EATING DISORDERS

Nurpudji Astuti
Nutrition Department
School of Medicine
2003

Eating Disorders
Anorexia Nervosa
Bulimia Nervosa

Objectives
To understand the differences between
various eating disorders e.g. anorexia and
bulimia nervosa.
To consider causative factor presenting
features, at risk groups, medical
complications, prevention and treatment.

Eating Behaviors
Why do we eat?
Internal hunger
Energy external pleasure, social,
personality, environment
What is abnormal eating behavior?
Abnormal eating behavior = eating
disorder?

Eating behaviors
Why do we stop eating ?
We stop eating when we are satisfied?
Eating is a behavior Not necessarily
related to hunger or fullness

Body Image Scale

Circle the number on the line closest to
the present size, scale 1 (very thin) to 17
( obese ) grade 5 7 = average or BMI 20
25 grade = eating disorder i.e. think they
are fatter than they are
Circle the number on the line closest to
the size you would like to be grade 1 =
eating disorder

Introduction
Mr. Dukes daughter in S. Mary Axe, in the year 1684
and the eighteenth year of her age, In the month of July
fell into a total suppression of her monthly courses from
a multitude of cares and passions of her mind but
without any symptoms of the green-sickness following
upon itI do not remember that I did ever in my practice
see one, that was conversant with the living so much
wasted with the greatest degree of consumption ( like a
skeleton clad only in skin ) yet there was no feveronly
her appetite was diminishedshe was after three month
taken with a fainting-fit, and died

Greenfield et al. Yale University

81% of girls between 13-19 reported often
feeling fat
26% of boys 13-19 yrs reported often feeling fat
46% of girls thought they were overweight (12%
in reality)
46% of girls uses crash diets
40% of girls fasted>/day
15% had used diet pills

Hill et al.
41% of 9 year old girls choose a preferred body
shape thinner than their current shape (18%
chose broader)
41% of boys choose a broader shape and 28%
choose a thinner ideal shape
In ranked studies, the overweight was below the
child in a wheelchair or with facial disfigurement
Girls are less accepting of overweight same sex
peers than are boys

Anorexia Nervosa
3rd most common chronic illness
in girls 15-19 yrs
Prevalence of 0.5%
Increasing number of young patients 8-14 yrs
Average duration of 4 years
Long term mortality of 20-25%
Suicide rate ~ 5%
50% relapse rate in 1 year

Bulimia
Patients can be underweight, normal weight or
overweight
Often keep binge eating + purging secret
Pre-occupied with weight, appearance, body
image
Misuse insulin or thyroid medication
Laxative of abuse more common
Occurs on a continuum from a few
times/month to several times a day

Definition of
Anorexia Nervosa
Criteria :
a. Refusal to maintain bodyweight at or above a
minimally normal weight for age and height
b. Intense fear of gaining weight or becoming fat
c. Undue influence of body weight on selfevaluation denial of seriousness of current low
body weight
d. Amenorrhea absence of consecutive
menstrual cycles
Types : Restricting, Binge eating

Definition of
Bulimia Nervosa
Criteria :
a. Eating in discrete period of time (e.g. within any 2-hr
period) and amount of food that is definitely larger than
most people would eat OR a sense of lack of control
over eating during the episode (feeling one cant stop
eating)
b. To prevent weight gain : self induced vomiting, misuse
of laxative, diuretics, enemas, fasting
c. binge eating or vomiting/laxatives etc at least twice a
week for three months
d. Self evaluation unduly influenced by body shape

Differential Diagnosis

IDDM
Thyrotoxicosis
Malignancy
Mal-absorption
HIV
depression

At Risk
Female adolescent
Young children
Children with mother who have eating
disorders
Athletes dancers, gymnastics
Older women
Patients with a history of sexual abuse
Victims of rape

Male Anorexia
One in ten patients with an eating
disorders is male
Increasing incidence of eating disorders in
male homosexuals
High incidence of substance abuse
Part of impulse control problem where
alcohol, drugs and food are misused
Increasing in sports such as wrestling,
body building, jockeys

Common Physical Finding

Emaciation
Bradycardia
Hypotension
Pallor
Acrocyanosis
Ankle edema
Breast atrophy
Growth stunting ( pre-pubertal )

Medical Complications of Anorexia

Nervosa and Bulimia Nervosa

Cardiovascular: arrhythmia, bradycardia, oedema cardiomyopathy,

hypotension, peripheral cyanosis
Dermatologic: callus formation on hands, carotene pigmentation, dry
skin/nails, lanugo hair, thinning scalp hair, irritation at corners of
mouth
Endocrine: amenorrhoea, decreased triiodothyronine and thyroxine
levels, increased cortisol and growth hormone levels
Gastrointestinal : bloating, early satiety, constipation, dental caries,
diarrhoea, oesophageal rupture
Hematologic: mild anaemia, low white blood cell count
Metabolic: hypokalemia, hyponatremia, hypokalemia
Musculoskeletal: delayed bone maturation, reduced stature,
osteoporosis, seizures

Etiology
Genetic monozygotic twins, 55% concordance
dizygotic twins, 7% concordance
But may be mediated by :
- growth rate in childhood
- Predisposition to obesity
- Personality type
- Predisposition to psychiatric illness

Etiology
1694 Morton : destruction of tone of nerves
Early 1900s : pituitary dysfunction
Mid 1980s : peptides i.e. CCK, NPY, substance
P
1990s :
1. imbalance in serotonin mechanisms
2. common end-point of stress, depression
and anxiety

Serotonin
Serotonin (5HT) is responsible for
suppression of food intake
Serotonin acts to induce satiety
Serotonin regulates body weight via
thermo genesis and nutrient selection
Serotonin function is different in men &
women BUT may be a secondary
condition related to starvation

SEVERITY TEATMENT

CARE PROVIDER

Excessive psycho-education dieting

Counseling, weight monitored

General practitioner or self

help

Anorexia: early onset parental or

short illness counseling

General or child psychiatrist

Specialist eating disorder unit

Anorexia: long out patient illness or

family therapy recurrences or
individual or inpatient

Key Points
The aims of treatment of anorexia nervosa
is to establish healthy eating habits and
normal weight through the consumption of
regular meals and snacks building up to
2000 kcal/day, and to address factors to
result in relapse

Key points continues ..

The process involves education, support,

encouragement, nutritional counseling and
psychiatric treatment involving family
therapy and cognitive behavior therapy
Energy rich drinks may help in the
weight gain

Key points continues .

The most effective of bulimia nervosa is

cognitive behavior therapy to modify the
disturbed eating habits and the concerns
about shape and weight
Other eating disorders exist but are less
well understood. Binge eating disorders is
best treated by conventional behavior
weight control on a one - to - one basis.