Gastrenteritis
Food Poisoning
Pregnancy
Eating Disorder
Eating Disorders
Serious eating disorders are grouped into three categories: refusing to maintain a minimally normal body weight (anorexia nervosa), eating in binges and then purging (bulimia nervosa), and bingeing without purging (binge eating disorder). Bingeing is the rapid consumption of large amounts of food in a short period of time accompanied by a feeling of loss of control. Purging is self-induced vomiting or misuse of laxatives, diuretics, or enemas to rid the body of food.
Anorexia Nervosa
Anorexia nervosa is a disorder characterized by a distorted body image, an extreme fear of obesity, refusal to maintain a minimally normal body weight, and in women, the absence of menstrual periods.
About 95 percent of the people who have this disorder are females. It usually begins in adolescence, occasionally earlier, and less commonly in adulthood. Anorexia nervosa primarily affects people in middle and upper socioeconomic classes. In Western society, the number of people who have this disorder seems to be increasing.
Anorexia nervosa may be mild and transient or severe and long lasting. Death rates as high as 10 to 20 percent have been reported. However, because mild cases may not be diagnosed, no one knows exactly how many people have anorexia nervosa or what percentage die of it.
Its cause isn't known, but social factors appear to be important. The desire to be thin pervades Western society, and obesity is considered unattractive, unhealthy, and undesirable. Even before adolescence, children are aware of these attitudes, and two thirds of all adolescent girls diet or take other measures to control their weight. Yet, only a small percentage of these girls develop anorexia nervosa.
Symptoms
Many women who later develop anorexia nervosa are meticulous and compulsive, with very high standards for achievement and success. The first indications of the impending disorder are increased concern with diet and concern about body weight, even among those who already are thin, as are most people who have anorexia nervosa. Preoccupation and anxiety about weight intensify as the person becomes thinner. Even when emaciated, the person claims to feel fat, denies that anything is wrong, doesn't complain about lack of appetite or weight loss, and usually resists treatment. The person usually doesn't see a doctor until brought by family members who are concerned.
Anorexia means "lack of appetite," but people who have anorexia nervosa are actually hungry and preoccupied with food. They study diets and calories; they hoard, conceal, and deliberately waste food; they collect recipes; and they prepare elaborate meals for others.
Half the people who have anorexia nervosa binge and then purge by vomiting or taking laxatives and diuretics. The other half simply restrict the amount of food they eat. Most also exercise excessively to control weight.
Women stop having menstrual periods, sometimes before losing much weight. Women and men may lose interest in sex. Typically, they have a low heart rate, low blood pressure, low body temperature, swelling of tissues caused by fluid accumulation (edema), and fine, soft hair or excessive body and facial hair. Anorectics who become very thin tend to remain active, even pursuing vigorous exercise programs. They don't have symptoms of nutritional deficiencies and are surprisingly free of infections. Depression is common, and people who have this disorder frequently lie about how much they have eaten and conceal their vomiting and their peculiar dietary habits.
Hormonal changes resulting from anorexia nervosa include markedly reduced levels of estrogen and thyroid hormone and increased levels of cortisol. If a person becomes seriously malnourished, every major organ system in the body is likely to be affected. Problems with the heart and with fluids and electrolytes (sodium, potassium, chloride) are the most dangerous. The heart gets weaker and pumps less blood through the body. The person may become dehydrated and prone to fainting. The blood may become acidic (metabolic acidosis), and potassium levels in the blood may decrease. Vomiting and taking laxatives and diuretics can worsen the situation. Sudden death, probably from abnormal heart rhythms, may occur.
Diagnosis and Treatment
Anorexia nervosa is usually diagnosed on the basis of severe weight loss and the characteristic psychologic symptoms. The typical anorectic is an adolescent girl who has lost at least 15 percent of her body weight, fears obesity, stops having menstrual periods, denies being sick, and otherwise appears healthy.
Usually, treatment consists of two steps. The first is restoring normal body weight. The second is psychotherapy, often supplemented with drugs.
When weight loss has been rapid or severe--for example, to more than 25 percent below the ideal body weight (see box, page 647)--restoring body weight is crucial; such weight losses can be life threatening. The initial treatment usually is carried out in a hospital where experienced staff members firmly but gently encourage the patient to eat. Rarely, the patient is fed intravenously or through a tube inserted in the nose and passed into the stomach.
When the person's nutritional status is acceptable, long-term treatment, which is best conducted by specialists in eating disorders, is begun. This treatment may include individual, group, and family psychotherapy as well as drugs. When depression is diagnosed, antidepressants are prescribed. (see page 406 in Chapter 84, Depression and Mania) Treatment is aimed at establishing a calm, concerned, stable environment while encouraging the consumption of an adequate amount of food.
Bulimia Nervosa
Bulimia nervosa is a disorder characterized by repeated episodes of binge eating followed by purging (self-induced vomiting or taking laxatives, diuretics, or both), rigorous dieting, or excessive exercising to counteract the effects of bingeing.
As in anorexia nervosa, most people who have bulimia nervosa are female, are deeply concerned about body shape and weight, and belong to the middle or upper socioeconomic classes. Although bulimia nervosa has been portrayed as an epidemic, only about 2 percent of college women, believed to be those at highest risk, are true bulimics.
Symptoms
Bingeing (rapidly and quickly consuming relatively large amounts of food while feeling a loss of control) is followed by intense distress as well as by purging, rigorous dieting, and excessive exercising. The amount of food consumed in a binge may be quite large or no larger than a normal meal. Emotional stress often triggers bingeing, which usually is done in secret. A person must binge at least twice a week to be diagnosed as having bulimia nervosa but may binge more often. Although bulimics express concern about becoming obese and a few are obese, their body weight tends to fluctuate around normal.
Self-induced vomiting can erode tooth enamel, enlarge the salivary glands in the cheeks (parotid glands), and inflame the esophagus. Vomiting and purging can lower potassium levels in the blood, causing abnormal heart rhythms. Sudden death from repeatedly taking large quantities of ipecac to induce vomiting has been reported. Rarely, people who have this disorder eat so much during a binge that their stomach ruptures.
Compared with people who have anorexia nervosa, those who have bulimia nervosa tend to be more aware of their behavior and to feel remorseful or guilty about it. They are more likely to admit their concerns to a doctor or other confidant. Generally, bulimics are more outgoing. They also are more prone to impulsive behavior, drug or alcohol abuse, and obvious depression.
Diagnosis and Treatment
A doctor suspects bulimia nervosa if a person is overly concerned about weight gain and has wide fluctuations in weight, especially with evidence of excessive laxative use. Other clues include swollen salivary glands in the cheeks, scars on the knuckles from using the fingers to induce vomiting, erosion of tooth enamel from stomach acid, and a low level of potassium detected in a blood test. The diagnosis isn't confirmed until the person describes binge-purge behavior.
The two approaches to treatment are psychotherapy and drugs. Psychotherapy, generally best conducted by a therapist with experience in eating disorders, may be very effective. An antidepressant drug often can help control bulimia nervosa, even when a person is not obviously depressed, but the disorder may return after the drug is discontinued.
Binge Eating Disorder
Binge eating disorder is a disorder characterized by bingeing that isn't followed by purging.
In this disorder, bingeing contributes to excessive caloric intake. Unlike bulimia nervosa, binge eating disorder occurs most commonly in people who are obese and becomes more prevalent with increasing body weight. People who have binge eating disorder tend to be older than those who have anorexia nervosa or bulimia nervosa, and more (nearly half) are men.
Symptoms
People who have this disorder are distressed by it. About 50 percent of obese binge eaters are depressed, compared with only 5 percent of obese people who don't binge. Although this disorder doesn't result in the physical problems that can occur with bulimia nervosa, it is a problem for a person who is trying to lose weight.
Treatment
Because binge eating disorder has only recently been identified, no standard treatment programs have been developed for it. Most people who have it are treated in conventional weight-loss programs for obesity, which pay little attention to bingeing--even though 10 to 20 percent of the people in these programs have binge eating disorder. Most people who have the disorder accept this situation because they are more concerned about their obesity than their bingeing.
Specific treatments for binge eating are being developed, based on the treatment of bulimia nervosa; they include psychotherapy and drugs--antidepressants and appetite suppressants. Although both treatments are reasonably effective in controlling binge eating, psychotherapy appears to have longer-lasting effects.
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... I am not even a puker, berely ever.
