Can regular vomiting cause dental problems for people with eating disorders?

Dr J Gerschman and the Anorexia and Bulimia Nervosa Foundation of Victoria Inc.
Yes. In the long term, frequent vomiting can cause dental problems for both people with bulimia nervosa and anorexia nervosa (purging type). These can often be permanent and professional advice is important. If your client has concerns about their dental health it is best to recommend they have these checked by their regular dentist.
Some of the common signs and symptoms of dental problems associated with an eating disorders include:

• erosion of dental enamel

• thermal hypersensitivity (cold/hot sensitive)

• salivary gland enlargement

• dryness of the mouth and decreased salivary flow

• redness of the throat and palate

• reddened, dry and cracked lips and fissures at angles to the lips

It is recommended that people with eating disorders:

1. Rinse their mouth immediately after vomiting, with sodium bicarbonate or magnesium hydroxide (place on teaspoon in half a glass of water and rinse, or use a proprietary preparation such as Dexal or Dexal Lemon).

2. Brush daily with fluoride toothpaste.

3. After brushing, apply stannous fluoride gel, for example, Floran, or rinse with neutral sodium fluoride rinse such as Oroflour or Dentamint.

4. Floss with dental floss daily.

5. If necessary, consider restoration of teeth with resins or crowns.

6. Have regular dental checkups.

Source: Eating Disorders Online
ejournal of the Eating Disorders Internetwork Project
Volume 1 Number 2 June 1998

How do I approach a Student suspected of having an Eating Disorder?

Anorexia and Bulimia Nervosa Foundation of Victoria
Approaching someone you suspect to be suffering from an eating disorder is often one of the most difficult decisions facing the teacher or school counsellor. A number of factors should be considered:

Who will approach the student ?

A teacher who the student particularly likes/trusts and has a positive relationship with, is the best person to talk to the student. A school counsellor's role may by 'behind the scenes', supporting the teacher. Building trusting relationships between teachers and students is, therefore, very important.

When is the best time ?

Timing is of the essence. Your timing may not equate with the readiness of the student. If the student is a minor, or looks to you to be losing their grip on life, it is reasonable to confront them.

How should parents be involved ?

Involve parents at your discretion. Often family members will recognise symptoms early, however, some may be blinded by the illusion that the weight loss is 'healthy' or a positive thing. Family relationships , confidentiality boundaries, and timing are some issues to consider. Students can be encouraged to address their parents and/or may ask for your support to do this.

What tone should be taken ?

Empathic, clear, non-blaming and assertive statements are helpful. Aggressive approaches are not. First, ask the student about how they have been feeling lately, giving them the opportunity to disclose the problem, before telling them what you have noticed or what you are concerned about. For example, "Jane, I've noticed lately that … (e.g. you've lost a lot of weight, you seem pretty unhappy and you're not going out as often, your school work is getting more difficult for you, you've lost your 'sparkle', you've drastically changed your eating habits etc.) and I'm really concerned about you. Have you noticed these things ?" "I've been doing some reading and …"

How will the they respond ?

The student's response may be unpredictable. Common reactions are either:

• "relief" - i.e. they may welcome your concern and confirm your suspicions. This acknowledgements is one of the first steps to recovery; or

• "get lost" - i.e.. they may respond with fear, anger, denial, resentment or despair. They may say you are over reacting, interfering, and/or insist that they are OK.

What preparation needs to be done ?
Do your homework beforehand. Read some literature, contact the Eating Disorders Association (Tel: 07 3891 3660), discuss the best approach, and become informed about support and referral services available before approaching the student.

What is my ongoing role ?

Consider how you will best assist the student after confronting them. Offer this assistance when you speak to them. Be careful when giving advice. Your aim is for the student to begin to take responsibility for the problem.

Reassuring comments will help to guard against the guilt and shame that are often associated with eating disorders.


Adapted with the kind permission of the Anorexia and Bulimia Nervosa Foundation of Victoria (Inc.). 1513 High Street, Glen Iris, 3146. Tel: 03 9885 0318. Fax: 03 9885 1153.

Source: Eating Disorders Online
ejournal of the Eating Disorders Internetwork Project
Volume 1 Number 1 April 1998

 

The Epidemiology of Eating Disorder Behaviours - an Australian community-based survey

Hay P., (1998) International Journal of Eating Disorders., 23: 371-382
Joanne Blair, Coordinator, Eating Disorders Association Inc., Queensland
This study is one of the few to report on the prevalence and distribution of eating disorder behaviours in a representative community-based sample of an Australian population.

The Study
"This study was part of the Autumn 1995 Health Omnibus Survey, under the auspices of the South Australian Health Commission."
The stated aim of this study was "to assess the prevalence of binge eating, purging, and strict dieting or fasting in a general population sample. Further aims were to evaluate the relationship of these behaviours to age, gender, weight and marital status, and to estimate the prevalence of the subtypes of bulimia nervosa and binge eating disorder."
Subjects came from 3001 households, one person per household, from metropolitan as well as rural areas. The mean age of the subjects was 46 years ranging from 15 years to 94 years.

The Findings
binge eating and dieting were most common in people who where in their early to mid thirties

• dieting and purging, but not regular binge eating, were more common in women than in men

• purging was most common in the 35-44 year age range

• unmarried subjects were less likely to diet than married subjects

Most of the findings of the study were in line with common understanding of eating disorders, for instance that strict dieting/fasting is five times more common in women than men, and more common in younger ages.
One of the unexpected results was that purging behaviours were found to be most common in the 35 to 44 year age group. Only 23% of people with either bulimia nervosa or binge eating disorder were found in the under 25 year age group. The question is posed as to whether this is due to the age of onset for bulimic behaviours rising, or the identification of behaviours that have persisted over a long course of the disorders. Either way, this finding points to the need for services for people with eating disorders from a broader spread of ages, and for programs aimed specifically at the 35-44 year age range.
Purging behaviours were also found to be exclusive to women. This result is not explored in the paper, which seems remiss. Such a result may be related to the way in which purging behaviours were identified. Interviewers asked: "Over the past 3 months, have you regularly used any of the following: laxatives, diuretics (water tablets), made yourself sick, gone on a very strict diet or eaten hardly anything at all for a time, in order to control your shape or weight?". There were no questions related to excessive exercise. Neither were there questions that related these behaviours to compensating for binge eating specifically, as compared to controlling weight or shape. This may have resulted in the non-identification of a significant number of men and women who might have been included in the numbers practising purging behaviours.
Regular binge eating which was not frequent enough for a diagnosis of binge eating disorder was found at about the same rate in men as in women (3.2%). This rate was also found in the younger ages (mean age 35). Purging and strict dieting were not found to be as prevalent in men. It was suggested that further investigation is needed to ascertain what protects men from the more severe forms of eating disorders. Such information would be very useful.
No difference was found in the weights of people with symptoms of bulimia nervosa and the weights of the people with symptoms of binge eating disorder. There was however, an association between the two disorders and obesity. The author suggests this may be due to obesity being a possible risk factor for the development of an eating disorder.
The study found that strict dieting was less common in people who were married or living with a partner. It was suggested that this may be because being married inhibits extreme dieting behaviour or mediates behaviour, or that this behaviour is mediated through things such as emotional support or improved self-esteem. Thus it is concluded that a focus on improving relationships may be a valid intervention for eating disorders. This finding was also discussed with another interpretation: that people who have disordered eating are more likely to have difficulty with relationships. However, it was also pointed out that the more severe problems of purging and bingeing were not found to be more common in those who were unmarried, and that the small number of people identified with eating disorders was not enough to get details of relationship issues. Further research in this area was suggested.

• 3.2% of respondents had regular episodes of binge eating

• 1.6% regularly fasted or used strict dieting

• 0.8% purged

• 0.3% had bulimia nervosa

• 1% had binge eating disorder

This study discusses the possibility that people with an eating disorder might not take part in a questionnaire such as the one described, and that this might affect the rate of these problems found in the sample. As the author points out this is less likely in a survey such as this one, a Health Omnibus Survey, that is not identified as being about eating disorders. However, the possibility that people with eating disorders might not answer the questions truthfully, especially as there were only two questions relating to eating disorder behaviours in the whole survey, is not discussed in this paper. It is entirely possible that people with an eating disorder, who have a lot of distressing emotions associated with the bingeing or purging behaviours and are in the habit of concealing the behaviours, may deny or minimise the behaviours in question.
The overall prevalence rates of eating disorders, using the Oxford criteria for frequency of bingeing, were found to be 2.5% for binge eating disorder and 0.7% for bulimia nervosa. Using DSM IV criteria, the rates were 1% for binge eating disorder and 0.3% for bulimia nervosa. The study did not screen for anorexia nervosa. In the conclusion to this article, it is stated that "problematic eating disorder behaviours … were relatively uncommon". This is a questionable conclusion however when one consider the question, relative to what? There are not many serious disorders that would be found at rates any higher than this. For instance, Insulin Dependant Diabetes affects only 0.2 to 0.3% of the general population. To conclude that eating disorder behaviour is uncommon also does not take into account the fact that these disorders are found mostly in the young to middle age groups. It is the prevalence of disorder in these high risk group which need to be considered in planning services for the future.
Analysis of prevalence rates according to age groups, would have been useful addition to this paper. In another recent Australian study to use a community sample subjects in the 18 to 22 year old age group were assessed for possible eating disorders, and the rates found were much higher. The Australian Longitudinal Women's Health Study (1997) had 15,000 women in this age cohort, of whom several questions, framed around DSM IV criteria for eating disorders, were asked. The results were that 4.8% of females in this younger group were found to fulfil the criteria for bulimia nervosa and 19.6% had symptoms of binge eating disorder.
Conclusion
It is good to see eating disorders being examined in Australian studies such as this one. Without more local epidemiological information proposals for increased funding and improved service provision often go unsupported, making it difficult to achieve any change in the current situation where a considerable gap exists between the demand for resources and the services available to people affected by eating disorders. Information from studies such as this validate the anecdotal information from professionals who find themselves overwhelmed by the needs of this often difficult area of practice.

Source: Eating Disorders Online
ejournal of the Eating Disorders Internetwork Project
Volume 1 Number 2 June 1998

 

The Long Term Course Of Severe Anorexia Nervosa in Adolescents

Survival analysis of recovery, relapse and outcome predictors over 10-15 years in a prospective study
Strober M., Freeman R., and Morrell W., International Journal of Eating Disorders, 22:339-360, 1997.
Dr Michael Theodoros, Consultant Psychiatrist, Team Leader, Eating Disorders Unit, New Farm Clinic, Brisbane; and Senior Clinical Lecturer, Department of Psychiatry, University of Queensland.
This paper is an important new outcome study in severe anorexia nervosa. Compared to previous outcome studies, the impressive results from the this study provide for improved optimism in relation to anorexia nervosa.

The Study
The study is a naturalistic, longitudinal prospective study of 95 adolescents with anorexia nervosa who were hospitalised in a university-based speciality treatment centre in Los Angeles, California. Following their initial admission, the progress of patients was followed for between 10 and 15 years.

The Treatment
During the index admission, target weights were set at 90% to 95% of average expected weight. Combined with this, treatment was intensive and multi-modal and included individual, group and family therapy; nutritional counselling; and high intensity nursing management. Brief admissions were avoided and the patients were discharged only after target weights were achieved.

The study provided for ongoing assessment and follow up twice a year in the first five years and then annually for a further 10 years.

Outcome Measures
An important part of this study was that stringent criteria were required for full recovery to be deemed to have occurred. This was defined as weight restored with normal, with menses, and an absence of eating disorder behaviours and attitudes.

The Findings
At follow up a full recovery rate of 76% was achieved and a further 10% were partially recovered. This left 14% of the subjects with ongoing disorder and without any meaningful recovery being achieved.

At the time of the follow up, between 10 and 15 years, there were no deaths in the study sample. From previous mortality data it could have been expected there would be in the order of 10 deaths. Whilst 30 per cent of subjects experienced post discharge relapse, most of this occurred in the first 12 months following release from hospital, and rarely was there relapse following full recovery.

The Implications
In comparison to previous long term outcome studies of anorexia nervosa, these results constitute improved morbidity and mortality and have important implications for the way in which this disorder is treated.

In recent years, the higher relapse rate following hospital-based weight restoration programs has lead to limitations in inpatient treatment of anorexia nervosa as a cost management strategy. The development of partial hospitalisation programs for eating disorders has been another consequence of this cost containment.

What this study shows is that a well funded intensive inpatient program, that achieves weight restoration and addresses the psychological needs of the individual, results in improved outcome.

The average time for full recovery was 79 months (6.58 years) and for partial recovery 57 months (4.75 years). This finding conveys the often protracted nature of anorexia nervosa and the need for all concerned to take a long term perspective in relation to this disorder. Health care systems have to provide continuity of care for these patients over an extended period of time, and sufferers of anorexia nervosa, and their families, should be warned against unreal expectations of rapid recovery.

In summary, this research is a highly informative and valuable contribution to our knowledge of outcome in eating disorders. Whilst the study provides more evidence of the protracted nature of anorexia nervosa, the results also provide for renewed optimism if and when intensive, multi-modal treatment is provided for this baffling disorder.

Source: Eating Disorders Online
ejournal of the Eating Disorders Internetwork Project
Volume 1 Number 1 April 1998

Book Review:
"Overcoming Binge Eating"

Fairburn, C (1995) Guilford Press
Elizabeth Gwynne, Psychologist in Private Practice, Brisbane.
Having conducted volumes of research and thousands of hours of clinical practice with clients with eating disorders, Christopher Fairburn is undoubtedly one of the world's leading authorities in this domain. 'Overcoming Binge Eating' provides a synthesis of much of his work, which has focused on developing and evaluating new treatments for bulimia nervosa and binge eating disorder.
The book is organised in two sections with Part One presenting the most current information about binge eating problems, and Part Two providing a self-help manual based on principles that have been found to be the most effective in the treatment of binge eating.
Topics covered in Part One include:

• features that distinguish between occasional episodes of overeating, binge eating problems, and binge eating disorders;

• the psychological, social and physical problems associated with binge eating;

• factors that contribute to the development and maintenance of binge eating problems;

• whether or not binge eating is a form of addiction; and

• a discussion of the various approaches to treatment that have been used in the last twenty years, with cognitive-behavioural therapy being proposed as the treatment of choice for lasting change.

Part Two is written in the form of a comprehensive, user friendly self-help manual. The introduction provides essential preparatory reading for sufferers addressing important issues such as : Why Change? The advantages and the disadvantages; the options available to support a change in binge eating behaviour; when to change and when self-help may not help; what to change; and how to use the program.
The six steps in the program are outlined:
Step 1: Getting Started
Self-monitoring
Weekly weighing
Step 2: Regular Eating
Establishing a pattern of regular eating
Stopping vomiting and misusing laxatives and diuretics
Step 3: Alternatives to Binge Eating
Substituting alternative activities
Step 4: Problem Solving and Taking Stock
Practicing problem solving
Reviewing progress
Step 5: Dieting and Related Forms of Avoidance
Tackling the three forms of dieting
Tackling other forms of avoidance of eating
Step 6: What Next?
Preventing relapse
Dealing with other problems
Included in the appendices is a comprehensive reference list providing sources of further information of relevance to each chapter.
Importantly, the book is written with great insight and compassion, qualities that will convey to sufferers a sense of encouragement and understanding and provide invaluable support as they venture along the rocky and challenging road to recovery. In the words of Kelly Brownell, director of the Yale Centre for Eating and Weight Disorder, "You can trust this book. It is a landmark."

Source: Eating Disorders Online
ejournal of the Eating Disorders Internetwork Project
Volume 1 Number 2 June 1998