By Ni Ketut Alit A Faculty Of Nursing Airlangga University Sli de 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 (10 th 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.

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REVIEW

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Body Weight

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Body Mass Index ( BMI)

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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 Sli de 4

 ◦ ◦ ◦ ◦ 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 Sli de 5

 ◦ 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 Sli de 6

   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 Sli de 7

 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 Sli de 8

 ◦ 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 Sli de 9

 ◦ ◦ 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” Sli de 11

 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 Sli de 12

 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 Sli de 14

 ◦ ◦ 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 Sli de 15

   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 Sli de 16

  ◦ ◦ ◦ 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 Sli de 17

  ◦ ◦ ◦ 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 Sli de 18

  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 Sli de 19

  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” Sli de 20

  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  bingeing Laxatives and diuretics greater hunger and Almost completely fail to reduce the number of calories consumed Sli de 21

 ◦ Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating Over time, however, a cycle develops in which purging  bingeing  purging… Sli de 22

 ◦ ◦ 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 Sli de 23

 ◦ ◦ ◦ ◦ ◦ ◦ ◦ 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 Sli de 24

 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 Sli de 25

 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 Sli de 26

 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 Sli de 27

 ◦ 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 Sli de 28

 ◦ 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 Sli de 29

 ◦ 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 Sli de 30

 ◦ ◦ 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 Sli de 31

 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 Sli de 32

 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 Sli de 33

 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 Sli de 35

 ◦ 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 Sli de 36

 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 Sli de 37

 ◦ ◦ 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 Sli de 38

 ◦ 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) Sli de 39

 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 Sli de 40

 ◦ ◦ 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 Sli de 41

 ◦ ◦ ◦ The initial aims of treatment for anorexia nervosa are to: Restore proper weight Recover from malnourishment Restore proper eating Sli de 42

   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 Sli de 43

 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 Sli de 44

 ◦ 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 Sli de 45

 ◦ ◦ Another focus of treatment is changing family interactions Family therapy is important for anorexia The main issues are often separation and boundaries Sli de 46

  ◦ 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 Sli de 47

 ◦ ◦ 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 Sli de 48

 ◦ ◦ 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 Sli de 49

  Treatment programs are relatively new but have risen in popularity Treatment is frequently offered in specialized eating disorder clinics Sli de 50

  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 Sli de 51

 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 Sli de 52

 ◦ 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 Sli de 53

 ◦ 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 Sli de 54

 ◦ 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 Sli de 55

   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 Sli de 56

  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 Sli de 57

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