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The Alliance for Eating Disorders Awareness


Eating Disorders 101: How to Screen, Assess, and Diagnose Students with Eating Disorders The Alliance for Eating Disorders Awareness Joann Hendelman, Ph.D., R.N ... – PowerPoint PPT presentation

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Title: The Alliance for Eating Disorders Awareness

Eating Disorders 101 How to Screen, Assess,
and Diagnose Students with Eating Disorders
  • The Alliance for Eating Disorders Awareness
  • Joann Hendelman, Ph.D., R.N., FAED, CEDS-S
  • Clinical Director
  • Johanna S. Kandel
  • Founder/CEO

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Eating Disorders Stats
  • More than
  • 30 Million Americans
  • are currently battling
  • eating disorders

College Students and Eating Disorders
  • 25 of college-aged students have eating
    disorders (NIMH 2012).
  • College administrators report a 24.3 rise in
    eating disorder behavior among college students
    (2010 National Survey of Counseling Center
  • 91 of women on college campuses have attempted
    to control their weight through excessive dieting
  • At least three quarters (75) of college students
    are dissatisfied with their weight (Soet, J. and
    T. Sevig, 2006)
  • Less than 20 who screened positive for EDs
    report receiving treatment on college campuses
    (Stanford 2013)

College Students and Eating Disorders
  • ACHAs 2010 National College Health Assessment
  • 44 of college women are dieting to lose weight
  • 27 of college men are dieting to lose weight
  • 61 of college women are exercising to lose
  • 45 of college men are exercising to lose weight

  • The mortality rate for those with anorexia
    nervosa is estimated at 5 per decade making it
    one of the leading contributors to excess
    mortality of any of the psychiatric disorders.
    Research tells us that anorexia is a brain
    disease with severe metabolic effects on the
    entire body. While the symptoms are behavioral,
    this illness has a biological core, with genetic
    components, changes in brain activity and neural
  • currently under study.
  • Thomas Insel, M.D., Director, National
    Institute of Mental Health, Bethesda, MD,
    April 2007

Heritability in Anorexia and Bulimia
  • 50 to 80 of cause is genetic
  • AN BN share common genes
  • AN BN run in families

Contributing Factors
  • Genetics
  • Traumatic experiences
  • Family difficulties
  • Onset of mental illness
  • History of substance abuse
  • History of dieting
  • Sports/activities where weight regulation is
  • Physical illness that causes weight loss
  • Perfectionism
  • Vegetarianism

  • Eating disorders display substantial co-morbidity
    with other mental health disorders.
  • While eating disorders often coexist with other
    mental health disorders, eating disorders often
    go undiagnosed and untreated.
  • A low number of sufferers obtain treatment for
    their eating disorder hence inaccurate measures
    of incidence
  • (Only 1 in 10).

  • Eating disorders frequently impair the sufferer's
    home, work, personal, and social life.
  • Binge Eating Disorder is more common than
    anorexia or bulimia and is commonly associated
    with severe obesity.
  • Researchers found a surprisingly high rate of
    anorexia and bulimia among men, representing
    approximately one fourth of all the cases of each

  • Eating disorders DO NOT discriminate between age,
    gender, race and class

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New Trends
  • Men
  • Women in Midlife
  • Young Children
  • Which of these trends has the
  • highest percent increase?

Women in Midlife
  • Triggers
  • Desire to remain young in a society that does not
    let you grow old gracefully.
  • Divorce Rate in the U.S. (50)
  • Menopause
  • Empty Nest Syndrome
  • Loss (i.e. spouse, parent, child)
  • Eating Disorders that were not treated years

Males and Eating Disorders
  • Recent research indicates that 1 in 4 people with
    eating disorders is male
  • Rate of men with BED is similar to women
  • Greater tendency to use compulsive exercise
    rather than purging for weight control.
  • Preferred body image is muscular.
  • Increasing evidence as concerned about body image
    as women.

Eating Disorders in Children
  • 10 of eating disorders clients are lt 10 years of
  • 119 increase in hospitalizations in children lt
    12 yrs.
  • Nearly HALF of 3- to 6-year-old girls reported
    they worry about being fat (Tantleff-Dunn, 2009)
  • Children maturing earlier and earlier
  • Being teased by peers
  • Societys obsession with thinness

Anorexia Nervosa (Self-Starvation)
  • A self-imposed starvation resulting from a
    distorted body image and an intense fear of
    gaining weight.

Demographics of Anorexia
  • 1 of suburban female teens
  • Bimodal peak of onset
  • 12-13 years old
  • 17 years old
  • 50 restrictors (limit food and exercise)
  • 50 bulimic subtype
  • also purge

Anorexia Nervosa (Self-Starvation)
  • Restricting type - dieting, fasting
  • and/or excessive exercise
  • Binge-eating/purging type - vomiting,
  • misuse of laxatives, enemas and/or
  • diuretics carries greater medical risk.

Review of Symptoms Anorexia
  • Dizziness/fainting
  • Loss/delay menses (Amenorrhea)
  • Orthostatic hypotension
  • Self mutilation
  • Sleep disturbance
  • Brittle nails
  • Thinning/dull hair
  • Sizeable weight change
  • Disturbed body image
  • Cold intolerance/hypothermia
  • Constipation
  • Loss of muscle mass
  • Depressive symptoms
  • Anxiety
  • Cognitive impairment

Physical Findings Anorexia
  • Hyperkeratosis
  • Edema
  • Anemia
  • Cyanotic extremities
  • Hypotension
  • Gastroparesis
  • Emaciation
  • Bradycardia
  • Hypothermia
  • Lanugo hair
  • Dry skin
  • Carotenemia

Anorexia The Dangerous Reality
  • Mortality
  • Anorexia Nervosa has the highest mortality rate
    among all psychiatric disorders.
  • 10 20 will die
  • Death from cardiac arrest, suicide, starvation,
    other medical complications

Bulimia Nervosa (Binge-Purge)
  • A disorder in which an individual engages in
    episodes of bingeing and purging.

Demographics Bulimia
  • 21 of college-aged women
  • Peak onset college age
  • Duration before presentation 5 years
  • Normal weight range
  • 30 hx of obesity
  • 20 hx anorexia

Bulimia Nervosa (Binge-Purge)
  • 75 - 85 of individuals with Bulimia are normal
    weight to overweight

Review of Symptoms Bulimia
  • Average weight w/ weight fluctuation
  • Disturbed body image
  • Depressive symptoms
  • Anxiety
  • Dizziness and fainting
  • Fatigue
  • Chipmunk facies
  • Abdominal pain
  • Self mutilation
  • Feelings of shame and guilt
  • Sleep disturbance
  • Bloating/heartburn
  • Bowel paralysis

Physical Findings Bulimia
  • Edema
  • Extremity weakness
  • Esophagitis
  • Electrolyte imbalance
  • Sore throat
  • Dehydration
  • Normal or Overweight
  • Hypertensive
  • Parotid enlargement
  • Dental erosions
  • Russell's sign - scars on knuckles
  • Boerhaave Syndrome

Binge Eating Disorder (Bingeing)
  • Recurrent episodes of
  • binge eating without the
  • purging behavior of
  • Bulimia Nervosa.

Binge Eating Disorder
  • Recurrent episodes of binge eating with
  • Eating in discrete period of time an amount of
    food larger than most people would eat
  • A sense of lack of control over eating during the
    episode (a feeling that one cannot stop eating or
    control what or how much one is eating)
  • The binge eating occurs at least once a week for
    three (3) months.
  • The binge eating episodes are associated with
  • eating much more rapidly than normal
  • eating until feeling uncomfortably full
  • eating large amounts of food when not feeling
    physically hungry
  • eating alone because of feeling embarrassed by
    how much one is eating
  • feeling disgusted with oneself, depressed, or
    very guilty afterwards

Binge Eating Disorder Physical Findings
  • Overweight or obesity
  • Gallbladder disease
  • Increased BP
  • Increased cholesterol
  • Heart disease
  • Type II diabetes
  • Lipid abnormalities
  • Osteoarthritis
  • Sleep apnea

  • 30-50 of hospital based obese population have
  • 20-30 of patients seeking medical weight loss
    treatment have BED
  • Treatment issues of obesity with consideration of
    eating disorders (obesity prevention)
  • Following involvement in an obesity prevention
    program, 30 of children aged 6-14 displayed
    one or more behaviors that could be associated
    with the development of an eating disorder
    (Science Daily, 2012)

Eating Disorders Not Otherwise Specified
  • Significant eating disorder that does not exactly
    meet criteria for AN or BN

Avoidance/Restrictive Food Intake Disorder
  • Persistent disturbance in eating leading to
  • Weight loss/inadequate growth
  • Significant nutritional deficiency
  • Dependence on tube feeding/nutritional
  • Impaired psycho-social functioning/inability to
    eat with others
  • Exclusions
  • Lack of food, cultural practice
  • Other medical/psychological issues
  • Irrational fear of weight shape eating

Other Types of Eating Disorders
  • Orthorexia
  • Muscle Dysmorphia
  • Drunkorexia
  • PICA
  • Diabulimia

  • Coined in 1997 by Steven Bratman, MD
  • Defined as an obsession with "healthy or
    righteous eating.
  • It often begins with someone's simple and genuine
    desire to live a healthy lifestyle.
  • The severe restrictive nature of orthorexia could
    easily morph into anorexia.
  • Can result after major illness

Muscle Dysmorphia
  • Obsess/worry about being small, underdeveloped,
    and/or underweight.
  • Many are obsessed with having the perfect
    physique and are addicted to lifting weights.
  • Muscle-bound, but believe their muscles are
  • Steroid abuse, unnecessary plastic surgery, and
    even suicide.

  • A non medical term, for the practice of swapping
    food calories for those in alcohol.
  • Statistics suggest that 30 of 18-24 year olds
    skip food in order to drink more.
  • Also known as a mixture of alcoholism, bulimia
    and anorexia
  • Prominent among young college women who skip
    meals so they can get drunk at night and not
    worry about the calories

PICA (as an Eating Disorder)
  • Pica is disorder in which a person has a strong
    desire to eat, lick, or chew non-food items in
    lieu of eating caloric foods.
  • Persistent eating of nonnutritive substances for
    a period of at least 1 month. The eating of
    nonnutritive substances is inappropriate to the
    developmental level.

Diabulimia Type 1 Diabetes
  • "Diabulimia" is used to describe people with
    diabetes that manipulate their intake of insulin
    in order to temporarily alter their weight.
  • "Diabulimia" is extremely serious
  • Doubled rate of physical toll taken on the body
    than diabetes or an eating disorder alone.
  • Manipulation of ketone levels may result in
    dehydration, kidney dysfunction, and blindness.
  • 40 mortality rate.

  • Do NOT ask your patient if
  • they are manipulating
  • their insulin in order to
  • lose weight. You do not
  • want to teach them a
  • trick!

Screening Questions
  • Do you feel big/small in your body?
  • When/what did you last eat? What did you eat
    yesterday? Do you have forbidden foods?
  • What is your ideal body weight? How often do you
    weigh yourself? Have you lost/gained weight
    within the last 3 months? What has your weight
    range been?
  • Do you make yourself sick (i.e. purge) when you
    feel uncomfortably full?
  • Do you binge? What constitutes a binge for you?
  • Do you eat when youre hungry and stop when you
    are full? Do you worry you have lost control
    over how much you eat?
  • Would you say that food/ food thoughts dominate
    your life?
  • What is your exercise regimen?
  • Be mindful when screening not to ignore males!!

Evaluation of patients with eating disorders
  • History
  • Weight/diet history
  • Menstrual history pattern
  • Body image disturbance
  • Eating habits
  • Binge eating purging behaviors
  • Current past medications
  • Substance abuse
  • Exercise regimen
  • Compensatory behaviors laxative, diuretic, diet
    pills/stimulants, ipecac use
  • Suicidal ideations
  • Psychiatric history
  • including - family history of disordered eating,
    addictive disorders, depression, anxiety, etc.
  • Sexual history

Evaluation Continued
Physical exam
  • Systems
  • Vitals
  • Body temperature
  • Heart rate
  • Blood pressure
  • Height weight
  • Heart
  • Cardiac arrhythmias
  • Heart palpitations
  • Chest pain
  • Heent
  • Perimyolysis
  • Dental caries
  • Chipped teeth
  • Mouth sores
  • Sialadenosis

Evaluation Continued
Physical exam
  • Endocrine
  • Amenorrhea/irregular menses
  • Loss of libido
  • Decreased bone density
  • Osteoporosis
  • Infertility
  • Poor glucose control diabetic ketoacidosis (in
  • Skin
  • Dry skin
  • Brittle nails
  • Carotenemia
  • Pigmentation
  • Hair loss/thinning
  • Lanugo hair
  • Russells sign
  • Poor wound healing

Evaluation Continued
  • Labs/Studies
  • EKG
  • CBC w/ diff
  • Full thyroid panel (T², T³, T?, TSH)
  • Urinalysis specific gravity, sodium
  • Bone density scan
  • Complete metabolic profile
  • Full chemistry amylase
  • Serum magnesium/glucose/electrolytes
  • Amenorrhea evaluation

Evaluation Continued
  • Special Circumstances (e.g. clients lt15 IBW)
  • Chest x-ray
  • Complement 3
  • 24 hour creatinine clearance
  • Uric acid
  • Brain scan
  • Echocardiogram
  • Skin testing for immune functioning
  • DXA scan (amenorrhea 6 months)
  • Estradiol level (or testosterone in males)
  • ANA, amylase, lipase, LH, FSH, prolactin

Laboratory Clues
  • Low Glucose Poor nutrition
  • High Glucose Insulin omission
  • Low Potassium Vomiting, laxatives, etc
  • Low Chloride Vomiting
  • High Chloride Laxatives
  • High Blood Bicarbonate Vomiting
  • Low Blood Bicarbonate Laxatives
  • High Blood Urea Nitrogen Dehydration

Laboratory Clues
  • High Creatinine Dehydration
  • Low Calcium Poor nutrition at expense of bone
  • Low Phosphate Poor nutrition or refeeding
  • Low Magnesium Poor nutrition or laxatives
  • High Amaylase Vomiting, pancreatitis
  • High Lipase Pancreatitis
  • High Total Bilirubin Liver dysfunction
  • High Total Protein/Albumin Malnutrition

Occasional Lab Findings
  • Hormones
  • Low Estradiol (Females)
  • Low Testosterone (Males)
  • Lipids anything goes
  • High Cholesterol Short term starvation
  • Low Cholesterol Long term starvation
  • Sick euthyroid
  • Low T4, normal TSH

  • Usually normal
  • Bradycardia or other arrhythmias
  • Signs of hypokalemia
  • Low voltage changes
  • Prolonged QTc Greater than 440
  • Occasional ST-segment depression

Criteria for Hospitalization
  • Weight more than 25 below IBW
  • Bradycardia lt 50 BPM
  • Temperature lt 96 degrees F (lt 35.6 C)
  • Hypotension lt 80/50 mm Hg
  • Orthostasis gt 20 BMP
  • Hypokalemia lt 3
  • Renal failure
  • ECG abnormalities
  • Failure in outpatient intervention
  • Suicidality

Role of the Practitioner
  • Selling patients treatment they dont want for a
    problem they dont think they have

Motivational Interviewing
  • Offer empathy
  • Roll with the resistance
  • Avoid accusations/arguing/ pressuring
  • Ask open ended questions
  • Listen reflectively
  • Affirm/validate
  • Summarize

  • Do not believe all patient reports are accurate
  • Do not tell an underweight person with EDs to
    just eat or they are lucky to be thin
  • Do not tell an overweight person to just stop
  • Do not expect this will go away with time
  • DONT DELAY with early onset ED symptoms

Clinic Culture
  • Weighing
  • Office staff must be trained to use standardized
    protocols to record consistent, reliable
  • Scale should be located in a private area
  • Client should be weighed backwards to avoid
    revealing their true weight to them (Blind
  • Be aware that clients may drink extra fluids
    (water-loading), put weight in pockets/rocks in
    underwear, and/or wear layers of extra clothing
    before being weighed

Clinic Culture
  • Weighing
  • Never leave chart unattended and do not
    vocalize number or share whether its up/down
  • Comments about weight should be minimized and
    made discretely

Clinic Culture
  • When words have unintentional meanings
  • Healthy
  • Fat
  • Gained weight
  • Out of Control
  • Look Better
  • Fat
  • Gained weight
  • Out of Control
  • You look very nice today
  • Fat
  • Gained weight
  • Out of Control

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Clinic Culture
  • They Said What???
  • If you have an eating disorder, then why arent
    you skinnier?
  • So what? An eating disorder? Ive had one of
    thoseThis is all your choice. Some people have
    real problems.
  • Youre a guy, and guys dont get eating
  • No you dont have an eating disorderyoure not
    that skinny and your teeth are not yellow.
  • I had an eating disorder when I was younger, but
    I weighed much less than you do now.
  • You can starve yourself, and binge and purge as
    much as you want as long as you take vitamins,
    and dont hit your head when you pass out.
    Youll grow out of this stage eventually.

Hostile Recovery Environment
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We are In A Hostile Recovery Environment
  • Pervasive on college campuses
  • Glamorization/encouragement of the illness
  • Thinness control, popularity, success,
    relational connection
  • Fat out of control, shunned, failure,
    relational rejection
  • Readily available and legal drug of choice
  • War on Obesity

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  • Questions?

For more information, please call The Alliance
for Eating Disorders Awareness (866)