ByNi Ketut Alit A

Faculty Of Nursing Airlangga University Slide 1

Black, J.M. & Matassarin E, (1997). Medical Surgical Nursing: Clinical Management for continuity of care. J.B. Lippincott.co.

Barbara C.L & Wilma J.P. (2006). Essentials of Medical Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.

Smeltzer, S.C., & Bare, B. (2003). Brunner and Suddarth's Textbook of Medical-Surgical Nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

Ignativicius & Bayne. (2001). Medical and Surgical Nursing. Philadelphia: W.B. Saunders Company.

Luckman & Sorensen. (2000). Medical Surgical Nursing. Philadelphia: W.B. Saunders Company.

Journals and article related to..

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REVIEW

Body WeightBody Mass Index ( BMI)Daily Calori Need - Haris Benedict

Current Western beauty standards equate thinness with health and beauty

There has been a rise in eating disorders in the past three decades◦ The core issue is a morbid fear of weight gain

Two main diagnoses:◦ Anorexia nervosa◦ Bulimia nervosa

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The main symptoms of anorexia nervosa are:◦ A refusal to maintain more than 85% of normal

body weight◦ Intense fears of becoming overweight◦ A distorted view of body weight and shape◦ Amenorrhea

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There are two main subtypes:◦ Restricting type

Lose weight by restricting “bad” foods, eventually restricting nearly all food

Show almost no variability in diet

◦ Binge-eating/purging type Lose weight by vomiting after meals, abusing

laxatives or diuretics, or engaging in excessive exercise Like those with bulimia nervosa, people with this

subtype may engage in eating binges

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About 90–95% of cases occur in females The peak age of onset is between 14 and 18

years Around 0.5% of females in Western

countries develop the disorder◦ Many more display some symptoms

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The “typical” case:◦ A normal to slightly overweight female has

been on a diet◦ Escalation to anorexia nervosa may follow a

stressful event Separation of parents Move or life transition Experience of personal failure

◦ Most patients recover However, about 2 to 6% become seriously ill and die as

a result of medical complications or suicide

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The key goal for people with anorexia nervosa is thinness◦ The driving motivation is FEAR:

Of becoming obese Of losing control of body shape and weight

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Despite their dietary restrictions, people with anorexia are extremely preoccupied with food◦ This includes thinking and reading about food and

planning for meals◦ This relationship is not necessarily causal

It may be the result of food deprivation, as evidenced by the famous.

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People with anorexia nervosa also demonstrate distorted thinking:◦ Often have a low opinion of their body shape◦ Tend to overestimate their actual proportions

Adjustable lens assessment technique – overestimate size by 20%

◦ Hold maladaptive attitudes and beliefs “I must be perfect in every way” “I will be a better person if I deprive myself” “I can avoid guilt by not eating”

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People with anorexia may also display certain psychological problems:

◦ Depression (usually mild)◦ Anxiety◦ Low self-esteem◦ Insomnia or other sleep disturbances◦ Obsessive-compulsive patterns◦ Perfectionism

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Caused by starvation:◦ Amenorrhea◦ Low body temperature◦ Low blood pressure◦ Body swelling◦ Reduced bone density

◦ Slow heart rate◦ Metabolic and

electrolyte imbalance

◦ Dry skin, brittle nails◦ Poor circulation◦ Lanugo

Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges:◦ Bouts of uncontrolled overeating during a limited

period of time Often objectively more than most people

would/could eat in a similar period

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The disorder is also characterized by compensatory behaviors, which mark the subtype of the condition:◦ Purging-type bulimia nervosa

Vomiting Misusing laxatives, diuretics, or enemas

◦ Nonpurging-type bulimia nervosa Fasting Exercising excessively

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Like anorexia nervosa, about 90–95% of bulimia nervosa cases occur in females

The peak age of onset is between 15 and 21 years

Symptoms may last for several years with periodic letup

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Patients are generally of normal weight◦ May be slightly overweight◦ Often experience weight fluctuations

“Binge-eating disorder” may be a related diagnosis◦ Symptoms include a pattern of binge eating with

NO compensatory behaviors (such as vomiting)◦ This condition is not yet listed in the DSM

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Teens and young adults have frequently attempted binge-purge patterns as a means of weight loss, often after hearing accounts of bulimia from friends or the media

In one study:◦ 50% of college students reported periodic binges◦ 6% tried vomiting◦ 8% experimented with laxatives at least once

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For people with bulimia nervosa, the number of binges per week can range from 2 to 40◦ Average: 10 per week

Binges are often carried out in secret◦ Binges involve eating massive amounts of food

rapidly with little chewing◦ Binge-eaters commonly consume more than

1500 calories (often more than 3000 calories) per binge episode

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Binges are usually preceded by feelings of tension and/or powerlessness

Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and “discovery”

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After a binge, people with bulimia nervosa try to compensate for and “undo” the caloric effects

The most common compensatory behaviors: ◦ Vomiting

Affects ability to feel satiated greater hunger and bingeing

◦ Laxatives and diuretics Almost completely fail to reduce the number of calories

consumed

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Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating◦ Over time, however, a cycle develops in which

purging bingeing purging…

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The “typical” case:◦ A normal to slightly overweight female has been

on an intense diet◦ Research suggests that even among normal

subjects, bingeing often occurs after strict dieting For example, a study of binge-eating behavior in a

low-calorie weight loss program found that 62% of patients reported binge-eating episodes during treatment

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Similarities:◦ Onset after a period of dieting◦ Fear of becoming obese◦ Drive to become thin◦ Preoccupation with food, weight, appearance◦ Elevated risk of self-harm or attempts at suicide◦ Feelings of anxiety, depression, perfectionism◦ Substance abuse◦ Disturbed attitudes toward eating

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Differences:◦ People with bulimia are more worried about

pleasing others, being attractive to others, and having intimate relationships

◦ People with bulimia tend to be more sexually experienced

◦ People with bulimia display fewer of the obsessive qualities that drive restricting-type anorexia

◦ People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping

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Differences:◦ People with bulimia tend to be controlled by

emotion – may change friendships easily◦ People with bulimia are more likely to display

characteristics of a personality disorder◦ Different medical complications:

Only half of women with bulimia experience amenorrhea vs. almost all women with anorexia

People with bulimia suffer damage caused by purging, especially from vomiting and laxatives

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Most theorists subscribe to a multidimensional risk perspective:◦ Several key factors place individuals at risk◦ More factors = greater risk◦ Leading factors:

Sociocultural conditions (societal and family pressures) Psychological problems (ego, cognitive, and mood

disturbances) Biological factors

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Many theorists argue that current Western standards of female attractiveness have contributed to the rise of eating disorders◦ Standards have changed throughout history

toward a thinner ideal

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Certain groups are at greater risk from these pressures:◦ Models, actors, dancers, and certain athletes

Of college athletes surveyed, 9% met full criteria for an eating disorder while another 50% had symptoms

20% of surveyed gymnasts met full criteria for an eating disorder

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The socially-accepted prejudice against overweight people may also add to the “fear” and preoccupation about weight◦ About 50% of elementary and 61% of middle

school girls are currently dieting

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Families may play a critical role in the development of eating disorders◦ As many as half of the families of those with

eating disorders have a long history of emphasizing thinness, appearance, and dieting

◦ Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves

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Abnormal family interactions and forms of communication within a family may also set the stage for an eating disorder◦ Minuchin cites “enmeshed family patterns” as

causal factors of eating disorders These patterns include overinvolvement in, and

overconcern about, family member’s lives Such families can be affectionate and loyal but can also

foster clinginess and dependency Children are allowed little room for individuality and

independence

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Bruch : eating disorders are the result of disturbed mother–child interactions which lead to serious ego deficiencies in the child and to severe cognitive disturbances

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Bruch : parents may respond to their children either effectively or ineffectively

◦ Effective parents accurately attend to a child’s biological and emotional needs

◦ Ineffective parents fail to attend to child’s internal needs; they feed when the child is anxious, comfort when the child is tired, etc.

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There is some empirical support for Bruch’s theory from clinical sources◦ People with bulimia eat in response to emotions;

many mistakenly think they are also hungry◦ People with eating disorders rely excessively on

the opinions, wishes, and views of others They are more likely to worry about how they are

viewed, to seek approval, to be conforming, and to feel a lack of life control

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Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression◦ Theorists believe mood disorders may “set the

stage” for eating disorders

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There is some empirical support for the claim that mood disorders set the stage for eating disorders

◦ Many more people with an eating disorder qualify for a clinical diagnosis of major depressive disorder than do people in the general population

◦ Close relatives of those with eating disorders seem to have higher rates of mood disorders

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Biological theorists suspect that some people inherit a genetic tendency to develop an eating disorder◦ Consistent with this model:

Relatives of people with eating disorders are 6 times more likely to develop the disorder themselves

◦ These findings may be related to low serotonin

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Other theorists believe that eating disorders may be related to dysfunction of the hypothalamus◦ Researchers have identified two separate areas

that control eating: Lateral hypothalamus (LH) Ventromedial hypothalamus (VMH)

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Some theorists believe that the LH and VMH are responsible for weight set point – a “weight thermostat” of sorts

◦ Set by genetic inheritance and early eating practices, this mechanism is responsible for keeping an individual at a particular weight level

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Eating disorder treatments have two main goals:◦ Correct abnormal eating patterns◦ Address broader psychological and situational

factors that have led to and are maintaining the eating problem This often requires the participation of family and

friends

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The initial aims of treatment for anorexia nervosa are to:◦ Restore proper weight◦ Recover from malnourishment◦ Restore proper eating

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In the past, treatment took place in a hospital setting; it is now often offered in an outpatient setting.

In life-threatening cases, clinicians may force tube and intravenous feeding

Most common technique now is the use of supportive nursing care and high calorie diets

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Therapists use a mixture of therapy and education to achieve this broader goal◦ One focus of treatment is building autonomy

and self-awareness

Therapists help patients recognize their need for independence and control

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Another focus of treatment is correcting disturbed cognitions, especially client misperceptions and attitudes about eating and weight◦ Using cognitive approaches, therapists correct

disturbed cognitions and educate about body distortions

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Another focus of treatment is changing family interactions◦ Family therapy is important for anorexia◦ The main issues are often separation and

boundaries

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The use of combined treatment approaches has greatly improved the outlook for people with anorexia nervosa◦ But even with combined treatment, recovery is

difficult The course and outcome of the disorder

vary from person to person

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Positives of treatment:◦ Weight gain is often quickly restored 83% of patients still showed

improvements after several years◦ Menstruation often returns with return to normal

weight

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Negatives of treatment:◦ Close to 20% of patients remain troubled for

years◦ Even when it occurs, recovery is not always

permanent Relapses are usually triggered by stress Many patients still express concerns about body

shape and weight

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Treatment programs are relatively new but have risen in popularity

Treatment is frequently offered in specialized eating disorder clinics

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The initial aims of treatment for bulimia nervosa are to:◦ Eliminate binge-purge patterns◦ Establish good eating habits◦ Eliminate the underlying cause of bulimic patterns

Programs emphasize education as much as therapy

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Several treatment strategies:◦ Individual insight therapy

The insight approach receiving the most attention is cognitive therapy, which helps clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape As many as 65% stop their binge-purge cycle

If cognitive therapy isn’t effective, interpersonal therapy (IPT), a treatment that seeks to improve interpersonal functioning, may be tried

A number of clinicians also suggest self-help groups or self-care manuals

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Several treatment strategies:◦ Behavioral therapy

Behavioral techniques are often included in treatment as a supplement to cognitive therapy Diaries are often a useful component of

treatment Exposure and response prevention (ERP) is used to

break the binge-purge cycle

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Several treatment strategies:◦ Antidepressant medications

During the past decade, antidepressant drugs have been used in bulimia treatment Most common is fluoxetine (Prozac), an SSRI Drugs help 25 to 40% of patients

Medications are best when used in combination with other forms of therapy

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Several treatment strategies:◦ Group therapy

Provides an opportunity for patients to express their thoughts, concerns, and experiences with one another

Helpful in as many as 75% of cases, especially when combined with individual insight therapy

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Left untreated, bulimia can last for years Treatment provides immediate, significant

improvement in about 40% of cases◦ An additional 40% show moderate improvement

Follow-up studies suggest that 10 years after treatment, about 90% of patients have fully or partially recovered

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Relapse can be a significant problem, even among those who respond successfully to treatment◦ Relapses are usually triggered by stress◦ Relapses are more likely among persons who:

Had a longer history of symptoms Vomited frequently Had histories of substance use Have lingering interpersonal problems

Finally, treatment may also help improve overall psychological and social functioning

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