is
the fact that society has certain expectations about beauty.
According to the National Association of Anorexia Nervosa
and Associated Diseases, 69% of girls in grades 5 - 12
reported that magazine pictures influenced their idea of
perfect body type. It should be noted that only 5% of the
population possess the type portrayed in advertising as the ideal is, so for most of us, this is an
unrealistic goal. And desperately trying to reach
this goal can have serious health-related consequences.
Warning Signs
Someone suffering from Anorexia will be preoccupied with body shape, weight, food, calories and
dieting. He/she may have caloric values of
different foods committed to memory and make
comments about feeling or being “fat,” even
though his/her appearance suggests otherwise. A
refusal to eat certain foods (cookies/doughnuts/ice cream)
can progress to the avoidance of whole categories of food
(all carbohydrates). The individual may engage in an
excessive, rigid exercise program, working out despite
adverse weather, fatigue, illness or injury, in order to “burn
off” calories; he or she may also withdraw from usual
friends and activities. Rigid thinking is common; it is all or
nothing, black or white, good or bad. Moderation (I can
have a doughnut once in a while without any harm) is not
a concept that works in Anorexia. Heightened
anxiety around mealtime may manifest as an
excuse to be absent from the dinner table (I need
to study for a test, I’m going out to eat with a
friend, etc.). There may be frequent “mirror gazing”
to monitor progress, but it is important to remember that what that individual sees is a distortion of reality.
This person will have experienced a dramatic weight loss
and look quite thin; ribs and shoulder blades may be quite
apparent; the circumference of the knees can be larger
than that of the thighs or calves. Since the fat beneath the
skin (which serves to insulate us and help regulate body
temperature) is gone, people with Anorexia will feel cold
most of the time (fine hair called lanugo may begin to grow
in order to compensate and provide some insulation).
Health-Related Consequences
With Anorexia, the body is literally starving, so it slows its
metabolism and tries to conserve energy in order to
survive. The heart rate slows and blood pressure tends to
drop. Often the person feels tired and weak. Since the body
is not getting the nutrients it needs, it will break down and
digest fat, and eventually muscle tissue, in order to survive.
Inadequate calcium intake causes osteoporosis and brittle
bones. Hair loss occurs as follicles fail to receive necessary
nutrients (hair condition is an accurate reflector of one’s
health). Inadequate fluid intake can cause dehydration.
Electrolyte imbalances, particularly low potassium, can lead
to serious heart problems. Starvation changes the amount
of concentrated hydrogen (pH) in the blood, and this can
lead to metabolic alkalosis or metabolic acidosis, both lifethreatening medical emergencies.
Eating Disorders | Page 3
HCQU Northwest
Introduction
In Latin, bulimia means “ravenous
hunger.” The term is descriptive of
the bingeing aspect of the disease;
the other aspect consists of compensatory behaviors to prevent weight
gain. Teen bulimia can go on for long
periods of time without anyone
knowing it. Five to ten years following
presentation of bulimia, 50% of
Bulimia Nervosa
patients recover fully while 20% still
have full bulimia nervosa. A teenager
with bulimia usually eats more during
one sitting than his/her peers eat.
The reason that people with bulimia
do not tend to lose weight is that
during a bingeing session, they can
consume 3,000-5,000 calories, and by
the time they purge, many of those
calories have already been absorbed.
Therefore, people with bulimia do not
present with the emaciated appearance that is characteristic of Anorexia,
but appear to be of average or above
average weight. Approximately onethird of teens with this disorder shoplift
to feed their binges.
Diagnosis
Criteria include: recurrent episodes of uncontrolled binge eating in which a person consumes more food than most
people would eat in the same amount of time; recurrent inappropriate compensatory behavior in order to prevent weight
gain, such as fasting or exercise, self-induced vomiting, misuse of laxatives, diuretics or enemas; binge-eating and
inappropriate compensatory behaviors both occur, on average, at least twice a week for three months; self-evaluation is
unduly influenced by shape and weight; the disturbance does not occur only during episodes of Anorexia Nervosa.
Psychological Factors
People with Bulimia fit a psychological profile quite different from those with Anorexia. While Anorexics are quite
deliberate, rigid and seek control over their bodies, Bulimics tend toward impulsive behaviors and can appear to lack
control. They may engage in substance abuse, sexual promiscuity and shoplifting. There may be wild mood swings
from elation to depression. It is not uncommon for people with Bulimia to have experienced physical, sexual, or emotional abuse and family dysfunction.
Warning Signs
Obvious evidence of Bulimia is the disappearance of large
amounts of food from the house in relatively short periods
of time. There may be a trail of empty containers or
wrappers. The person suffering from Bulimia usually
makes frequent trips to the bathroom, especially after
mealtime, in order to “purge” oneself of the ingested food.
There might be prescription (Lasix, Aldactone, Bumex) or
non-prescription (caffeine) medications to remove excess
fluid and hence cause weight loss. Laxatives such as Milk
of Magnesia, and even enemas, may also be used to
speed the elimination of waste. The smell of vomit in the
bathroom, bedroom, or emanating from the individual is a
tell-tale sign, especially if it is recurrent. The individual may
try to mask the smell with air freshener, perfume, incense,
gum or breath mints. Repeated self-induced vomiting
introduces stomach acid into the throat and mouth, and
consequently the parotid and salivary glands become
inflamed and enlarged, giving the appearance of “chipmunk
cheeks.” The acid can wear away tooth enamel and cause
staining of the teeth. Vocal cord irritation may cause
hoarseness of the voice. Callouses form on the knuckles
and hands from repeatedly forcing them past the teeth in
order to trip the gag reflex and vomit. As with Anorexia,
someone with Bulimia may adhere to an excessive, rigid
exercise program and may avoid socializing as much as he
or she had done before.
Health-Related Consequences
As with Anorexia, electrolyte imbalances can occur, leading to irregular
heartbeat, heart failure, and death
from purging (vomiting, and using
diuretics and laxatives).
Repeated
vomiting can lead to damage of the
mouth,
throat
and
esophagus.
Vomiting is normally a protective
mechanism to rid the body of harmful
or toxic substances, and occasional
reflux of stomach acid will not harm
these structures, but repeated insults
will. Tooth enamel erodes, mouth
sores form, salivary and parotid glands
become inflamed and enlarged, and
esophageal ulcers and even esophageal rupture can occur. Although it is
rare, an overzealous binge session
can cause gastric rupture due to the
sheer volume of food ingested.
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HCQU Northwest
Binge Eating Disorder
Introduction
Binge-Eating Disorder is more common than either Anorexia or Bulimia, affecting approximately 3.5% of females and
2% of males. It is characterized by insatiable cravings for food that can occur any time of day or night, periods of
uncontrollable eating, and associated feelings of distress and shame. Unlike Bulimia, the binge-eater does not exhibit
any compensating behaviors such as a rigid exercise program or self-induced vomiting. This is not just occasional
“pigging out” or over-eating; it is a consistent, ongoing series of episodes in which a person eats enormous amounts of
food and is powerless to stop.
Diagnosis
For a true diagnosis of Binge Eating, there must be: a loss of control over the amount of eating; marked distress over the
bingeing episode; bingeing must occur at least once a week for three months, plus at least three more of the following
criteria: eating more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not
hungry; eating alone out of embarrassment; feeling guilty or ashamed after a binge session.
“Approaching someone with an eating disorder can be a delicate situation...An
eating disorder is often a coping mechanism to protect a fragile inner core. “
Psychological Factors
As many as 50% of all people with Binge Eating Disorder are depressed or have had depression in the past. Those who
seek comfort in food may receive it for a brief moment, but then, when the bingeing session is done, feelings of regret,
shame and self-loathing set in. Binge eating often leads to weight gain and obesity, which only reinforces compulsive
eating. The worse a binge eater feels about himself and his appearance, the more he uses food to cope. Hence, the
vicious cycle: eating to feel better, then feeling even worse, then turning back to food for comfort or relief.
Warning Signs
A person with this disorder may eat “normally” when he or she is in the presence of others, but will gorge rapidly on large
amounts of food when alone. Binge eaters are often ashamed of their eating habits and therefore eat in secret to avoid
embarrassment. They will hide and stockpile food to eat privately at a later time. Eating does not follow any scheduled
time for them, there is not the traditional breakfast-lunch-dinner routine but often an almost continuous ingestion. Eating
is not so much a pleasurable activity that provides nourishment as it is their only way to relieve anxiety, distress or
tension; a binge eater often feels numb while bingeing, as though he or she were on auto-pilot. Following a session
there are feelings of guilt, shame and depression, leading to more anxiety and distress, and the cycle repeats. Since
these people do not engage in any purgative activities, they gain weight and are often obese.
Health-Related Consequences
Binge Eating has its own set of adverse effects which are quite different from those of Anorexia or Bulimia. Taking in far
more food than necessary with a sedentary lifestyle leads to obesity. Excess visceral fat (fat deposited in and around the
abdominal organs) causes insulin resistance, leading to Diabetes Type 2. DM 2 leads to arteriosclerosis, hypertension,
visual problems, renal failure, strokes, foot ulcers, and amputations. Too much food and too much fat overwork the liver,
which produces bile (the substance that breaks down fat for digestion), and the gall bladder, which stores it. Eventually
gall stones can develop. Excessive fat, sugar, and chemicals in processed food all can increase the risk of cancer.
Arthritic degeneration and joint pain develop from carrying too much bodyweight. Obesity increases the risk of Sleep
Apnea, a disorder in which a person’s airway becomes obstructed during sleep, causing the individual to stop breathing
several times a night, which increases the risk of cardiac arrhythmia, heart attack and stroke. Repeated apnea causes
frequent nighttime awakening, resulting in morning headaches, constant fatigue and moodiness.
Eating Disorders | Page 5
HCQU Northwest
Eating Disorders Not Otherwise Specified (EDNOS)
Anyone who displays an unhealthy relationship with food
that does not fit within any of the diagnostic criteria for
each of the three major eating disorders will fit into this
category. Over half of the people with eating disorders fit
under this diagnosis. If a female meets all the criteria for
Anorexia but has regular menstrual periods, she is
classified as EDNOS. A person who meets all criteria for
Bulimia, but binges and purges only once a week instead
of twice a week, is diagnosed with EDNOS. The point is
that the essence of a person’s problem may be starving
himself, or bingeing and purging, or eating uncontrollably,
but does not display all of the criteria for the listed disorders, he/she falls into EDNOS. Rarely an individual may
chew food and spit it out instead of swallowing it; this
would be considered EDNOS.
Eating Disorders and Borderline Personality
Disorder
Borderline Personality Disorder (BPD) is characterized by
impulsive behavior, unstable relationships, problems
regulating emotions and thoughts, and problems with
anger and irritability. These people lack a strong identity,
and may engage in self-destructive or self-injurious
behavior (unsafe sex, reckless driving, drug abuse,
spending sprees, criminal behavior). In many cases,
there has been a history of pathological family experiences (sexual/emotional/physical abuse), abandonment, poor
emotional support by the parents, hostility, and an
invalidating family environment, i.e., the child’s feelings
are rejected or criticized instead of being accepted and
validated. The result of this is that the child grows up
without developing a core identity or sense of self.
BPD is diagnosed three times more often in females and
the onset is typically in early adulthood. People with BPD
have a greater prevalence of eating disorders than
people in the general population. One study indicated
that 53.8% of patients with BPD also met criteria for an
eating disorder. However, the majority of people with
eating disorders do not have BPD, so while there has not
been any cause-effect established, it is important that
caregivers be aware that the two problems often co-exist.
Eating Disorders and Intellectual or
Developmental Disability
Studies report that people with intellectual disabilities are
more likely to have weight problems, and that 35%-72% of
adults with severe and profound intellectual disability are
significantly underweight. The number of people of
abnormal weight who also suffer from eating disorders is
unclear. This is because much depends on the individual’s
ability to communicate regarding self-image; most people
with mild ID and many of the people with moderate ID
may be able to do this to some extent. With regard to
people suffering from severe or profound ID, it may still be
possible for health care personnel to gain information
using pictures of people of different sizes and shapes, or
by speaking with knowledgeable informants (family
members or caregivers).
Prader-Willi Syndrome is a genetic disorder that includes
both cognitive disability and hyperphagia (overeating);
people with this syndrome have a chronic, insatiable
appetite that can look a lot like binge-eating (even though
it is not), and they often become obese. Physical characteristics of Prader-Willi include a delayed onset of puberty,
short stature, almond-shaped eyes, a prominent nasal
bridge, small hands with tapered fingers, and extremely
flexible joints.
Treatments for Eating Disorders
Treating people with eating disorders
can be challenging. It can be difficult
for a person with such a disorder to
admit that he or she has a problem;
denial can be incredibly strong. Few
insurance carriers cover the cost (up
to $2000/day) of treating eating
disorders, Finally, eating disorders are
not quick, easy fixes; it can take
months or years for a person to
overcome an eating disorder.
Medical treatment may be necessary
for a person suffering from severe
malnutrition, dehydration, electrolyte
imbalance or other life-threatening
problem secondary to the eating
disorder. Often, after the patient’s
acute medical problem has been
stabilized, an in-hospital psychiatric
stay is recommended to address core
issues behind the behavior. Nutritional
counseling may be provided, focusing
on health rather than weight, hoping
that if the person with the eating
disorder understands the specific
adverse effects on health caused by
the eating disorder, he or she may be
motivated to change the behaviors.
Pharmacology can be helpful to
manage symptoms of anxiety or
depression that can co-exist with the
(Continued on page 6)
Eating Disorders | Page 6
HCQU Northwest
(continued from page 5)
eating disorder. Finally, for any lasting success, some type of mental health counseling is essential. There are some
different approaches currently being used to treat people with eating disorders.
Psychotherapy can be very helpful in addressing underlying problems associated with an eating disorder and can help
with anxiety or depression. This type of therapy is often used with people who have Anorexia or Bulimia. The frequency
and duration of one-on-one sessions can vary, depending on the therapist, and psychotherapy can involve a significant
amount of time and money.
Cognitive Behavioral Therapy focuses on identifying and changing distorted thinking patterns, attitudes and beliefs that
contribute to a person’s pattern of harmful eating behaviors. It challenges black-and-white thinking and helps the patient
better understand his or her irrational beliefs about self-image, body shape and dieting, for example, “I will not be
accepted by my peers unless I look like a model.” Cognitive therapy is often the treatment of choice for people with
eating disorders because it is time-limited (and therefore, less expensive than psychotherapy) and focuses on specific
goals.
Family Based Therapy has shown promise in terms of long-term success in treating individuals with eating disorders.
Unlike other forms of therapy, it, as its title suggests, believes that eating disorders do not occur in a vacuum and family
Helping People with Eating Disorders
It is important to assess for signs of eating disorders. Noticing psychological factors and warning signs of these disorders is the first step in helping someone suffering from such problems. If you recognize that the person needs help,
understand that he or she may be in denial.
Denial says that everything is okay even when it isn’t. It can be very dangerous when it blinds a person from seeing that
he or she could be in medical danger. Approaching someone with an eating disorder can be a delicate situation. Denial
is not an attempt to be stubborn or argumentative; it is born out of fear. An eating disorder is often a coping mechanism
to protect a fragile inner core.
There must be a balance between dealing with the reality of significant danger and proceeding gently and carefully so as
not to overwhelm the person and cause the denial to become even stronger. Express concern and listen nonjudgmentally. Sharing is usually more effective than “You should . . .” Better to indicate that you are worried and that
something must be bothering that person if he/she has stopped eating. It is okay to ask if he or she is thinking of suicide.
You may need to call 911 if that is the case. If it is not a crisis situation, give reassurance and information, whether it be
about professional help or self-help groups (plenty are accessible on-line). Aligning with a person is often more supportive than confronting or arguing. Remember that someone with an eating disorder is trying to gain control over his life
and turn himself into someone he can accept. These people are struggling, and support is more effective than criticism.
Prevalence vs. Funding
Despite the prevalence of eating disorders, they continue to receive inadequate
research funding.
Illness
Alzheimer’s Disease
Autism
Schizophrenia
Eating disorders
Prevalence
5.1 million
3.6 million
3.4 million
30 million
NIH Research Funds (2011)
$450,000,000
$160,000,000
$276,000,000
$28,000,000
Research dollars spent on Alzheimer’s Disease averaged $88 per affected individual in
2011. For Schizophrenia the amount was $81. For Autism $44. For eating disorders the
average amount of research dollars per affected individual was just $0.93. (National
Institutes of Health, 2011)
Source: http://www.nationaleatingdisorders.org/get-facts-eating-disorders, 7/12/13, 9:25am
MilestonePA.org
HCQU Northwest
EATING DISORDERS TEST
Name: _________________________________________
Title: _______________________________________
Agency: ________________________________________
Date: ______________________________________
Please provide contact information (email address, fax number, or mailing address) where you would like your certificate to be sent: _________________________________________________________________________________
_______________________________________________________________________________________________
You must submit your completed test, with at least a score of 80%, to receive 1 hour of training credit for this
course.
To submit via fax, please fax the test and evaluation to 814-728-8887.
To submit via email, please send an email to HCQUNW@MilestonePA.org. Please put “Eating Disorders
Test” in the subject line, and the numbers 1—10, along with your answers, job title, and agency in the
body of the email.
To submit via mail, send the test and evaluation pages to Milestone HCQU Northwest, 247 Hospital Drive,
Warren PA 16365.
Knowledge Assessment
1. Eating disorders most frequently occur in males.
True
False
2. People suffering from Anorexia Nervosa have a poor appetite.
True
False
3. Eating disorders are relatively easy to treat and usually resolve quickly.
True
False
4. Appetite stimulants like Megestrol are the primary means of treating Anorexia Nervosa.
True
False
5. Individuals with Bulimia Nervosa are often secretive about their bingeing and purging habits. True
False
6. Identifying an eating disorder in someone with an intellectual disability may be more difficult because it may be difficult for that person to communicate with you regarding self-image.
True
False
7. Aside from some minor nutritional deficits, eating disorders have relatively harmless consequences.
True
False
8. Treatments for eating disorders can be very expensive, and are rarely covered by health insurance.
9. It is rare for people with Borderline Personality Disorder to also have an eating disorder.
True
False
True
False
10. A firm, authoritative approach is the best way to motivate a person with an eating disorder to seek help.
True
False
MilestonePA.org
HCQU Northwest
Evaluation of Training
Training Title:
Eating Disorders
Please check the box that best describes your role:
 Direct Support Professional
Date:
 Program Specialist
 Provider Administrator/Supervisor
 Provider Clinical Staff
 Consumer/Self-Advocate
 Support Coordinator
 PCH Staff/Administrator
 Family Member
 Support Coordinator Supervisor
 FLP/LSP
 County MH/MR/IDD
 Other (please list): __________________________________________
Please circle your PRIMARY reason for completing this home-study training:
 It’s mandatory
 interested in subject matter
 need training hours
 convenience
Please circle the best response to each question.
5 = Strongly Agree
4 = Agree
3 = Undecided
2 = Disagree
1 = Strongly Disagree
1.
As a result of this training, I have increased my knowledge.
5
4
3
2
1
2.
I learned something I can use in my own situation.
5
4
3
2
1
3.
This training provided needed information.
5
4
3
2
1
4.
The training material was helpful and effective.
5
4
3
2
1
5.
Overall, I am satisfied with this training.
5
4
3
2
1
6.
I am glad I completed this training.
5
4
3
2
1
Suggestions for improvement:
Additional information I feel should have been included in this training:
I would like to see these topics/conditions developed into home-study