Author's note:
This section is a departure for me. Much of the rest of the
Office focuses on common childhood medical
problems. Much of my academic practice now is as a pediatric hospitalist
(a pediatrician who specializes in inpatient pediatrics). However, through my
experience as a hospitalist I also have considerable experience with patients who
have anorexia or bulimia. For many years I have been caring for patients with
eating disorders, both in and out of the hospital, and this section is based on
that experience. As with other medical problems, I cannot give anyone specific
advice on eating disorders other than my own patients or patients whose regular
doctors have consulted me. (If you live in Southwest Lower Michigan, or if you
are a physician caring for a patient with an eating disorder and are interested
in advice, please see my information on
my real office.)
Eating disorders -- anorexia nervosa, bulimia nervosa, and related problems
-- are among the most commmon psychologic problems seen in developed
countries. They often start gradually and become full-blown before the
patient or her family realise that there is a problem. (I use feminine
pronouns throughout this section because most patients with eating
disorders are women. However, there are increasing numbers of men with
eating disorders, including many patients who I see professionally.)
In this section I describe the symptoms and signs of anorexia nervosa and
bulimia nervosa. I also discuss, on a separate Web page, the principles
and some of the techniques used to treat patients with these diseases.
There are some less well-defined eating disorders that are also defined
by medical and psychological authorities which I (so far) do not talk
about here, but the treatment for these eating disorders is similar to
that for anorexia and bulimia.
Anorexia nervosa (which means "nervous loss of appetite" in Greek) is a
disease in which someone, often initially healthy, sometimes overweight at the
outset, becomes so obsessed with weight that she will do anything -- including
avoiding almost all food, and often including incredible amounts of exercise --
to lose weight or to avoiding gaining weight.
One feature of anorexics is that they think they are fat
even when they look like walking skeletons. Another is that they will often go
to great lengths to keep their families, friends, and doctors from knowing that
they are losing weight and not eating: their tactics may include wearing baggy
clothes, drinking huge amounts of water or hiding weights in their clothing
before doctors' visits, and cutting their food up in small pieces so that people
eating with them don't notice how little they are actually eating. Some (but not
all) anorexics may purge after eating, but anorexics don't usually binge the way
that bulimics do.
Anorexic patients eventually become severely malnourished. Our bodies
continue to produce energy to keep the really important parts (brain and heart)
working, and in the face of starvation they will do so by cannibalizing
everything else. Spare fat is the first thing to go, of course, but with
long-term malnutrition a patient will lose muscle mass -- including heart
muscle mass -- and calcium from her bones. Eventually there are no reserves
left: it's not common, but it's possible for someone to die of severe
malnutrition. The medical treatment must include refeeding the patient, but
this must be done carefully and under close supervision since refeeding a
starving patient too quickly can make her sick and sometimes even kill her.
In bulimia nervosa ("nervous ox hunger" in Greek -- probably because oxen
have very large appetites) a patient, who may be underweight or overweight,
regularly "binges" (eats large amounts of food -- sometimes thousands of calories
at one binge), and then purges shortly after the binge in an attempt to get rid of
the weight they put on in the binge. They may purge by vomiting (induced by
sticking something down their throats, or by using medicines such as ipecac;
experienced bulimics sometimes learn to vomit at will), by abusing laxatives,
or sometimes by using diuretics to increase urine output and get rid of "excess"
fluid.
Although some bulimics manage to lose weight, many stay the same or even
gain weight. Many of their medical problems stem from the side-effects of their
purging techniques. Vomiting, diuretic abuse, and laxative abuse can all alter
a patient's balance of electrolytes (mainly sodium and potassium; calcium and
phosphorus are also important) -- sometimes to the point of causing seizures
or stopping the heart, which has happened in some very (in)famous cases. Even
if purging doesn't throw a patient's electrolytes that far out of whack, the
purging method she uses may cause other problems: for example, ipecac can damage
muscles -- including the heart muscle -- if it is used too often or for too
long.
A majority of patients with eating disorders are either anorexic or bulimic.
However, there are relatively strict diagnostic criteria for both diseases, and
there are some patients who do not quite meet those criteria but whose eating
problems are severe enough to require treatment similar to that for anorexia or
bulimia.
The treatment for these disorders is threefold.
Medical
Simply refeeding the patient is dangerous, even if they will let you feed
them: refeeding must be done gradually with close monitoring of blood
chemistry. With close monitoring the physical process of refeeding can be
a little faster in the early stages when it can also be most dangerous;
this is one reason why we sometimes hospitalise badly-malnourished anorexic
patients. Patients who are not grossly malnourished can often be refed
without having to be admitted to the hospital, but they still must be
monitored (including lab work) regularly during early refeeding. The
monitoring required may not be practical for an outpatient, especially
one who has lost a great deal of weight. Also,
chronically malnourished patients lose other important nutrients besides
potassium, calcium, and phosphorus; although depletions of these other
minerals may not be immediately life-threatening, they need to have their
levels checked and may need to take supplements to restore their supplies
of these nutrients. Finally, there are some physical diseases that can
make patients lose their appetite to the point of malnutrition; these need
to be checked for as well.
Dietary
Refeeding is something we (doctors) generally don't do without the help of a
registered dietitian. (A little secret: many medical schools and residency
programs don't teach very much about the nuts and bolts of nutrition and
diet planning.) More important, most patients with anorexia and bulimia
don't know very much about the nuts and bolts of nutrition either, although
they are very good at calorie counting and are convinced that they
are "eating healthy". The dietitian's main role in treatment is not only
to lay out a healthy diet plan (although that is important early in
treatment) but to teach the patient how to lay out her own healthy diet plan
which usually starts with teaching her what "eating healthy" truly means.
Psychosocial
An eating disorder is at its root a problem with the patients' perception
of food and eating. Sometimes the eating disorder is the only behavioural
problem, but most often the patient has other issues as well, both
individually and within her family. These need to be addressed in both
individual and family therapy, and others in the family may also require
individual therapy of their own. Psychologists and other therapists
usually provide this kind of therapy. Occasionally medication is helpful
for some patients for their psychosocial issues, but these are usually
prescribed by psychiatrists who are experienced in eating-disorder therapy,
since many of these medications must be used cautiously in malnourished
patients.
An overview of eating disorders, emphasising the behavioural aspects of the
diseases and of their treatment, which I contributed to a textbook for
physicians on behavioural problems in children. The bibliography
(like that in any medical textbook) is rather comprehensive, and
the references I cite there are also those I used to prepare this
section.
Rome, ES, Ammerman, S, Rosen, DS, et al, Children and Adolescents
With Eating Disorders: The State of the Art,
Pediatrics
111:e98-e108 (January, 2003).
A consensus report by fifteen specialists in eating-disorder
management on the diagnosis and treatment of patients with anorexia
and bulimia.
One of the oldest, and one of the most comprehensive, Web sites on
eating disorders, including information on the disorders and on
treatment resources.
PLEASE NOTE: As with all of this Web site, I try to give
general answers to common questions my patients and their parents ask me
in my (real) office. If you have specific questions about your
child you must ask your child's regular doctor. No doctor can give
completely accurate advice about a particular child without knowing and
examining that child. I will be happy to try and answer
general questions
about children's health, but unless your child is a regular patient of
mine I cannot give you specific advice.
