Eating Disorders Nursing CE Course

h bulimia, and 78.9% of patients with BED. Across all three of these disorders, anxiety was the more prevalent comorbidity. The impact of eating disorders in the US is substantial, especially when considering the cost of care and the reduction in well-being. According to the National Eating Disorders Association (NEDA), males represent 25% of individuals with anorexia nervosa and are at a higher risk of dying. This increased mortality risk is partly due to males being less likely to get an accurate diagnosis since many people, including HCPs, see eating disorders as a female-only issue and fail to recognize the problem (NEDA, n.d.-b).

Streatfeild and colleagues (2021) conducted a cost-of-illness study to estimate the one-year costs to the US healthcare system. They also estimated intangible costs related to reduced well-being using a disability-adjusted life year calculation. Their study found that the total economic costs associated with eating disorders was $64.7 billion, equivalent to $11,808 per affected person. Of these costs, a diagnosis of otherwise specified feeding or eating disorder accounted for 35% of the total costs, followed by BED (30%), bulimia nervosa (18%), and anorexia nervosa (17%). The researchers also valued the reduction in well-being associated with eating disorders at $326.5 billion. These findings highlight the urgency of identifying effective policy actions to reduce the impact of eating disorders through primary prevention and screening in schools, primary care offices, and workplaces. According to the EDC, there is little federal funding for eating disorder research compared to other mental health diagnoses. Eating disorder research is apportioned approximately $28 million annually, whereas depression is allocated $328 million, schizophrenia $352 million, and attention-deficit hyperactivity disorder (ADHD) $105 million (EDC, n.d.).

 

Risk Factors for Eating Disorders

Eating disorders typically begin in the teen years and young adulthood but can develop at any age and affect all genders, races, ethnicities, and body weights. Research has shown that eating disorders are caused by a complex interaction of biological, behavioral, genetic, psychological, or social factors. As recognized in Table 1, mental health disorders commonly coexist with eating disorders and can also be risk factors for the development of eating disorders. Many people with eating disorders suffer from low self-esteem and self-dissatisfaction with their appearance and often feel helpless. Other personality traits that can increase the risk of developing an eating disorder include perfectionism, impulsivity, harm avoidance, and neuroticism. Eating disorders habitually begin as a method to cope with daily living. Consistent across each eating disorder is the risk related to family discord, parental substance use, sexual and physical abuse, and parental mood disorder. Sociocultural factors can include exposure to cultures (i.e., western culture) that value slimness for women, and social media plays a major role in promoting these sociocultural factors. Genetics also plays a role in the risk of developing an eating disorder. Additionally, each eating disorder has individual risk factors (Balasundaram & Santhanam; NIMH, n.d.).

Risk factors for anorexia include being an adolescent female, a perfectionist, having more controlling caregivers, childhood obesity, participating in weight-conscious sports or activities such as gymnastics/dance, and ongoing exposure through social media to models, actors, and excessively thin role models. Particularly young females may feel pressured to be thin due to societal expectations and feel unattractive otherwise. Anorexia does carry a genetic predisposition, with an 11-fold increased risk for female relatives of a proband with the disorder. Obsessive-compulsive disorder, depression, and anxiety are associated with the development of anorexia. Studies also show that patients with anorexia often have abnormally low levels of serotonin and norepinephrine and higher than normal levels of cortisol and vasopressin (Attia & Walsh, 2022a; Guarda, 2023; Moore & Bokor, 2022).

Individuals with bulimia are often impulsive, and negative emotions can trigger binge eating and purging. Genetics is a risk factor for bulimia, and patients with a first-degree relative, such as a parent or a sibling, with a history of an eating disorder, are more likely to develop bulimia. Childhood obesity or teen obesity, psychological or emotional issues (i.e., disinhibition or impairments in emotional self-regulation), including depression, anxiety disorders, or substance use disorders (SUDs), are all triggers for bulimia. Additionally, those individuals whom diet have a higher risk of developing bulimia; many will severely restrict calories between binge episodes. However, unlike anorexia, patients with bulimia are usually average or above-average weight. Several studies have also found altered brain structure and function in individuals with bulimia, including dysfunction in brain reward circuitry. In addition, the severity of illness appears to be associated with the degree of neural changes. However, it is unclear if these changes are etiologic or consequences of the disorder (Attia & Walsh, 2022c; Guarda, 2023; Jain & Yilanli, 2022).

BED was first recognized as a distinct disorder in the DSM-5 in 2013; it was formerly thought to be about personal choices and not an actual disorder. Unlike anorexia or bulimia, BED occurs more commonly in individuals with overweight and obesity, with 30% of individuals in weight-reduction programs experiencing BED. BED is also more prevalent in males and those who are older. Rigid eating habits, previous anorexia, and previous dieting can trigger BED. Traumatic events, physical abuse, perceived risk of abuse, stress, body criticism, history of childhood obesity, negative comments from others about their weight, low self-esteem, sexual abuse history, or potentially a genetic component can be associated with the development of BED. Several studies have found decreased inhibitory control and higher impulsivity in individuals with BED. Neuroimaging studies have found that individuals with BED are more responsive to food cues and demonstrate increased blood-oxygen-level-dependent activation in reward-related brain regions when presented with food stimuli (Attia & Walsh, 2022b; Guarda, 2023; Iqbal & Rehman, 2022).

Pathophysiology of Eating Disorders

The cause of eating disorders is multifactorial and includes a combination of biological, psychological, and sociocultural factors. The pathophysiology of each eating disorder is unique. Genetic factors appear to be the strongest in anorexia but are also present in bulimia and BED. Anorexia leads to a state of severe starvation and malnutrition. Although bulimia does not lead to near starvation, the patient can still have serious pathophysiological effects. The pathophysiology and complications of BED are due to the effects of obesity (Guarda, 2023).

Anorexia Pathophysiology

Several studies have linked anorexia nervosa with deficits in dopamine (i.e., eating behavior and reward) and serotonin (i.e., impulse control and neuroticism). In addition, there is differential activation of the corticolimbic system (i.e., fear and appetite) and diminished frontostriatal circuit activity (i.e., habitual behaviors). The lack of nutritional intake and availability with anorexia leads to various pathophysiological alterations and consequences. Medical complications associated with anorexia are directly attributable to weight loss and malnutrition, accounting for half of all deaths due to anorexia nervosa. This mortality rate is the highest among all mental illnesses. As weight loss occurs, fat storage is depleted, and muscle mass is further lost. Since there is little to no body fat, intolerance to cold and a lowered body temperature ensues. Nearly every system in the body is affected in severely malnourished individuals. The clinical manifestations include:

• hypothyroidism: since the thyroid does not have adequate nutrition to produce hormones, the patient may develop fatigue, dry skin, thinning hair, mental health issues, difficulty remembering things, muscle weakness, pain, infertility, and cardiac implications
• mental health issues: secondary to thyroid dysfunction, depression may develop early in the disease process and worsen as the hypothyroidism worsens
• infertility: with lower levels of thyroid hormones, ovulation, and the menstrual cycle can be altered
• cardiac implications: secondary to thyroid dysfunction, subsequent cardiac issues can arise, including bradycardia, chest pain (angina), heart failure (HF), cardiomyopathy (enlargement of the heart), decreased cardiac output (due to the HF), and increased "bad" cholesterol (low-density lipoproteins [LDL]; Attia & Walsh, 2022a; Mehler, 2022; Moore & Bokor, 2022)

Hypothyroidism is noted by low total thyroxine (T4) and low triiodothyronine (T3). Thyroid-stimulating hormone (TSH) is typically in the normal range, similar to euthyroid sick syndrome (ESS). ESS is characterized by abnormal thyroid function tests outside of pre-existing thyroid gland dysfunction. After recovery from the causative process (in this case, anorexia), the abnormalities should be reversible. In addition to those mentioned above, further cardiac problems may include a loss of cardiac muscle mass, arrhythmias, hypotension, and cardiac arrest, particularly as the disease progresses. With progression, the QT interval will be prolonged, leading to torsade de pointes, a life-threatening ventricular arrhythmia that may progress to ventricular fibrillation and cardiac arrest. Metabolic disturbances due to the lack of nutritional intake by those with anorexia include hypokalemia (serum potassium level less than 3.5 mEq/L), hypochloremia (serum chloride level less than 98 mEq/L), hypomagnesemia (serum magnesium level less than 1.5 mEq/L), hypocalcemia (serum calcium level less than 8.9 mg/dl), and hyponatremia (serum sodium level less than 135 mEq/L; Attia & Walsh, 2022a; Aytug, 2022; Halter, 2017). See Table 2 for signs and symptoms related to these conditions.

Table 2

Signs and Symptoms Related to the Metabolic Disturbances of Anorexia or Bulimia Nervosa

Metabolic Disturbance	Cause of Disturbance	Signs/Symptoms
Hypokalemia	Vomiting Diarrhea Laxative abuse Diuretic abuse Lack of nutritional intake	Muscle weakness Nausea/vomiting Sluggish bowel sounds Constipation Paralytic ileus Irregular heart rate Electrocardiogram (ECG) with flattened or inverted T-waves, depressed ST segment, or U-wave present Cardiac arrest
Hypochloremia	Vomiting Diarrhea Laxative abuse Diuretic abuse Lack of nutritional intake	Muscle cramps Muscle weakness Agitation Twitching Tetany Hyperactive deep-tendon reflexes Seizures, coma, or respiratory arrest with continued untreated hypochloremia
Hypomagnesemia	Vomiting Diarrhea Laxative abuse Diuretic abuse Lack of nutritional intake	Generalized weakness Muscle cramps Tachycardia Tremors Vertigo (dizziness) Ataxia (lack of muscle coordination with voluntary movements) Depression
Hypocalcemia	Vomiting Diarrhea Laxative abuse Lack of nutritional intake	Brittle bones Dry skin and hair Hypotension Hyperactive deep-tendon reflexes Prolonged ST segment Prolonged QT interval Decreased myocardial contractility Osteoporosis
Hyponatremia	Vomiting Diarrhea Laxative abuse Lack of nutritional intake	Nausea Vomiting Confusion Drowsiness Fatigue Muscle weakness, spasms, cramps Seizures Coma

(Attia & Walsh, 2022a; Halter, 2017; Klein & Attia, 2023)

Gastrointestinal (GI) disorders associated with anorexia include abdominal pain, delayed gastric emptying, and an enlarged or inflamed pancreas that leads to other symptoms discussed later. The pathogenesis of anorexia causes these GI symptoms and is not a different pathology unrelated to anorexia. Dermatologic issues related to anorexia include dry, cracked skin, loss of skin turgor, edema, lanugo (fine, downy hair over the body due to heat loss), and acrocyanosis (bluish discoloration of the hands and feet due to poor circulation). Reproductive system concerns include decreased estrogen, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). This hormone imbalance leads to ovulation failure, infertility, and amenorrhea (Attia & Walsh, 2022a; Halter, 2017; Klein & Attia, 2023).

Bulimia Pathophysiology

Even though bulimia does not lead to starvation, serious fluid and electrolyte imbalances can result from binging and purging food. Potential imbalances include hypokalemia, hyponatremia, or hypochloremia resulting in symptoms as listed in Table 2. Additionally, metabolic alkalosis can result from elevated bicarbonate levels in the blood. This state is evidenced by a blood pH above 7.45 and a bicarbonate level above 26 mEq/L caused by the excessive loss of acid in the GI tract from vomiting. Diuretic use can also promote metabolic alkalosis. Thiazide diuretics such as hydrochlorothiazide (HCTZ, Hydrodiuril) or loop diuretics such as furosemide (Lasix) cause fluid loss along with the loss of potassium, hydrogen, and chloride through the kidneys. The low serum potassium levels cause the kidneys to excrete hydrogen ions to conserve potassium. The potassium moves out of the cells, allowing hydrogen to move into the cells, resulting in alkalosis. Metabolic alkalosis can result in slow, shallow respirations that lead to hypoxemia (a low level of oxygen in the blood) in the early stages; then, as the condition progresses, respirations may increase to correct the hypoxemia. Long-term bulimia can lead to overall poor health outcomes such as hypertension, arrhythmias, severe tooth decay, gum disease, esophageal erosion and bleeding, gastric rupture due to repeated vomiting episodes, irregular periods, and mental health disorders such as anxiety, depression, personality disorders, SUD, or suicidal tendencies. Severe dehydration can lead to renal failure (Attia & Walsh, 2022c; Engel et al., 2023; Halter, 2017; Thomas, 2022).

BED Pathophysiology

BED has a similar pathophysiology as SUD. Research has found that BED occurs due to difficulty in reward processing and inhibitory control, emotional regulation, and emotional awareness. Neuroimaging studies have shown hyperactivity of the medial orbitofrontal cortex and hypoactivity in the prefrontal network in individuals with BED. The pathophysiology of BED is mainly related to weight gain and subsequent obesity. The increased weight leads to hypertension, elevated cholesterol, and triglycerides leading to cardiovascular disease, type 2 diabetes, gallbladder disease, sleeping disorders such as obstructive sleep apnea, dental problems due to the foods that are chosen during binges such as high-fat, high-carbohydrate foods, and coronary artery disease (CAD). Mental health concerns include depression and suicidality due to weight gain and the self-dissatisfaction associated with binge eating (Guarda, 2023; Halter, 2017; Iqbal & Rehman, 2022). For more on obesity complications, please see the Bariatric Surgery NursingCE module.

Screening

The US Preventative Services Task Force (USPSTF, 2022) notes that evidence is insufficient to recommend for or against screening for eating disorders in patients (age 10 and older) with a normal or high BMI. However, eating disorders can be challenging to identify and often go undiagnosed. In addition, an eating disorder cannot be predicted by assessing weight or BMI. Given the prevalence of eating disorders in adolescents and young adults, the American Academy of Pediatrics (AAP) recommends that pediatricians screen all preteens and adolescents for eating disorders by discussing eating patterns and body image (Hornberger et al., 2021). Similarly, the American Psychiatric Association (2023) recommends screening all individuals for an eating disorder as part of a routine psychiatric evaluation. HCPs should also screen patients at high risk for eating disorders, including the following:

• history of childhood adversity or trauma
• young adults
• transgender individuals
• females
• athletes
• patients with signs and symptoms of eating disorders (e.g., rapid weight loss, amenorrhea, bradycardia, preoccupation with eating and appearance)
• depression or anxiety
• rigidity or perfectionism (Guarda, 2023)

HCPs can screen patients informally by asking about concerns about weight, body image, body shape, and eating behaviors. Various screening tools are also available to identify patients who need further evaluation. The USPSTF recommends the SCOFF questionnaire, a 5-item tool that is easy to administer (Guarda, 2023). The HCP-administered questions include (Morgan et al., 1999):

• Do you make yourself sick because you feel uncomfortably full?
• Do you worry you have lost control over how much you eat?
• Have you recently lost more than one stone (14 lbs or 6.35 kg) in a three-month period?
• Do you believe yourself to be fat when others say you are too thin?
• Would you say that food dominates your life?

A positive screen is denoted by a "yes" to two or more questions and should prompt further assessment. This cutoff has been determined to have good sensitivity and specificity for detecting bulimia and anorexia nervosa in young females (Morgan et al., 1999).

A second screening tool that can be used is the 5-item Easting Disorder Screen for Primary Care (ESP), with a sensitivity of 97% to 100% and a specificity of 40% to 71%. A positive response is denoted by two or more abnormal answers to the following questions (Guarda, 2023):

• Are you satisfied with your eating patterns? (No is abnormal).
• Do you ever eat in secret? (Yes is abnormal).
• Does your weight affect the way you feel about yourself? (Yes is abnormal).
• Have any members of your family suffered from an eating disorder? (Yes is abnormal).
• Do you currently suffer with or have you ever suffered from an eating disorder? (Yes is abnormal).

Additional screening options include the Eating Attitudes Test (EAT), one of the most widely used self-reporting screening instruments. A 26-item short version (EAT-26) has been translated into many languages and is deemed valid and reliable. The Ch-EAT is a modified version for children ages 8 to 13. The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire is a self-reported instrument to screen and diagnose mental health disorders, with a category for bulimia nervosa and BED (Guarda, 2023).

Diagnosing Eating Disorders

Anyone can suffer from an eating disorder, and families are often unaware of the problem. The person is often aware that their behavior is abnormal and may isolate themselves socially, deny that they have an issue when confronted, or hide their eating habits from others. Research indicates that many people with eating disorders will go untreated; less than 3% of those with an eating disorder during adolescence are diagnosed and treated. Failure to treat can lead to death, particularly with anorexia (Attia & Walsh, 2022a, 2022b, 2022c; Guarda, 2023). While there can be non-distinct manifestations of eating disorders, such as weight fluctuation, others are more recognizable. Symptoms of anorexia, bulimia, and BED can be seen in Table 3.

Table 3

Common Symptoms and Behaviors of Eating Disorders and Diagnostic Criteria per DSM-5-TR

Eating Disorder	Common Symptoms and Behaviors	Diagnostic Criteria from DSM-5-TR
Anorexia Nervosa	restricted food intake compulsive exercise overuse of laxatives extreme weight loss preoccupation with weight, food, or diet dizziness constipation feeling cold sleep disturbances irregular menstruation muscle weakness poor wound healing thin hair delayed puberty lanugo hormonal imbalance headaches high cholesterol levels osteoporosis bradycardia hypothermia extreme fatigue anemia anxiety	limitation of caloric intake leads to a markedly decreased body mass index (BMI) or weight compared to similar individuals of the same sex, age, or height an extreme dread of an increase in weight or of being overweight, or actions that prevent weight gain, despite being severely underweight distorted perception of their body and weight, an exaggerated impact of their weight on their self-regard, or a consistent disregard or lack of awareness of the consequences of their health condition or their behavior The patient may display one of two types: restricting: the limitation of food and weight through diet, exercise, and caloric restriction binge-eating/purging: weight loss is obtained through repeated episodes of binging followed by the misuse of laxatives/enemas or vomiting
Bulimia Nervosa	large amounts of food disappearing eating in private or secrecy frequent use of the bathroom after meals smelling like vomit erosion of tooth enamel lack of control over eating alternating between overeating and fasting weight fluctuations broken vessels in the eye enlarged glands in the neck chronic dehydration gastric reflux peptic ulcers esophageal inflammation infertility electrolyte imbalances resulting in cardiac arrhythmia, MI, or death oral trauma to the mouth or throat from vomiting	repeated occurrences of binge eating, defined as: the ingestion of a much larger quantity of food within a window of time (i.e., typically no more than 2 hours) than a typical person would ingest at the same time perception of not being able to regulate the quantity or selection of food consumed during the occurrence in response, individuals will attempt to counteract the eating occurrences described above and avoid an increase in weight through purging, which may include vomiting, fasting, exercise, or medication to empty the gut, such as a laxative or diuretic the eating occurrences and purging are experienced once or twice weekly for 12 weeks or more the patient's body weight and size directly inform their self-regard and self-esteem the symptoms do not coincide with occurrences of anorexia nervosa
BED	eating even when full stockpiling food to eat secretly when alone eating normal amounts in public and gorging in private feelings of stress or anxiety that are relieved by eating feeling numb when binging unable to achieve satiation (feeling full), regardless of the amount eaten gallbladder disease type 2 diabetes sleep apnea muscle or joint pain depression or anxiety cardiovascular disease hypertension	repeated occurrences of binge eating, as defined above, at least once a week for three months patients sense a lack of control over eating in addition, three or more of these characteristics must be present: eating until the point of discomfort not eating in front of others due to humiliation at the quantity of food being consumed eating significantly faster than typical eating significant quantities despite no sense of hunger feelings of shame, sadness, repulsion, or self-reproach following the occurrences of eating the eating occurrences are experienced once or more per week for 12 weeks or more the eating occurrences cause significant anguish the symptoms do not coincide with occurrences of anorexia nervosa or responsive purging BED is differentiated from bulimia by the absence of compensatory behaviors (i.e., excessive exercise, fasting, self-induced vomiting, and use of laxatives)

(American Psychiatric Association, 2022; Attia & Walsh, 2022a, 2022b, 2022c)

For suspected eating disorders, HCPs should obtain a patient history focusing on eating patterns, attitudes towards eating, changes in food repertoire (e.g., breadth of food variety, narrowing or eliminating food groups), purging behaviors or medication use, exercise, and appearance. A family history of obesity, eating disorders, and psychiatric disorders such as depression, anxiety, or SUD should also be completed (NEDA, n.d.-a). The American Psychiatric Association (2023) guidelines recommend the examination should include the following:

• physical examination, including weight, height, body mass index (BMI), growth chart assessment for children or adolescents, skin condition, hair distribution or loss, evidence of self-abuse/injury, and cardiovascular/peripheral vascular function
• body temperature
• orthostatic blood pressure
• oral examination (with a focus on dental condition if vomiting is suspected)
• laboratory tests
  • complete blood count (CBC)
  • comprehensive metabolic profile (CMP)
    • blood glucose
    • electrolytes, including magnesium and phosphate
    • bicarbonate
    • blood urea nitrogen (BUN)
    • creatinine
    • liver enzymes (ALT, AST, ALP)
    • total bilirubin
  • ECG
  • urinalysis
    • ketones
    • urine specific gravity
  • thyroid screen
    • T3
    • T4
    • TSH (American Psychiatric Association, 2023; Iqbal & Rehman, 2022; Jain & Yilanli, 2022; Moore & Bokor, 2022; NEDA, n.d.-a)

If there is an uncertain diagnosis, further testing might include an estradiol level (lowered estrogen levels are expected with anorexia), erythrocyte sedimentation rate (ESR), and radiographic studies of the brain, upper GI, or lower GI series. A dual-energy x-ray absorptiometry (DEXA) scan for bone density measurement should be done for extremely underweight females with sustained amenorrhea. Urine pregnancy, LH, FSH, and prolactin testing should be completed in those without a menstrual period for over six months. The primary HCP typically conducts screening for mental health disorders, and referral to a mental health professional may be indicated (Halter, 2017; Iqbal & Rehman, 2022; Jain & Yilanli, 2022; Moore & Bokor, 2022; NEDA, n.d.-a).

Avoidant/Restrictive Food Intake Disorder

ARFID, previously known as a selective eating disorder, is characterized by limiting the amount or type of foods eaten without a distorted body image or fear of gaining weight. The diagnostic criteria include the following:

• food restriction that leads to significant weight loss, failure to grow in children, significant nutritional deficiency, and/or marked disturbance of psychosocial functioning      
• food restriction is not from the unavailability of food, cultural practices (i.e., fasting), physical illness, medical treatment (i.e., chemotherapy), or another eating disorder
• no evidence of a disturbed perception of body image or shape (American Psychiatric Association, 2022; Guarda, 2023)

Pica

Individuals with pica tend to eat nontoxic materials (i.e., wool, chalk, dirt, paper) that is not considered developmentally appropriate. Pica does not usually cause serious harm; however, some complications could include intestinal obstruction, lead poisoning, or parasitic infection. Usually, pica lasts for several months and resolves independently, rarely impairing social functioning. Swallowing objects to cause self-harm is not considered pica. The diagnostic criteria include the following:

• persistently eats nonnutritive, nonfood material for ≥ 1 month
• ingestion is inappropriate for the patient's developmental level
• ingestion is not part of a cultural tradition
• if ingestion occurs in a patient with another disorder (i.e., autism, intellectual disability) or condition (i.e., pregnancy), or it is sufficiently persistent and severe to warrant treatment (American Psychiatric Association, 2022; Guarda, 2023)

Rumination Disorder

Rumination disorder is characterized by the effortless regurgitation (i.e., no nausea or involuntary retching) of recently ingested food into the mouth after meals. The individuals can spit out the food or rechew and swallow the food. This regurgitation occurs several times a week, usually daily. HCPs can often observe regurgitation directly. The diagnostic criteria include the following:

• repeated regurgitation of food for ≥ 1 month
• GI disorders (i.e., gastroesophageal reflux) or other eating disorders have been excluded
• if regurgitation occurs in a patient with another disorder, it is severe enough to warrant specific treatment (American Psychiatric Association, 2022; Guarda, 2023)

Other Specified or Unspecified Eating Disorders

Other specified or unspecified eating disorders occur when symptoms cause distress or impair psychosocial functions but do not meet the full criteria for an eating disorder. The DSM-5-TR further identifies the following other specified eating or feeding disorders (American Psychiatric Association, 2022):

• Atypical anorexia nervosa occurs when the individual maintains a BMI in the normal range (i.e., ≥ 18.5 kg/m²) despite meeting all the other diagnostic criteria for anorexia.
• Bulimia nervosa of low frequency or low duration occurs when the individual meets all criteria for bulimia except for frequency (once or more per week for 12 weeks or more). Instead, these behaviors occur less than once per week and/or for less than three months.
• BED of low frequency or limited duration occurs when the individual meets all criteria for BED except for frequency (once or more per week for 12 weeks or more). Instead, these episodes occur less than once per week and/or for less than three months.
• Purging disorder occurs when there are recurrent episodes of purging to influence body shape or weight in the absence of binge eating.
• Night eating syndrome is characterized as episodes of binge eating at night (i.e., eating after awakening or overeating after the evening meal). Medication effects, SUD, general medical disorders, or changes in sleep-wake cycles do not explain night eating. This person is aware of their behavior but has no other symptoms of BED.

Treatment Interventions for Eating Disorders

Treatment for all eating disorders begins with an accurate diagnosis and recognizing the mitigating circumstances that may have led to the condition, such as an underlying mental health disorder. A mental health condition can be a risk factor for developing an eating disorder or a result of the disorder. So, a clear diagnosis and prompt treatment of the mental health aspects of eating disorders is vital. A team approach is taken for eating disorders, especially with anorexia. The complexity of the disease and its effects on multiple body systems necessitates a multidisciplinary approach to meet the patient's needs fully. Ongoing psychotherapy, nutritional counseling, and monitoring of physiological needs are required with each. A closer look at the treatment for each disorder is below (Halter, 2017; NEDA, n.d.-a).

Anorexia Treatment

The American Psychiatric Association (2023) makes the following recommendations for the treatment of anorexia nervosa:

• Individualized weight gain and target weight goals should be set weekly for patients who require nutritional rehabilitation and weight restoration.
• Adults should be treated with eating disorder-focused psychotherapy, including normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects (i.e., fear of weight gain, body image disturbance).
• Adolescents with an involved caregiver can be treated with eating disorder-focused family-based treatment that includes caregiver education aimed at normalizing eating and weight control behaviors and restoring weight.

Hospitalization is often required to meet the immediate needs of patients with anorexia nervosa. These patients may present emergently with heart arrhythmias, dehydration, electrolyte imbalances, or a psychiatric crisis. If the patient cannot eat upon hospitalization, they may be admitted for intensive treatment and/or malnutrition. Patients may be placed in a facility specializing in eating disorders for intensive therapy over a longer period. Although weight gain is important, restoring weight by refeeding patients too rapidly can lead to refeeding syndrome, which can be fatal. Refeeding syndrome is a metabolic disturbance when too much food is eaten during the initial four to seven days following a malnutrition event. This results in a sudden shift in electrolytes as the body shifts from fat to carbohydrate metabolism, causing insulin secretion to increase. Electrolyte imbalances that can occur with refeeding syndrome include hypophosphatemia, abnormal sodium and fluid levels, thiamine deficiency, hypomagnesia, and hypokalemia (Moore & Bokor, 2022; Yager, 2022).

Medical care for patients with anorexia nervosa focuses on immediate threats to health, including electrolyte imbalances, acid-base imbalances, and rehydration. In more severe cases, the patient may require a feeding tube. Mortality rates for severe cases of anorexia are as high as 10%. However, with appropriate treatment, half of all patients regain most, or all of the lost weight, and endocrine and other complications are reversed. Approximately 25% of patients have intermediate outcomes and may relapse, while the final 25% have poor outcomes, including relapse and persistent mental and physical complications (Attia & Walsh, 2022a; Yager, 2022).

The primary goal of treatment is to achieve a healthy weight. Most aspects of anorexia can be corrected by maintaining a healthy weight and good nutrition. The primary HCP, mental health professional, dietician or nutritional expert, and family or friends will all be involved in the healing process for patients with anorexia. Individual and family-based psychotherapy, specifically cognitive-behavioral therapy (CBT), is recommended for these patients. Teenagers, in particular, need family-based therapy to assist them in making good choices for their health and engaging the family in their recovery. This treatment helps the caregivers learn to communicate therapeutically with the teen with anorexia and aids in promoting weight restoration. The secondary goal of treatment for anorexia is to help change the patient's beliefs and thoughts that led to restrictive eating in the first place. Individual psychotherapy is used to this end, and while teens benefit as well, adult patients seem to respond best to individual CBT. Psychotherapy treatment should continue for a year after restoring weight (Attia & Walsh, 2022a; Yager, 2022).

Nutritional supplementation is often used with behavioral therapy and clear weight-restoration goals. HCPs should consider starting supplementation with approximately 30 to 40 kcal/kg/day, with a goal of 1.5 kg/week of weight gain during inpatient treatment and 0.5 kg/week during outpatient treatment. Although solid foods are best, liquid supplementation may also be needed. Since many patients with anorexia have bone loss, HCPs should consider supplemental calcium (1200 to 1500 mg/day) and vitamin D (600 to 800 IU/day; Attia & Walsh, 2022a).

Medications are not typically used to treat anorexia; however, antidepressants or other psychiatric medications may be useful in treating underlying or subsequent mental health disorders. Olanzapine (Zyprexa) up to 10 mg orally daily may be used to aid with weight gain. For patients with a comorbid psychiatric disorder, a combination of olanzapine (Zyprexa) with a selective serotonin reuptake inhibitor (SSRI) is recommended. If SSRIs are not effective, HCPs should consider a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are not recommended due to concerns for cardiotoxicity in malnourished patients. In addition, bupropion (Wellbutrin) is contraindicated in patients with eating disorders due to the risk of seizures. One of the greatest barriers to treating anorexia is the patient's perception that they do not need treatment; they may see their weight as a lifestyle choice or have an unrealistic fear of gaining weight. Due to these firmly held beliefs, relapses are common, particularly during times of stress. Therefore, ongoing monitoring of the mental and physical indications of anorexia is needed to ensure lifetime success and optimal patient outcomes (Attia & Walsh, 2022a; Halter, 2017; Moore & Bokor, 2022).

Bulimia Treatment

The American Psychiatric Association (2023) makes the following recommendations for the treatment of bulimia nervosa:

• Adults should be treated with eating disorder-focused CBT and an SSRI (e.g., fluoxetine [Prozac] 60 mg daily) either initially or at six weeks if the response to psychotherapy is minimal.
• Adolescents with an involved caregiver should be treated with eating disorder-focused family-based treatment.

The team approach to treating bulimia is effective. In addition, the use of psychotherapy and antidepressants is noted as highly effective in overcoming the disorder. A dietician experienced in eating disorders can be a useful team member along with a primary care HCP and mental health professional. Psychotherapy is generally focused on individual CBT. Therapy usually involves 16 to 20 individual sessions over four to five months. CBT eliminates binging and purging in 30% to 50% of patients. Interpersonal psychotherapy may also help teach communication and problem-solving skills with personal relationships, including family and friends. The patient needs support to normalize their eating patterns and address the underlying feelings that led to the disorder initially. These behaviors must be replaced by healthy and positive behaviors supporting a healthy weight and nutritional intake. Teenagers with bulimia may benefit from family therapy to support the caregivers in recognizing unhealthy behaviors and guiding them to healthier habits and behaviors. The entire family is often involved in the underlying issues that lead to bulimia behaviors and should understand the implications for the teen's future health and how to support the development of healthy behaviors (Attia & Walsh, 2022c; Halter, 2017; Yager, 2022).

The antidepressant most often used in patients with bulimia is fluoxetine (Prozac). Fluoxetine (Prozac) is an SSRI that may help patients with bulimia, even where depression is not present. It is the only medication approved by the Food and Drug Administration (FDA) to treat bulimia. Citalopram (Celexa) and sertraline (Zoloft) have also been shown to reduce symptoms of bulimia nervosa. Evidence for other medication classes in treating bulimia is limited. Trazadone (Desyrel) has been shown to reduce the frequency of binge-eating episodes significantly. Due to potential side effects, monoamine oxidase inhibitors (MAOIs) and TCAs are reserved for resistant cases. Buproprion (Wellbutrin) is contraindicated in patients with eating disorders due to the risk of seizures (Attia & Walsh, 2022c; Jain & Yilanli, 2022; Yager, 2022).

Nutritional education will be focused on a healthy eating plan that helps to decrease hunger and cravings. Consuming small nutritious meals and snacks throughout the day helps to keep the patient satisfied. This approach is less restrictive than three meals that are more restrictive in caloric content and quantity of food. Bulimia is not usually treated in the hospital and does not usually result in an emergency department visit. Rather, programs that offer day treatments or outpatient therapy are preferred. Treatment challenges can include periods of binging and purging, often triggered by stress or life events. Lifestyle changes and home remedies to incorporate into the treatment plan include being cautious with exercise, sticking to the treatment plan developed by the healthcare team, empowerment through education, getting the right nutrition daily, nurturing caring relationships that can support the journey of recovery, and resisting urges to fall back into unhealthy habits like daily weights or looking in the mirror frequently. Dietary supplements and herbal products are tempting but can be part of the unhealthy weight loss cycle. Therefore, the use of any of these products should be discussed with the healthcare team to determine if appropriate (Attia & Walsh, 2022c; Jain & Yilanli, 2022; Yager, 2022).

Caregivers of patients with bulimia may blame themselves for their child's disorder. Focusing on helping the patient is most important during recovery, and they should be taught communication strategies to support optimal outcomes. Suggestions include asking the teen to participate in family activities after eating to reduce the temptation to purge, listening to the patient and allowing them to express their feelings, planning regular family mealtimes, and communicating about concerns without placing blame. Eating disorders affect the entire family, and learning to communicate is very important. Finally, relapse is possible, and the patient should be aware of this. When a patient falls back into the binge-purge cycle, visiting the primary HCP, mental health professional, and/or dietician can help stop the cycle and get back on the road to recovery. If relapse occurs, rather than feeling guilty, it is important to be empowered to seek help (Attia & Walsh, 2022c; Halter, 2017; Yager, 2022).

BED Treatment

The American Psychiatric Association (2023) makes the following recommendations for the treatment of BED:

• Patients with BED should be treated with eating disorder-focused CBT or interpersonal therapy, either individual or group sessions.
• Adults with BED who prefer medication or have not responded to psychotherapy alone should be treated with an antidepressant or lisdexamfetamine dimesylate (Vyvanse).

The primary goals for treating BED are reducing the binges, controlling eating habits, and ensuring proper nutrition. Since BED may be interwoven with mental health disorders such as depression and anxiety, these issues must be addressed if they are present. Psychotherapy may be done individually or in a group setting. CBT, interpersonal therapy, and dialectical behavioral therapy have all been identified as useful components of BED management. CBT can aid in developing coping mechanisms to avoid binge eating, while interpersonal psychotherapy focuses on relationships with others that may trigger binge episodes. Dialectical behavior therapy can help the patient learn skills to tolerate stress better and regulate emotions, thus lowering the desire to binge (Attia & Walsh, 2022b; Iqbal & Rehman, 2022).

Medications are a vital part of BED management. Lisdexamfetamine dimesylate (Vyvanse), approved for attention-deficit hyperactivity disorder originally, was approved by the FDA to treat moderate to severe BED in adults. Lisdexamfetamine dimesylate (Vyvanse) is a stimulant and can be habit-forming or abused. Common side effects include insomnia and a dry mouth; more serious side effects include tachycardia, hypertension, and palpitations. Central nervous system (CNS) side effects can include irritability, anxiety, jitteriness, emotional liability, nightmares, or tic disorders. Erectile dysfunction, urinary tract infection, dyspnea, fever, GI disturbances, and hyperhidrosis can occur. Cardiovascular events have occurred, including sudden death, stroke, and MI. Drug-drug interactions can occur with lisdexamfetamine dimesylate (Vyvanse), including acebrophylline (Adbrophyll), Iobenguane I-123 (AdreView), MAOIs such as selegiline (Zelapar), isocarboxiazid (Marplan), tranylcypromine (Parnate), and phenelzine (Nardil). These drugs are contraindicated with lisdexamfetamine dimesylate (Vyvanse) and should not be administered simultaneously (Pope, 2023). Other medications that may reduce the symptoms of BED include topiramate (Topamax), an antiepileptic drug that decreases binges associated with BED. Topiramate (Topamax) side effects include dizziness, drowsiness, difficulty concentrating, and nervousness. Other antidepressants, including SSRIs, may reduce binge-eating episodes (Attia & Walsh, 2022b; Iqbal & Rehman, 2022).

Weight loss programs are not typically indicated with BED until the disorder is treated. Dieting can trigger further episodes of binge eating and/or further eating disorder development, such as anorexia or bulimia. Weight-loss programs should be done under the supervision of the entire healthcare team. People with eating disorders may misuse dietary supplements and herbals, and any use should be discussed with the primary HCP. The focus should be on the maintenance of the treatment plan. Eating plans developed by the dietician should be followed meticulously. Foods in the home should be limited to healthy choices allowed in the eating plan; junk foods and high-fat, high-carbohydrate snacks should be kept out of the house. Consistent physical activity is an important component of recovery from BED. The healthcare team should approve exercise plans, as they can help reduce stress and improve overall mood. A strong support team that is aware of the treatment plan and goals for health can improve compliance. Living with BED can be challenging and requires a strong support system. The person suffering from BED should avoid self-criticism, identify situations that trigger binges and avoid them, find positive role models in their life, develop strong relationships with trusted friends and family members, and find healthy ways to self-nurture such as yoga, walks, meditation, or massages. Journaling is another helpful tool for insight into feelings and recognizing stressors (Attia & Walsh, 2022b; Halter, 2017; Iqbal & Rehman, 2022).

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