Body Image and Eating Behaviours: Preventing disease or promoting health?

Lily O'Hara Lecturer in Community and Public Health, Sunshine Coast University, Queensland
'Stepping out of the shower and studying herself in the mirror, Edna was pleased with what she saw: a voluptuous middle aged cow'.
This caption is taken from a cartoon depicting a lovely Friesian cow admiring her form in the mirror. It is an unusual image, not because it depicts a cow standing on her hind legs and thinking in English. It is unusual because positive body images are so rarely depicted in any form of media that when presented with such an image, it seems amusing. It is so rare for us to see or hear of someone who is really happy with her looks or her body image. And yet having a positive body image is vitally important to good health and well being. Body image satisfaction also provides a perfect example of the difference between a health promotion approach and a disease prevention approach to improving health and well being.
The World Health Organisation defines health by as a complete state of physical, social and emotional well being, and not just the absence of disease or infirmity. Health should thus be seen as a resource for living, and not the object of living. WHO has defined health promotion as the process of enabling people and communities to increase control over and thereby improve their health. Health promotion therefore is an approach to improving health that incorporates three distinct elements:

• the recognition that being healthy and well allows people to get on with the business of living, loving, working, recreating, socialising and playing;

• recognition that to increase the stocks of this resource called health, the social, emotional and physical aspects of health must be considered as equally important components; and

• the recognition that individuals and communities must be involved in the process of increasing the stocks of the health resource.

A health promotion approach to body image, therefore, means that the issue must be considered as more than simply the prevention of eating disorders, illness or injury. A health promotion approach recognises the value to individuals of having a positive body image, and that feeling happy and accepting of your own body allows you to concentrate on the important business of getting on with your life. Positive body image is also a component of positive self esteem; a resource well recognised for its contribution to many positive outcomes in life. At a community level, the physical, emotional, social and cultural environments have a direct effect on the way people are treated in society. A health promotion approach means that collaborative, social action strategies are developed that enable people and communities to be part of the process of addressing the factors that contribute to the development of positive body image on both individual and societal levels.
If we move away from the health promotion approach and examine the disorder prevention approach, we see that the focus shifts primarily to what happens when you don't have a good body image. The prevention model includes investigation of the prevalence, incidence and severity of eating disorders, and in particular among young women. From this investigation, we know that eating disorders are important to prevent because of the physical, emotional and social cost to the individual and their family. Eating disorders are also costly to treat for the health system, and treatment methods have only a moderate success rate. There is also a high mortality rate for the disorders. Given these factors, it seems logical to think about how to prevent the development of eating disorders in the first place. Traditionally this has seen the epidemiology of eating disorders investigated and risk or contributory factors determined. These factors are then targeted by strategies aiming to prevent cases of eating disorders developing, or worsening.
From these two contrasting descriptions, it is apparent that the differences between the prevention approach and the health promotion approach lie fundamentally in the way that good health and well being are viewed. To tease out this distinction between these two different perspectives, an economic analogy can be used, whereby the place and role of money in society is examined.
Money is a resource that allows people to get on with living. It is not, for most people, the ultimate object of living. It is the goods and services that one purchases with money that allow life to proceed (in varying levels of comfort). There are many strategies and methods for procuring money including working for money, receipt of social security, inheritance, winning gold lotto, etc. There are also a range of options for keeping that money secure and accessible, including deposits in financial institutions, a household safe, or under the mattress. Then there are a range of strategies for making that money grow - investment portfolios, buying a house, superannuation, and so on.
Irrespective of the individual choices one makes, for most people, the primary reason for procuring, securing and growing their money is so that they have the financial capacity to do the things in life they need and want to do. Most people do not see these procurement, securement and growth strategies first and foremost as prevention strategies: that having the money will prevent them from becoming bankrupt, homeless, or starving. These are some of the worst-case scenarios that affect relatively small numbers of people in the community, and naturally they are important situations for individuals and society to address. However, for the majority of people, consciously avoiding these worst case scenarios is not the primary motivation for having money. The primary motivation for having money is to be able to do the things that they need to do in order to live life to the fullest. This is the health promotion approach to money.
But that's money - cold hard cash! What about a less tangible resource for living? Does the same distinction apply between health promotion and illness prevention perspectives. The issue of literacy can be examined using a similar argument. Most people learn to read and write before they are really old enough to make deeply considered decisions about whether literacy is a resource for living that is desirable to develop and maintain. Most children wish to be able to read and write because of the advantages that such skills provide - reading books and cartoons, writing notes to friends, preparing school work etc. There is little understanding at a young age of the life long disadvantages that illiteracy bestows in a society made for the literate, and so the avoidance or prevention of illiteracy is not the primary motivation for becoming literate. The primary motivation for learning to read and write is to be able to do all the things that kids need to do in order to live life to the fullest. This is a health promotion approach to literacy.
Good health, sufficient money, adequate literacy skills: all important resources for living. Of these resources for living, money and literacy skills are valued in their own right and are most commonly seen from a health promoting rather than an illness preventing perspective. As a result of the inherent value placed upon economic security and literary ability, significant investments of time, energy and finances (both personal, political and communal) are committed to ensure that individuals and the community are as economically and literately advanced as possible.
However, good health has not been seen as an equally important resource for living, and therefore the importance of personal, political and community investment in good health has long been under-valued. Investments in the health area have traditionally and predominantly been directed towards the treatment of illness and injury, and with comparatively small investments in the prevention of illness and injury. Investment in good health, its promotion and maintenance, has received minimal, almost insignificant, attention. According to the World Health Organisation, this situation, the funding and orientation of health (rather than disease) services, is an issue in need of major reform. A significant emphasis on investments and activities that promote health and well being is required as we move into the 21st century.
In the area of body image and eating behaviours support and assistance for programs that promote healthy long-term eating habits, active living and self (size) acceptance are essential if we are to achieve a sustained and effective response to these pressing public health issues. For this to happen a broader vision is necessary. Approaches that reject dieting and inappropriate weight loss interventions as ineffective, if not harmful, and that promote health-oriented solutions are needed.
Focusing on wellness rather than weight control, such a health-enhancing paradigm (summed up perhaps by the catch-phrase, 'aim to be healthy at any weight rather than this at any cost') can be seen to be slowly emerging around the world. In Australia, the past few years has seen several developments towards this goal: funding for health promotion programs relating to body image and eating issues; a national conference with a call to challenge the body culture; policy attention towards developing healthy lifestyles rather than reducing risk factors; and a slow but sure recognition of the role positive body image plays in better health. We've come a long way but of course we still have a long way to go. Let's each play our part.

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

 

Eating Disorders: the Prospects for Prevention and Health Promotion

Carmel Fleming, SunshineCoast Health Promotion Unit, Public Health Services, Queensland Health
The seriousness, spread and current cost of eating disorders to the Australian health system means we are at something of a crossroads in relation to this contentious area. Increasing amounts of public money are being earmarked for eating disorder programs and it is inevitable that the possibilities of, and prospects for prevention will soon be raised. Those to have proceeded down the path of prevention in other countries have usually chosen one of two ways: either via broad, population-based programs as seen in northern Americia, or more targeted, secondary attempts as in the UK.
The practice of prevention, as well as the theoretical positions taken in this area, have lead to considerable discussion of the topic in the eating disorder literature. Early opinion suggested that not enough was known about the causes of eating disorder to enable effective attempts at prevention. The emphasis was on the necessity of knowing all the links in the aetiological chain before taking action to interrupt the development of the disorder.
More recently however this view has been challenged. Many practitioners in the field have asked the question, 'Do we have to be able to answer all the why questions before we decide what we need to do in relation to these devastating problems?' In addition, with the rise of the relatively new discipline of health promotion, a subtle but significant shift in the debate can be detected. The discussion now often includes, not only the question of prevention of disease but also a focus on the maintenance of health to begin with. This more 'up stream' approach insists on the consideration of the relative influence of the individual, group and community factors that maintain health and well-being and not just answering the question as to which factors increase the risk of disorder.
The result has been work towards increasing awareness and understanding of more broadly-based influences that contribute to the development of eating disorder as well as the identification of protective factors such as good self esteem, enhanced resilience in children, improved coping strategies, and more critical consumption of the images from popular culture. This has meant a change in role for health and education professionals who are committed to reducing the prevalence of disorders such as anorexia nervosa and bulimia nervosa in the community. Previously primary and secondary prevention was the domain of those in primary health care, and tertiary prevention was limited to specialist treatment settings. The activities of health promotion however have become everyone's business.

Why a health promotion focus?

Technical advances in the medical field often receive the most publicity when health is covered in the media. Yet it is advances in prevention and improvements in lifestyle that have produced the biggest effects in population health. The major health improvements to have occurred this decade are not medical treatments, but health promotion efforts, for example, changes in tabacco use, improvements in blood pressure control, and the expansion of safety measures such as seat belts (Australian Consumer's Association 1996).

What exactly is health promotion?

Notwithstanding the World Health Organisation's description of health promotion as "the process of enabling people to increase control over and to improve their health" there is no single definition of health promotion that encompasses all the activities undertaken in this area. For some, health promotion remains closely related to disease prevention. For others, it is about the "big stuff" of unhealthy social practices and conditions such as pollution, and power inequalities. Practice in health promotion usually involves five basic tenets:

• developing individual skills,

• creating supportive environments,

• strengthening community action;

• reorienting health services; and

• building healthy public policy.1

This reflects the belief that individual health status is affected by a number of interrelated factors, often referred to as the 'determinants of health' which include: genetic/biological make-up; the environment in which people live; social and cultural attitudes; economic and political circumstances; and the availability and use of health services.2 Health promotion offers a systematic approach to influencing these determinants to improve health.
From a health promotion perspective, health is therefore defined in the broadest of terms. It is not the objective of living, but rather a resource for everyday life. Implicit in this definition is the notion that the health status of individuals goes beyond illness and that it is possible to enable individuals and communities to affect change in their current health status.
Prevention, in comparison, is usually described as three different activities:
1. Primary prevention refers to measures taken before illness begins and which is aimed at decreasing the incidence of illness, for example, rubella immunisation;
2. Secondary prevention is concerned with limiting disease by early disease detection and focuses on decreasing the duration of the disorder through early diagnosis and effective treatment, for example, screening for cervical cancer; and
3. Tertiary prevention refers to attempts to stop deterioration and is aimed at decreasing the impairment that may result from an established disorder, for example, rehabilitation programs for osteoarthritis.
In the field of eating disorders, the pathogenic orientation of preventive efforts to date has meant a focus on diagnostic categories and concentration on minimising presumed risk factors. Work therefore is done with high-risk-for-eating disorder-persons, that is, young women or dieters. This is primary prevention. General practitioners and mental health services work on secondary prevention via attempts at early identification and intervention. Attempts to limit the effects or stop an eating disorder from progressing to a chronic stage, for example, specialist eating disorder centres running inpatient or day patient programs and specialist outpatient services, are engaged in tertiary prevention, usually referred to as treatment.
People engaged in health promotion, may do any of these things but might also, or exclusively, work with a 'community' of people for example, in schools, gyms, and with the media, fashion and advertising industries, or with the general community in a given locality.
The community organisation principles in health promotion emphasise the process by which community social forces influence individual behaviour, that is, how behaviour is formed and influenced by the dominant culture. In the field of eating disorders there is believed to exist a "significant cultural determination" 3 in the development of body image dissatisfaction, dietary restriction, and other unhealthy weight control behaviours that characterise problems such as anorexia nervosa and bulimia nervosa.
Recognising this and promoting healthy long-term eating habits, active living and self (size) acceptance, as well as highlighting the dangers of inappropriate weight reduction dieting, identifying the pressures on people to confirm to a certain 'ideal', and encouraging the acceptance of a diverse range of body shapes and sizes are all examples of health promotion.

Taking action in health promotion:

The activities of health promotion can be clearly seen in the changes that have occurred in other health priority areas such as smoking, sun safety and drug and alcohol use. In these areas public policy activists have used creative epidemiology to capture the attention and achieve a high level of success in shifting public opinion and beliefs regarding the effects of these behaviours. The norms for cigarette smoking have changed dramatically in the past 20 years. This is a result of both individual, community and policy initiatives including warning labels on packs, advertising restriction, product liability suits, and increased health information. It may be possible to change the norms about dieting and thinness with many of the same measures. To this end, health promotion offers a range of strategies:
Develop healthy public policy - Use the advertising and broadcasting standards to challenge sex role stereotyping. Support the development of national guidelines for physical activity in order to clarify what are appropriate types and amounts of activity for the general population to maintain health and well being. Advocate for consumer rights legislation and codes of practice for weight loss industry, as well as uniform competency standards for the fitness industry.
Create supportive environments - Ensure that positive role models are provided in all health and educational materials. Supply nutritional information for consumers to make healthy food choices at the point of selection such as supermarkets and tuck shops. Encourage parents to allow their children to respond to their own appetites. Support physical activity for enjoyment and other health benefits and not merely for affecting appearance. Advocate for more affordable and accessible recreation facilities for families and individuals.
Strengthen community action - Enhance access to information, learning opportunities and funding support for education about body image and eating behaviours. Endorse self help and consumer support mechanisms in relation to body image and weight control problems. Apply the principles of community development to strengthen consumer and community involvement in programs and services for eating disorders.
Develop personal skills - Ensure that consumers are informed to make choices conducive to health. Enable the provision of assistance for people preparing for different life stages. Facilitate the deconstruction of media stereotypes to enhance the development of individual resilience to restrictive body beautiful ideas. Advocate for resources for further education and skill development in schools and the community. Discuss the importance of maintaining weight within a healthy range, highlight the dangers of inappropriate weight reduction dieting, identify the cultural pressures on people to confirm to a certain 'ideal' and promote healthy long-term eating patterns, active living and self acceptance. Promote the development of protective factors, such as good self-esteem within ourselves and others, and work to enhance resilience to body image lore, especially in children. Develop effective stress management and alternative coping strategies, and practice and advocate for more critical deconstruction of stereotypical images of appearance.
Reorient health services - Advocate for the health sector to move beyond responsibility for providing clinical and curative service and towards the promotion of health; for the range of treatment, rehabilitation and support options available to people with eating disorders and their families to be expanded; for the development of 'best practice' models and accepted standards of quality of care that incorporate a preventative focus; and for changes in professional education and training.

Health promotion in practice

It has been argued that primary care practitioners, such as GPs and school health workers, are ideally placed in the health-care system to provide preventative care4 but that considerable barriers exist for realising this health promotion potential in practice5. As noted, preventative actions with demonstrated effectiveness in decreasing morbidity and mortality have been developed for two of the most prominent contributory factors to the current ill health, tobacco use and alcohol consumption. However, diet and activity patterns, strongly linked to cardiovascular disease and obesity,6 seemed to have changed far less. Given the high rates of CVD, the well documented failure of traditional treatment strategies for obesity, and the evidence that populations in the west are getting fatter (despite decreases in energy intakes especially amongst children), work in this area is becoming increasingly important. There is also evidence that the desire towards thinness is intensifying. The unsurprising result is that many people currently feel too fat and are dieting to control their weight - a task made harder by their increasing affluence which normally results in an increase in body weight.
Is body image dissatisfaction a risk factor for eating disorders? Maybe not as males show body image dissatisfaction too. Rather it seems that it is the actual behaviour chosen to express the dissatisfaction, dieting, that increases the risk of developing an eating disorder. Psychological, behavioural and biological pathways have been investigated by researchers questioning this link between dieting and eating disorders. There is now considerable evidence that a period of weight-reduction dieting is a major risk factor for the development of eating disorders, with severe dieting has being associated with an eight fold increase in the probability of later eating disorders developing in adolescent females.7
The potential for health and education professionals to impact on the number of people practising dieting, a possibly modifiable risk factor for eating disorders, has only begun to be recognised. 69 per cent of Australian women are known to visit their general practitioner in a six-month period8 and 80 per cent of all adults do so annually9. The effectiveness of health promotion strategies in primary care settings such as GP surgeries and schools is supported by a range of empirical evidence from other areas. For example, smoking cessation programmes designed for implementation with in the primary care consultation have demonstrated effectiveness10 11, and research into early intervention for harmful alcohol consumption has also shown good results.12 13 Other, more informal, 'opportunistic' strategies for health promotion and disease prevention (such as cervical cancer testing) have also been shown to work well in primary care.
It should be recognised however that there are substantial barriers to health and education professionals increasing their role in health promotion activities. The 10.5 minute length of the average Australian GP consultation and the ever increasing content of the school curriculum need to be considered. There may also be a sense of low self-efficacy in relation to difficulties associated with lack of health promotion knowledge and skills in prevention.16
In relation to eating disorder this may not be an uncommon, or unfounded, perception among health workers. A study in the UK found family doctors have a low index of suspicion for eating disorders and had difficulty recognising possible eating disorder in patients, even those with marked symptoms17. When reported, the wish to diet was often taken at face value, despite the normal weight of the person. The failure to link such non-specific symptoms with the possibility of eating disturbance or body image dissatisfaction may indicate that doctors see such requests in light of a broader cultural expectation that women, of any weight, will be concerned with weight loss. The opportunity to intervene in a preventative manner is therefore lost.
We can not afford for this to remain the case however. Community workers, counsellors, dieticians, general practitioners, guidance officers, mental health professionals, nurses, psychiatrists, psychologists, social workers, teachers and all others in the health and education fields must become more aware of the damaging effects of body image dissatisfaction and the resultant body changing behaviours. Strict dieting, steroid abuse, cigarette smoking, vomiting and so on are all potentially dangerous activities. Their prevalence in young people especially means that our efforts at prevention, and the energy we put into health promotion, need to be unrelenting. As Richard Tinning has written,
Perhaps for some sectors ignorance is a legitimate excuse but the silence of those not ignorant is morally for more reprehensible. It is difficult to accurately determine the reasons we are silent about the social forces that promote thinness, however, it is equally clear that our professions should speak out loudly against the negative manifestations of the cult of slenderness. To remain mute is to implicitly support such practices and is tantamount to being a morally bankrupt profession, a profession without a social conscience.

References
1Ottawa Charter for Health Promotion (1987). Bulletin of the Pan American Health Organisation. 21: 200- 204.
2Central Sydney Area Health Service, Health Promotion Unit (1996). Getting the Edge: Managing the Health Promotion Process.
3Theodoros MT (1995). Eating Disorders in Primary Care. In Update in Women's Health. Merck Sharp & Dohm University Program for General Practitioners. Sydney. pp 160-166.
4Wiggers JH, Sanson-Fisher R (1994). General practitioners as agents of health risk behaviour change. Behaviour Change, 11:167-176.
5Bonevski B, Sanson-Fisher RW & Cambell EM (1996). Primary care practitioners and health promotion: A review of current practices. Health Promotion Journal of Australia, 6(1):22-31.
6Garner DM & Wooley SC (1991). Confronting the failure of behavioural and dietary treatments for obesity. Clinical Psychology Review, 11: 729-780.
7Patton GC (1992). Eating Disorders: Antecedents, Evolution and Cause. Ann Med. 24: 281-285.
8Australian Bureau of Statistics (`1984). Australian Health Survey 1983. ABS Cat No 4311.0. Canberra: Government Printer.
9Australian Bureau of Statistics. (1992). National Health Survey: Health related actions. Cat No 3475.0. Canberra: Australian Government Publishing Service.
10Cohen SJ, Stookey CK, Katz BP, Drook CA & Smith DM (1989). Encouraging primary care physicians to help smokers quit: A randomised, controlled trial. Annals of Internal Medicine, 110: 648-652.
11Gilbert JR, Wilson DMC & Singer J(1992). A family physician smoking cessation program: An evaluation of the role of follow up visits. American Journal of Preventative Medicine, 8: 91-95.
12Wallace P, Cutler S & Haines A. (1988). Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. British Medical Journal, 297: 663-668.
13Anderson p & Scoot E. (1993). Effectiveness of general practice interventions for patients with harmful alcohol consumption. British Journal of General Practice, 43: 386-389.
14Cockburn J, Hirst S, Hill D & Marks R. (1990). Increasing screening in women more than 40 years of age: An intervention in general practice. Medical Journal of Australia, 152: 190-194.
15Dickinson JA (1989). Preventive activities in general practice consultations. Doctoral Dissertation, University of Newcastle.
16Moser R, McCance KL & Smith KR (1991). Results of a national survey of physicians' knowledge and application of prevention capabilities. American Journal of Preventive Medicine, 7: 384-387.
17King MB (1989). Eating disorders in a general practice population. Psychological Medicine, Monograph Supplement 14.
18Tinning R (1985). Physical education and the cult of slenderness: A critique. The ACHPER National Journal. March: 10-13.

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

 

Nursing Patients with Eating Disorders

Mary Lacey, Clinical Nurse, Adult Eating Disorders Unit, RoyalBrisbaneHospital
Providing nursing care to patients with eating disorders in an inpatient setting is a multifaceted endeavour. This includes attention to the physical, psychological, environmental and social domains of health. Much has been written on the diverse range of treatment options, with supporting arguments and criticisms of each, however, there has been no consensus about the 'best' approach. This fuels the challenge, and possibly the sense of helplessness many clinicians experience when striving towards successful treatment. Following is a brief overview of the guiding principles adopted on an Adult Eating Disorders Unit of a general psychiatric ward for engaging and working with patients.
Multidisciplinary team involvement, collaboration and consistency are important components in treatment for all patients in a psychiatric setting. Nursing staff play an integral role in this process, not only in the development of treatment plans, but in their implementation. It is of paramount importance that nursing staff have the knowledge, skill and attitudes required for such patient care.
Recommended Reading
Full Lives: Women who have freed themselves from food and weight obsession.
Lindsey Hall. Gurze Books. 1997
Handbook of Treatment for Eating Disorders, 2nd Edition
David M. Garner & Paul E. Garfinkel (Eds.). Guilford Press. 1997.
Controlling Eating Disorders with Facts, Advice, and Resources
R. Lemberg. 1992.
Breaking Down the Barriers
It is the responsibility of nursing staff to facilitate change, not dictate it as a first line intervention.
Predominantly, hospital admissions for patients with eating disorders are about normalising eating patterns, restoring physical and nutritional health, helping the patients make sense of their illness and developing strategies to challenge it. Even patients voluntarily seeking admission rarely believe in the need for weight restoration, at least not to the level recommended by health professionals. Patients usually present scared, fearful, panicked and often angry about gaining weight. Comments from staff demonstrate that similar emotions may also be experienced by professional carers, for example:
'It doesn't matter what you do the patients are going to resist you all the way. They never get better anyway!'
'You need a strict behavioural programme, otherwise they'll manipulate, staff split, sabotage treatment, and act out every chance they get'
'They all get so attached and dependant'
'I never know how to approach them!'
Many factors contribute to staff anxiety when faced with patients with eating disorders in a treatment facility. For example:

• Societies' stereotypical image of individuals with eating disorders

• Media presentations of perceived mismanagement by health care providers

• Past experience, both personal and professional

• Preconceived treatment bias

• Perception of the illness

Before a staff member can effectively assist the patients in breaking down their barriers to treatment, they must start by breaking down their own. 'The most important shift we need to make to increase the possibility that we will be helpful has nothing to do with specific techniques - it has to do with the development of genuine empathy for the anorexic experience' (Bemis-Vitousek, 1997). Developing first an understanding of our own attitudes and expectations, enables staff to approach patients with an open mind, be less affronted by the illness and its associated behaviours, and to see the patients as individuals rather than a disorder. When this process has been achieved, it is interesting to observe the paradigm shift in staff.
Many adamant believers in strict behavioural programmes view treatment options through a different lens once they are able to empathise with the patients' perspective. More time is then spent engaging the patients, developing trust and in utilising non judgmental dialogue to unveil each individual's experience of the illness.

Setting Realistic Goals and Expectations
Provide individualised care within a supportive structure. If more time is spent on managing opposition than on facilitating goal achievement, it is not surprising that the negative aspects of patients' behaviour remain magnified and imprinted on staff perceptions and attitudes. Not all patients are ready to face the difficult road to complete nutritional restoration and recovery, however they may be prepared to improve their nutritional state to a level which results in fewer medical complications.
Take for example an exacerbation of psychotic symptoms in a patient with long-standing Schizophrenia. Periodically the patient becomes 'non compliant' with his traditional antipsychotic medication (Haloperidol) because of its side effects. It is believed by the treating team that the patient may experience less side effects on a novel antipsychotic agent such as Clozapine and therefore continue on his medication in the community. The patient refuses to trial Clozapine, however is agreeable to recommence his usual medication.
Would it seem reasonable under these circumstances to deny the patient access to visitors, phone calls, writing materials, television, etc., with the view to gradually increasing access to them once it has been proven by blood tests that the patient was taking Clozapine? Nursing staff in this situation would usually advocate on the patient's behalf and suggest that once the patient's mental state improved on their preferred medication, they may be more amenable to trial an alternative.
Patient goals may not always be in sync with what health professionals believe would be best for them. It is therefore important to remain focused on who the treatment is for, remain encouraging and non-judgemental and attempt to motivate the patient beyond their comfort zones. Remember a guiding principle of change - those who believe in the benefits of change are more likely to participate in it.
In some situations, the patient remains unable to commit to the change process. It is only at this point, when it is considered important for the patient's ongoing welfare, that other interventions are indicated and it may be reasonable for more restrictive measures to be implemented.

Developing the Motivation for Change
'I want to get better but I don't want to put on weight'
Developing empathy and establishing the desire to understand the patient's experience is the first step to facilitating the likelihood of engagement in treatment. Some useful strategies for developing and maintaining the motivation in patients to make the necessary changes in their eating patterns and nutritional status include:
Perceived advantages and disadvantages of the illness Encourage the patient to make a list of what they see as the personal costs and benefits of maintaining their illness. Quite often the costs will include physical complications, poor memory, poor concentration, hypothermia, and tension in family relationships. The benefits most commonly identified include feelings of self control, sense of accomplishment, and emotional numbness.
Letters to a friend Have the patient construct two letters to a friend both dated five years in the future. One is to be written as if the patient has recovered from their eating disorder, the other is what it would be like to still have the eating disorder.
These two exercises provide meaningful insights into the patients dreams, fears and experiences. Staff can use this information to tailor psychoeducation, and explore healthy options which may provide substitution for the perceived advantages.
Psychoeducation

• Provide education on the known effects of starvation on mood, behaviour and thinking. Present this information in a manner which instils intrigue in the patients whereby they may question their symptoms. Garner's chapter on psychoeducational material in the recent edition of the Handbook Of Treatment For Eating Disorders (1997: pp. 145-177) is very useful.

• Present information on the stages of development of anorexia nervosa and bulimia nervosa to reinforce how dieting / weight loss can lead to an illness. A useful outline is found in Controlling Eating Disorders with Facts, Advice and Resources, Lemberg, R. 1992.

• Provide ongoing education and support with emotional processing and personal effectiveness skills.

Reinforce the experimental nature of recovery

• Explain the phases of treatment.

• Reinforce that reversal of starvation is only the beginning in the process of recovery, that is, healthy weight does not mean recovered.

• Encourage the patient to allow themselves a trial period of normalised eating and weight of at least twelve months whilst continuing therapy. Reinforce they have the option of returning to their known behaviours at the end of this period.

• Prepare the patient for a period of uncertainty and feeling 'out of control' as they attempt to experiment with healthy coping patterns and intense emotions.

Responding to Resistance
Respond rather than react
Engaging in unhelpful behaviours such as purging, overexercising or self harm, is usually distressing for the patients. They often report feeling 'at a loss' as to how else they can achieve relief from the nagging self doubt and guilt they experience. Reframing these behaviours as 'difficulties encountered in response to anxiety regarding change' as opposed to intentional 'non-compliance' or 'sabotage', frees up the communication channel and promotes collaboration in working on more adaptive and helpful coping strategies. In the words of Zerbe (1993), "To function in life without resorting to harmful coping strategies, we must first develop a variety of healthy coping patterns which provide as much relief as the abhorrent techniques".
Knowledge of the patient's motivation for change combined with established rapport and empathy provides staff with a useful framework to address the difficulties experienced by the patient as they work towards their goals. Whether these difficulties are overt or covert, the manner and timing in confronting them impacts on the level of threat the patient perceives, and subsequently their willingness to work on strategies to overcome them. Resistance during periods of heightened anxiety should be anticipated as a normal reaction. Heightened anxiety states can be anticipated on the basis of:
Knowledge of your patient:

• In what behavioural form is their resistance most likely to manifest? For example: past history of self harm, purging, exercising, tampering with feeds, restriction, etc.

• What is the patient's motivation for change?

• What times of the day / week are the most stressful?

• Which activities do they fear the most?

• Which meal is the most difficult?

• How much does being weighed impact on their sense of self?

The physiology of reversing starvation:

• The re-emergence of feeling states

What are the psychological barriers for the patient? For example:

• The sense of loss of identity

• The sense of nullity without the eating disorder

• Fear of non acceptance

• Fear of failure - in work, study, relationships, etc.

• Fear of responsibility

Having already conveyed an understanding and awareness of the personal struggle involved in undertaking change from the inception of treatment often disarms the patient of the need and/or attempts to keep their difficulties a 'secret'. Nevertheless, patients need constant reassurance of this and reinforcement that we don't expect them to be 'perfect patients'. If it is evident or suspected that a patient is engaging in unhelpful or unhealthy behaviours the following strategies are recommended:
Work on an honesty system:- there is therapeutic value in awaiting confession if the behaviour is not life threatening or in need of immediate intervention (that is, with an overdose or self harm requiring suturing). Reinforce options and choices:- empower the patient with the ability to respond differently rather than enforce strategies whereby the patient feels they have been acted upon or punished. Establish links between cognition, behaviours & triggers:-Capitalise on the opportunity to assist the patient to make sense of their illness.
Take for example a patient, Zelah, who is approaching a psychological weight barrier. She has never been over 40kg and her current weight has stagnated at 38.5kg over the past two weighs. Zelah's weight had progressed from 32kg on admission, with a goal in the high 40's. Increased periods of overnight leave have been planned once Zelah reaches 40kg. You are aware that Zelah has been exercising because she has been observed powerwalking around the hospital complex. Zelah identifies that her main motivation for getting well is for her family because she sees that her illness puts a great burden on them.
Directly confronting such exercising is likely to result in a purely weight related response by the patient, for example, 'I've put on 8kg already and I don't want to put on any more!'. However, addressing the underlying anxieties about the meaning of reaching 40kg may elicit fears of family expectations and of not being able to cope at home. This then provides the opportunity for staff to offer increased support and to work through problem-solving strategies with the patient. Once this has been achieved, the patient may be agreeable to developing a contract to reduce the amount of exercise and continue working towards other already agreed upon goals.

Conclusion
Nursing patients with eating disorders can be a highly rewarding, albeit challenging, experience. It is hoped that through the strategies suggested here, more nursing staff will feel comfortable and competent in providing care to this group of patients.

References:
Bemis-Vitousek, K. (1997). Developing motivation for change in Individuals with eating disorders. Conference Proceedings. Challenge the Body Culture: Attitudes, Acceptance and Diversity into the 21st Century. Brisbane. Queensland University of Technology.

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

 

Anorexia Nervosa in a 16 Year Old Girl

Dr Jacinta Powell, Consultant Psychiatrist and Director, Eating Disorder Service, RoyalBrisbaneHospital
Kaylee was a 16 year old student in Year 11 at a private girl's school. She had begun losing weight for 9 months and after a number of phone calls and a visit to the GP, Kaylee's mother brought her for assessment to the eating disorders service of the public hospital. Kaylee was reluctant to attend and insisted that there was nothing wrong with her and that the problem lay with her mother, who was over reacting.

Current Wt: 38kg
Ht: 160 cm

Wt(1yr previous): 48kg        
Ht: 158cm

History of illness

Kaylee is a good student who just missed out on being Dux of Year 10. The previous year was difficult for her as she suffered a bout of glandular fever and missed quite a bit of school over a one month period. In addition her older sister, whom Kaylee idolised, moved out of the family home and in with her boyfriend. This situation created much family conflict with disapproval from both parents. As a result Kaylee felt torn between loyalty to her sister and to her parents. The weight loss appears to have commenced with the onset of glandular fever as Kaylee lost her appetite. On return to school, her fellow students commented on how good she looked and Kaylee felt she was noticed for the first time for her appearance rather than just her "brains". She decided to keep restricting her food intake so she didn't regain the weight she had lost through illness.

Within 2-3 months, Kaylee's parents had noticed her weight loss and began to confront her with what was happening. Kaylee denied any problems, but to keep her parents happy began to eat meals with them, but took to vomiting afterwards whilst in the shower. For a couple of months everything remained calm in the household as Kaylee appeared to be eating. Kaylee's mother noticed that Kaylee seemed particularly ravenous after school when she would have some weetbix, biscuits and bread before settling down in her room to do homework.

The situation finally came to a head however, when Kaylee's mother accidentally walked in on her daughter in the bathroom and saw her unclothed. She was horrified to see Kaylee's ribs clearly outlined under the skin and how wasted she appeared. They had a huge row but Kaylee agreed to see the family doctor, who conducted blood tests and arranged a referral for further assessment.

Kaylee denied that she was thin, stating that she felt fat and thought she could stand to lose some more weight. She was particularly upset about her thighs and abdomen, and described exercising in her bedroom at night for up to an hour. In addition she was walking to and from school, 4 km away. She described marked lethargy but had difficulty sleeping at night. She felt driven to walk but in the last two months had not enjoyed this. She denied any mood changes. Her mother however said, "Kaylee is a different person. She used to be sweet and cheerful and would do anything to help anybody. Now she is sullen, she stays in her room all the time, doesn't go out with her friends anymore. I am frightened to say anything to her because she either snaps at me or bursts into tears". Kaylee's teachers had also expressed concerns about her lack of attention in class and her falling grades, a situation which had become more obvious throughout year 11.


Oral Intake

Breakfast:	Toast x1 no butter or spread
	Black coffee
Morning tea:	Diet Coke
Lunch:	Diet Coke
Afternoon Tea:	Binge after school (pkt biscuits, ½ loaf bread, 6 weetbix)
	Vomit x1
Dinner:	Whatever mother prepared.
	Vomit x1

No laxative abuse, no use of cigarettes, alcohol, or drugs.

Periods:	Commenced when 13 years old
	Ceased 6 months ago.
Other Symptoms:	Cold all the time
	hair falling out
	skin dry and flaky
	slow pulse, dizziness and lethargy.

Family History

Lives with parents and brother.

Mother: 38 years old, healthy, walks daily and plays tennis weekly, works part time as an accountant and has done since her youngest child was 5 years old. Normal weight.

Father: 41 years old, runs a small sheet metal business and works long hours. Had a health scare two years ago with an episode of chest pain. Since then has given up smoking and alcohol, attends a naturopath and prepares his own meals following a low fat, non wheat diet. Normal weight. Doesn't have time to exercise.

Sister: 20 years old, university student, popular, outgoing and good at whatever she does include study, sport and music. Living with boyfriend of 2 years. A little overweight since adolescence. Her mother had expressed some concern about this but sister would not discuss her weight and apparently did not see this as an issue.

Brother: 12 years old, in Year 7 at boys private school, average academically, plays multiple sports. Relaxed and more interested in hanging around with his friends than in the family. Normal weight.

No family history of eating problems, alcohol abuse or depression. Kaylee's mother has dieted in the past but now tried to eat sensibly and ensure she exercised. She is not happy with her body but is more relaxed about it than she had been in the past.


Development

Kaylee described a happy childhood with no history of abuse. She had always been a good student and able to make friends without any problems. She idolises her big sister but at the same time feels she will never match up to her in terms of personality or achievements. She wasn't prepared for her sister moving out of home and misses her every day. Her relationship with her mother has been close until the last few months when there has been frequent conflict about food, eating and Kaylee's moods. Kaylee is not as close to her father and he has tended to leave the parenting to his wife as he is rarely available. Kaylee fights with her little brother but doesn't see this as significant. They see each other much less since her brother has become so involved with his friends and sport.


Assessment

Kaylee was assessed to be suffering from anorexia nervosa - bulimic subtype. She was noted to be depressed, lethargic and lacking in concentration, and was socially isolated; features consistent with starvation. Her pulse rate was 44 beats per minute and her blood pressure was 75/40, her temperature was 35.6 degrees C. Blood tests showed Kaylee to be low in potassium, a common problem as a result of vomiting. Low potassium results in muscle weakness and lethargy, but more alarmingly can cause arrhythmia's of the heart which place the person at risk of death. Her heart was small due to muscle loss which was evident throughout her body.

Kaylee did not accept this diagnosis and denied the seriousness of her condition despite extensive explanations about the risks to her health and her life. She expressed a desire to keep exercising and denied that she was vomiting despite knowledge her mother had found evidence in the shower including the smell.

The effects of starvation both physiological and psychological were discussed with Kaylee and her mother. Kaylee was able to recognise that her moods were consistent with what was described, and also that her grades were falling. It was at this point that she agreed to hospitalisation particularly when she realised how distressed her mother was.


Management

Kaylee was admitted to a hospital psychiatric unit which deals with patients with eating disorders on a regular basis. In view of the potential seriousness of her physical condition, Kaylee was seen by a medical team. She was assessed by a dietician and the clinical nurse in charge of the eating disorders unit.

Phase 1 - day 1-2

Replacement of potassium and fluids via an intravenous drip with monitoring of vital signs and blood tests. Cessation of exercise and encouragement of regular small meals. Kaylee complied with this plan but her oral intake remained poor. She did however, stop exercising and vomiting and her potassium normalised over two days.

Phase 2 - after day 2

Kaylee was reviewed by the dietician, doctors and nursing staff. She was feeling better physically and able to attend the dining room with the rest of the patients with eating disorders. She continued to struggle with intense guilt whenever she ate and was terrified that any intake would cause her to lose control and become incredibly fat. She was weighed twice a week, in the morning after waking.

Kaylee was started on three small meals and midmeal snacks of a glass of sustagen 3 times per day. Over the course of the next two weeks, Kaylee increased her weight to 40 kg. She was very apprehensive about weight restoration and required considerable reassurance, education and training in anxiety management strategies. The process was assisted by a primary nurse who came to know Kaylee well and was able to develop a good therapeutic relationship with her. She spent time with other patients with eating disorders in the formal group program as well as informally in the ward setting. This was a source of extra support for Kaylee early in her admission. Kaylee also had individual therapy sessions with the psychologist commencing anxiety management with a view to later moving to cognitive behavioural techniques specifically for dealing with the eating disorder. She saw the registrar regularly for extra support and to fully discuss the rationale for the actions of the treating team and the basis for treatment decisions.

Unfortunately when Kaylee reached 40 kg, she panicked and became increasingly upset. She began to ring her mother and begged to be allowed home, promising to eat regularly and do whatever her mother wanted. Kaylee's parents were seen by the hospital team and as they felt they now wanted to try and manage Kaylee's problems at home, she was given leave to go home with her family. Within 2 days the situation had deteriorated significantly and Kaylee was refusing to eat or drink anything at all, she would not go to bed and stood up all night moving around.

Phase 3 - after 3 weeks

Kaylee was returned to hospital by her family and was rehydrated with intravenous fluids. Her weight was 37 kg. In view of her intense guilt about actually eating, she was offered the option of night time nasogastric feeding via a tube through her nose into her stomach. She had seen other patients have this treatment and had spoken to them about it. As a result, she commenced on feeds overnight, inserting her own tube at night and removing it in the morning. During the day she went to meals with other patients and attempted to continue with small meals. Over the course of the next eight weeks, Kaylee gradually increased her oral intake at meals and gained on average 1 kg a week. This period was not without difficulty for her. At times she became incredibly anxious and could not stop herself from vomiting after meals. At other times she would slow the night time feeds down or empty them out. Regular sessions with her nurse and doctor however meant Kaylee eventually was able to tell them what she had done. This was also often be reflected in her weight. These problems were dealt with in a supportive, exploratory way and she was helped to deal with her anxiety. Kaylee was encouraged to keep a journal of her feelings and experiences and to share this with staff she had developed a good relationship with. Kaylee also requested help after meals. During these times she was most at risk of vomiting and a system of 1:1 nursing after meals was arranged. At times she would become angry with everybody around her, expressing anger at her parents for putting her in hospital; anger at the staff for what she saw as their control over her and for "making me fat"; and also particularly angry at herself for a myriad of perceived shortcomings in herself. It was important that these feelings were dealt with in a sympathetic way and that Kaylee was able to ventilate her emotions without turning to starvation or exercise as a way of managing them.

During the course of Kaylee's admission, her parents, and at times her siblings as well, were seen regularly by the team consultant, registrar and psychologist. They attended a family education programme run by a local private hospital and were encouraged to seek assistance from the Eating Disorders Association Resource Centre. They were perplexed about what had happened to their daughter and spent much time ruminating over where they had gone wrong. They also experienced shifting emotions from fear to frustration and anger. They recognised that they did not know where to place their anger. They felt they could not get angry with Kaylee so directed their anger at themselves, at each other, and at times to the treatment team. The situation was complicated by Kaylee's need for privacy and some sense of control over her own treatment as she attempted to overcome an illness which she felt very ambivalent changing. These needs conflicted with her parents' needs who felt guilty and confused and thus wanted to be involved in all aspects of Kaylee's treatment and her communication with hospital staff. These issues were dealt with in joint meetings involving both Kaylee and her parents. Kaylee's parents remained less than satisfied with the amount of information they were given but tried very hard to respect their daughter's wishes.

School: In the initial phase of treatment Kaylee was too ill to attend school. Her concentration was very poor and she was preoccupied with food and weight issues. As her health improved, her school sent over work and Kaylee was able to keep her in touch her lessons. School work was completed with supervision from nursing staff on the ward. At first Kaylee tried very hard to keep up and would frequently end up in tears as she fought to concentrate on the work. After discussing the situation with her parents and the school, Kaylee decided she would focus on achieving what she could this year and if necessary she would repeat Year 11 next year. With such an approach she was able to reduce the pressure she was placing herself under and in fact her work then improved considerably. This was also aided by her improved nutrition and better state of health. Kaylee began attending the hospital school once she was fit enough to leave the ward.

Phase 4 - after 11 weeks

In the preceding weeks Kaylee had begun to go home for weekends with her family. She would take the nasogastric pump and feeds with her. When she reached 45 kg, Kaylee began working on changing gradually from nasogastric feeds to oral supplements and continuing with meals. The process was not straightforward as Kaylee would reduce her night time feeds but would then balk at taking the supplemental drinks. However, as she realised that the process of weight restoration was proceeding as planned she managed wean herself off the nasogastric feeds. At this point Kaylee began attending her school again, initially for half days and gradually working up to full days. This process was difficult as Kaylee had missed a lot of social interaction with her peers over the previous months, although her friends had visited her in hospital. She felt self conscious upon returning to school, as though everyone was looking at her and watching her eat, a situation which in fact had some basis in reality. She was however assisted by teachers who had talked with hospital staff prior to her return to school, and by friends who had made an effort to understand how best to help her deal with the situation.

Phase 5 - Discharge

Kaylee was discharged from hospital at 48 kg, a less than ideal weight, but as she was managing well and had increasing periods of leave to home and school it became necessary to balance keeping her progress on the track with the need for her to be with her peers. Kaylee attended the hospital outpatient service once a week and had regular phone calls with her primary nurse-therapist. She was encouraged to use alternative coping strategies such as keeping a journal, supportive telephone calls, discussions with her family and friends, and relaxation strategies. Kaylee had commenced regular gentle exercise under physiotherapy supervision whilst in hospital and had a program to follow at home which she found useful as an anxiety release strategy. She continued to experience ongoing body image disturbance, but was much less preoccupied with food and eating, and her mood and anxiety had improved considerably.

Phase 6 - Ongoing outpatient therapy

During the assessment phase and throughout the admission it was impressed upon Kaylee and her family that the treatment for anorexia nervosa was likely to take at least 1-2 years and that most of the treatment would occur on an outpatient basis, after she left hospital. Whilst hospital is often necessary for weight restoration, which allows the person to think more clearly and become less anxious and depressed, ongoing therapy is needed both psychologically and nutritionally after discharge. Upon leaving hospital, Kaylee felt quite stressed, she had been anxious to leave but when she did so found she missed the structure of the hospital program and the reassurance of the ward staff. Along with the stress of being back at school and feeling under scrutiny, Kaylee expressed her disappointment that discharge from hospital didn't feel as good as she had anticipated. Her parents also needed help to understand this but were very supportive of their daughters attempts to eat regularly and attend school, and tried not to be intrusive during meal times.

Each week Kaylee saw her nurse therapist, the dietician and the doctor from the treatment team. She was encouraged to continue with keeping her journal. A mixed therapeutic approach was taken incorporating expressive, supportive and cognitive-behavioural strategies. During this phase Kaylee discussed the events and factors leading to the development of her eating problem, and talked about how anorexia had seemed to offer a magic solution to the difficulties she was experiencing. She described her growing awareness of her body from Year 8 and the way her friends focused on weight and eating at school. Even before developing glandular fever, Kaylee had become somewhat dissatisfied with her body and compared herself unfavourably with other girls who were taller and had males interested in them. Whilst admiring her sister greatly, she found it hard to accept the feelings of envy she had towards someone she loved greatly and had worked hard to quell this conflict in herself. Weight loss allowed her to have something she felt good at and that her sister was not. She later came to realise that, unconsciously, she was perhaps competing with her sister for her mother's attention. She may also have been punishing herself for unacknowledged feelings of pleasure from her idealised sister's conflict with her parents. It became obvious that the reasons for Kaylee's anorexia were multiple, complex and related to her phase of development. Once she began to lose weight however she found she was trapped in a vicious cycle from which she could not escape despite her at best, albeit ambivalent, intentions.

Kaylee continued in therapy over the next two years until the mid part of her first year at university. She had an up and down course with many pitfalls. Her weight increased to 54 kg. However, for a long time she hovered at 49 kg unable to break the psychological barrier of being 50 kg. At one stage, she became involved in her father's diet and attended his naturopath. On such a vegan diet she was unable to maintain her body weight or iron stores, and her weight dropped back to 45 kg. She was also tired and lethargic and the features of starvation made another appearance. With much support and encouragement from the treatment team and her family, particularly her father, Kaylee managed to avoid returning to inpatient treatment and was able to resume a more normal pattern of eating. Her periods returned after she had reached 51 kg, an event she had mixed feelings about but coped reasonably well with. At other times during this phase of her recovery, Kaylee returned to vomiting, particularly when she was anxious. However, as she matured and gained a much better understanding of herself, and with a good alliance with her therapists, this became much less of a problem.

Phase 7 - Termination of treatment

Kaylee had commenced a science course at university and was also working casually at Myer to earn some money and support herself in her studies as she was not eligible for Austudy. She met a male university student and began going out with him which improved her confidence. She had intermittent periods of depression and moments of self doubt but she was much more able to manage these herself as time went on. During the course of this year Kaylee explored termination with her nurse therapist and doctor and this was achieved with increasing spacing of her appointments. Kaylee was reassured she could return at any time in the future and was encouraged to seek help earlier rather than later if she experienced any relapse in symptoms whether this be depression or eating disorder. She subsequently kept in touch with occasional phone calls and Christmas cards to the treatment team and at last contact was continuing to do well.

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

 

Nutritional Management of Bulimia Nervosa: Common Concerns and Considerations

Leanne Wagner, Dietician in Private Practice, Brisbane
Unlike anorexia nervosa, bulimia nervosa is often a secret disorder, remaining hidden for many years before sufferers seek help. The characteristic features of bulimia nervosa - strict dieting, binge eating, and compensatory behaviours such as vomiting or laxative misuse, can produce a variety of physical consequences that, if present, need early recognition and ongoing monitoring. In particular, consideration needs to be give to symptoms of the starvation syndrome, delayed gastric emptying, fluid and electrolyte balance, and bowel changes that sufferers may experience.


Starvation Syndrome

When people are starved a number of physical and physiological changes may take place. In bulimia nervosa the focus is often on the bingeing and purging. It is easy to forget that the sufferer may have extended periods of food restriction between binges, or that the purging may mean that the food is not absorbed. In addition, excessive exercise may mean that insufficient energy is consumed for weight maintenance. In all, while the sufferer may appear in the healthy weight range, they may in fact be starved (starvation in the midst of plenty).

The effects of starvation are many :

Preoccupation with food.

Sufferers may think, dream, and talk about food incessantly. They may hoard food, collect recipes, love preparing elaborate meals and become quite agitated if some of the meal is left by those served.

Unusual eating habits.

People with bulimia nervosa may take a long time to eat their meal and become ritualistic about the order in which the meal is eaten. They may drink large quantities of fluids, chew lots of gum or smoke more heavily. Unusual combinations of foods may be eaten and condiments may be used excessively.

Mood swings and personality changes.

Sufferers may be moody, depressed, irritable and withdraw socially. Sleep can be disturbed and there can be difficulty in concentrating, and with decision making, comprehension and memory. There may be difficulty coping with changes in routine, and rigid, obsessional thinking.

This may make the management of bulimia nervosa difficult. While a flexible, healthy eating plan may be recommended, initially this might be very difficult for the person to achieve due to the effects of starvation. Information needs to be clear and written down ( even at the risk of being seen as a rigid "diet" to follow). Suggestions may need to be explained several times as memory and concentration can be effected. As the effects of starvation reverse with refeeding and reduction in the binge/purge cycle, the eating plan can then be made more flexible and new foods can be encouraged.


Delayed Gastric Emptying

One of the physical consequences of starvation is a delayed gastric emptying, that is, food sits in the stomach for longer than usual. It can be worse in those that have used vomiting as a way of purging after binges. The delay in gastric emptying means that the sufferer may feel considerable discomfort and bloating after eating relatively small amounts of food and may find compliance with a healthy eating plan difficult. Small, frequent snacks can help reduce the feeling of fullness however some sufferers may find this does not help. Medications such as cesopride can help gastric emptying and can be of valuable assistance in short term.


Fluid And Electrolyte Balance

When vomiting and laxative abuse are used as a means of purging there can be problems with fluid balance and electrolyte imbalances. In some cases this can produce a life-threatening situation. The levels of potassium, magnesium, phosphate, calcium, sodium and chlorides may be low and there may be volume depletion and dehydration. Hypokalaemic alkalosis may occur secondary to starvation, dehydration, vomiting and/or laxative abuse. Oedema may occur in starvation and is not uncommon in refeeding resulting in artificially large weight gains. The chemical changes may result in heart rhythm irregularities (with ECG changes), muscle weakness, cramps and spasms and epileptic fits.

It is essential to have full blood tests to assess the degree of electrolyte disturbance and when necessary appropriate supplements prescribed (e.g. K + where hypokalemia exists or remains an ongoing risk).

Be aware that normal electrolytes seen in one test may become abnormal in a very short period, for example, after a period of frequent bingeing and purging, and regular testing is recommended.


Bowel Changes

After laxative abuse a number of bowel problems may be seen in people with bulimia nervosa. Lactose intolerance may occur and there may be irritable bowel syndrome. On cessation of the laxatives, constipation is common. Apart from the wind and pain, the sufferer may feel very bloated and reluctant to eat. It is essential to ensure an adequate fluid intake and emphasise the importance of regular, high fibre meals and snacks.

Haemorrhoids and rectal prolapse may occur as a consequence of the constipation. Less frequently the bowel may not return to normal function or a megacolon may exist. While a high fibre diet is usually recommended, ever increasing amounts of bran are not advisable. Apart from the effects on binding essential minerals such as iron and calcium, the extra bran may only worsen the bloating, wind and abdominal distension. Laxatives that stimulate the bowel are to be avoided and osmotic agents such as Epsom salts or Sorbitol may be recommended (often with a fibre supplement such as Metamucil or Fibrogel).

A referral to a gastroenterologist may be needed when bowel function does not return to normal with a high fibre/fluid intake, regular meals and snacks and cessation/reduction of the laxative abuse.

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