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Eating Disorders

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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

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.

For more information, see my separate page on anorexia nervosa.

Bulimia Nervosa

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.

For more information, see my separate page on bulimia nervosa.

Treatment of Eating Disorders

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.

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.
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.
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.

For more information, see my separate page on treatment of eating disorders.

Other Resources

Professional Publications
Reddy, Vinay N. and Reid, Lesley A., "Anorexia Nervosa and Bulimia Nervosa", Chapter 23 in Behavioral Pediatrics (Greydanus, Patel, Pratt, and Calles, eds.), 3rd edition, Hauppauge, New York, Nova Science Publishers, 2009.
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 we 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.
Web Sites
The Something Fishy Website on Eating Disorders
One of the oldest, and one of the most comprehensive, Web sites on eating disorders, including information on the disorders and on treatment resources.
National Eating Disorders Association
A non-profit organization dedicated to providing education, resources and support to those affected by eating disorders .
The Academy for Eating Disorders
An association of professionals, both clinicians and reasearchers, in the eating disorder field.
The Southwest Michigan Eating Disorders Association (formerly the Kalamazoo Eating Disorders Professional Coalition)
A coalition of professionals (therapists, dietitians, physicians, social workers, and educators) in Southwest Lower Michigan who provide treatment to people with eating disorders and their families.
Beyond Physical Appearances: A Guide to Anorexia
Despite the weird URL, this page is actually very informative and provides a number of excellent resources for anorexia nervosa information including causes, treatment, recovery and much more.
(I am a member of NEDA, the Academy for Eating Disorders, and SMEDA.)

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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.

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Copyright © 2006, 2007, 2008, 2009, 2010, 2011 Vinay N. Reddy, M.D. All rights reserved.
Written 06/27/06; last revised 02/14/11 counter