Eating Disorders: Anorexia and Bulimia

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The following course content

Introduction: Glossary of Terms 

Eating Disorders Overview: 

• Restrictive Anorexia: Severely limits the amount and type of food they consume, resulting in extreme weight loss; has body image disturbances/ dysmorphia 

• Binge Purge Anorexia/ Bulimia Nervosa: Greatly restricts the amount and type of food they consume. But they also have binge-eating and purging episodes. They may eat large amounts of food in a short time and then intentionally vomit or use laxatives or diuretics to get rid of what they consumed. 

• Atypical Anorexia: The patient meets the qualifications of anorexia nervosa but does not have a BMI equal to being underweight. Patients with atypical anorexia may experience a large amount of weight loss, and still be overweight/ obese on a BMI chart. 

• Avoidant Restrictive Food Intake Disorder (ARFID): Intentional limiting of food intake; not related to distorted body image or desire to lose weight. In this eating disorder, the decision to limit food intake is due to other concerns, such as a fear of choking on certain foods, or avoidance of certain foods based on their texture or color and consistency. This specific eating disorder may be the result of an earlier trauma, such as an episode of forced feeding or food insecurity. Left untreated, this eating disorder can progress to malnutrition and cardia arrest. (3) 

• Binge-Eating Disorder (BED): This disorder is characterized by binge eating large amounts of food, eating past the point of fullness, and often eating alone. The disorder is defined as binge eating at least once weekly for a period of three months. The eating disorder is often associated with (patient) feelings of guilt, shame, despair, and extremely low self-esteem. (4) 

• Eating Disorder or Disordered Eating: The term disordered eating (versus the term eating disorder) reflects the “gray area” between what is considered normal eating patterns and a so-called eating disorder. The severity and frequency of behaviors associated with a true eating disorder are less but may still include restrictive or compulsive eating and rigid eating patterns. (5) 

Defining Eating Disorders 

Eating disorders can be defined as any abnormal behaviors, related to eating, that adversely affect ones physical and/or mental health.  Such behaviors may include either extreme- eating too much food or eating too little food- and left unaddressed/untreated, these behaviors can severely impact a person’s overall health and well-being.  Anxiety disorders, substance abuse and underlying depression may also be present for persons suffering with eating disorders, further compounding the effects of severity of illness. 

The term anorexia, in and of itself, simply means a loss of appetite. Anorexia may occur as the results of many medial conditions, medication side effects, anesthesia, pain and so forth. Conversely, anorexia nervosa refers to persons who intentionally starve themselves, despite feeling hunger. In the medical community, doctors will diagnose a patient as having anorexia if they have lost 15% or more of their ideal body weight. (6) 

Anorexia can be divided into two main subtypes. As mentioned previously, both types involve irrational fears of weight gain, but the behaviors associated with these eating disorders vary greatly on the amounts of food consumed and the behaviors surrounding both quality and quantity of food products, as well as attempts at elimination of excessive calorie intake. (7) 

• Restrictor Subtype: Noted by the severe limiting of both calories and quantity of food and fluids. This eating disorder is based on irrational fears of weight gain. 

• Binge/Purge Subtype: Noted by a substantial increase in volume of food intake (binge), followed by intentional elimination of the food (possibly through self-induced vomiting, laxatives and diuretics; purge) 

Epidemiology of Eating Disorders 

According to the website, National Association of Anorexia Nervosa and Associated Disorders (ANAD), here are some noteworthy statistics on eating disorders (8): 

• An estimated 9% of the U.S. population, or 28.8 million Americans, will have an eating disorder in their lifetime. 

• 15% of women will suffer from an eating disorder by their 40s or 50s 

• Fewer than 6% of people with eating disorders are medically diagnosed as “underweight.” 

• Anorexia has the highest case mortality rate of any mental illness. 

• 10,200 deaths each year are the direct result of an eating disorder—that’s one death every 52 minutes. 

With regards to the LGBTQIA population, this community was noted to be at a higher risk than the heterosexual population, with a noted 3x higher rate of having an eating disorder when compared to their heterosexual peers. Additionally, approximately 75 percent of transgender college students with a known eating disorder have attempted suicide. A percentage of transgendered persons have reported using an eating disorder to “modify or change” their physical appearance without the use of prescription hormone therapy. Eating disorders, in these cases, were used to reduce weight, that resulted in reduction of body development (normal fat distribution curves) and to induce amenorrhea.  

In the athlete population, eating disorders / disordered eating patterns were noted, in both men and women, most notably in “weight dependent” sports (mandatory weigh- ins such as in boxing tournaments, and weight dependent sports that have “weight specific” ranking (an athlete must weigh a certain amount to compete in a certain weight class; anything above this cut point on the scale would be grounds for elimination from a tournament). 

Finally, in the veteran population, eating disorders are often present, as this population engages in weight loss behaviors to “make weight” goals to qualify for service positions. Strenuous components of military training, including fitness requirements, often exacerbate patterns of disordered eating. Additionally, the ongoing stress levels of combat, trauma, and PTSD are attributed to increasing rates of atypical anorexia.  

Suffice to say, eating disorders are present in all walks of life. As healthcare professionals, we are in a unique position as front-line workers, to screen for these behavioral patterns and initiate appropriate, often lifesaving treatment.  

Pathophysiology of Anorexia and Bulimia 

It is believed that patients suffering from anorexia nervosa and associated eating disorders are dealing with numerous aspects of altered brain functioning, further impacted by environmental factors. There may be an underlying depressive disorder or a generalized anxiety disorder, which accounts for some of the behaviors associated with eating disorders in general (preoccupation with body image, distress over normal weight gains, and poor (suboptimal) coping skills related to outside “trauma” (bullying, teasing over appearance). (9) 

Brain Function 

Studies have shown the presence of altered brain function in patients with confirmed eating disorders, such as deficits in neurotransmitters often associated with eating behaviors and impulse control. The neurotransmitter dopamine, for example, is known to affect the areas of with pleasure and reward, as they related to behaviors. Serotonin, on the other hand, is associated with mood, and appetite. Both hormones are known as “happy hormones” with relation to their effects on positive emotions and mood. (10,11) 

Radiological studies, especially the neuroimaging results found with a diffusion weighted magnetic resonance imaging, have shown unique variances in the brain structures of patients suffering from these eating disorders. It is noteworthy to mention the observed changes on these studies, as influenced by diet, lipid and calorie intake (profound malnutrition) and associated neuro-pathophysiology, did improve when the patient’s weight and nutritional status were successfully treated.  Noted changes, in no particular order, are as follows: 

• Gray and white matter reduction indirect relation to the extent of malnutrition at time of studies 

• Reduction of the frontoparietal portion of the brain 

• Regionally decreased cortical thickness  

• Increased cerebrospinal fluid   

• Neuronal cellular degeneration 

• Altered neural activity in frontal, parietal, temporal and occipital lobes 

• Altered activity in the amygdala, thalamus, and cerebellum 

Causes 

Anorexia nervosa is a complex condition. As such, there is usually a combination of factors that may contribute to its occurrence (12). 

• Mental health issues such as overall emotional health and well-being. Many persons diagnosed with anorexia nervosa are thought to have difficulties in developing relationships, suffering from self-esteem issues.  

• Peer pressure/ societal influence. Teasing or bullying over one’s physical appearance may contribute to disorder eating patterns 

• Trauma physical/sexual abuse results in painful emotions and a feeling of loss of control. Anorexia nervosa provides a strong feeling of “being in control”. 

• Genetics: eating disorders often occur when the person has first degree relatives with an eating disorder medical history 

• Chemical changes in the brain: neurotransmitters can affect impulse regulation, as well as appetite and mood (Serotonin and dopamine) 

From a statistics standpoint (as will be discussed in this course), eating disorders are present worldwide and can affect persons of all ages, ethnicities, and genders. This course identifies the presence of eating disorders in some unique categories that may suggest the input of additional members of the treatment team.  

Clinical Signs and Symptoms 

Signs and symptoms of anorexia nervosa are multifactorial and may be the result of physical findings as well as behavioral or mental health influences. They are as follows (13): 

• Intense, obsessive fear with weight gain 

• Distorted body self-image 

• Hyper focused interest in foods, diets and calorie counting 

• Denial of a low body weight or dietary intake restriction 

• Intentional vomiting and misuse/overuse of laxatives 

• Intense/ excessive exercise routines 

• Noticeable change in eating habits and behaviors (elimination of certain foods/food groups) 

• Wearing layers of clothing/ excessively loose clothing to provide extra warmth and/or conceal weight loss 

• Significant weight loss over weeks/months 

• Inability to maintain appropriate body weight for growth charts (height/weight/BMI) 

• Going to the bathroom immediately upon finishing a meal 

• Sudden changes in food preferences, including elimination on entire food groups 

• Noticeable changes in eating habits, such as eating foods in a certain order, or frequently rearranging food on a plate (to give the appearance that food has been eaten) 

As weight loss continues and nutritional deficiencies (malnutrition) emerge, the following physical symptoms may become noticeable: 

• Extreme fatigue 

• Dizziness progressing often to actual syncopal episodes 

• Cardiac abnormalities/ dysrhythmias 

• Hypotension 

• Absent or irregular menstrual periods 

• Muscle weakness/ loss of muscle mass 

• Hair loss, tooth and gumline decay, dry skin 

• Poor (delayed) wound healing; frequent infections/ illnesses  

Case Scenario 

Reflect on the following case scenarios: 

• Your patient is experiencing frequent, irregular menstrual cycles. In addition to a suspected eating disorder, what other conditions may be affecting their menstruation? 

• Your patient is complaining of extreme fatigue, regardless of their food intake. What nursing interventions could be performed to learn more about their complaint? 

• Your adolescent patient is complaining of fatigue and had a known syncopal episode. What laboratory tests should be done? 

Diagnosing Eating Disorders 

The following table makes a side-by-side comparison of the Diagnostic and Statistical Manual of Mental Disorders (DSM) 4 and DSM 5. Note the critical differences in classifying an eating disorder based on percentiles, versus “significantly low,” which allows more patients access to earlier treatment options. Additionally, the change (removal) in using absent menstruation as a clinical marker for diagnosing an eating disorder allows further expansion of treatment options, as this single criterion may have multiple causative factors unrelated to weight loss. (14)  

A diagnosis of anorexia nervosa is based on three criteria: 

• A restriction of calories that result in weight loss/ failure to gain weight 

• An intense fear of actual weight gain 

• A distorted view on the seriousness of current health status.  

DSM-5 criteria typically classify the severity of anorexia according to current body mass index (BMI). For patients that meet the criteria for anorexia, but do not register the severity of BMI percentages, would be diagnosed with “atypical anorexia.” 

However, not all patients with a suspected eating disorder engage in the extremes of behaviors that result in severe malnutrition and visibly emaciated appearance. Atypical anorexia nervosa if often overlooked in healthcare settings where the focus is solely on a “BMI percentage”; starvation practices may actually be occurring in patients that register as normal, overweight, and even obese. It is advised to start the evaluation of a suspected eating disorder with “highest weight” and “previous weight” instead of a sole focus on “current weight” and “ideal weight.” (15) 

Case Scenario 

Your patient is being evaluated for fatigue and cold intolerance. Upon initial physical assessment, the patient is noted to be wearing several layers of clothes despite warm outdoor temperatures. They are hesitant to change into a hospital gown, despite being offered warm blankets to offset their cold intolerance. They are noted to have very dry skin, tooth and gumline erosion, and callus formation on their knuckles. The patient’s BMI is 19.5%.  

• With a preliminary diagnosis of a suspected eating disorder, what initial laboratory tests should be ordered?  

• Are there any other diagnostic tests that should be ordered at this time? 

• What additional consultations could be ordered to ensure follow-up care? 

• If this patient is diagnosed with an eating disorder, who should be part of the multidisciplinary care team for them? 

Diabulimia and Orthorexia 

Diabulimia and orthorexia are also considered eating disorders, but present with uniquely different behaviors, as well as treatment guidelines. They are included in this section to prompt further evaluation of an eating disorder prior to initiating a plan of care.  

Diabulimia 

Diabulimia is a serious, potentially life-threatening eating disorder that often occurs in persons with type 1 diabetes mellitus. In this eating disorder, the insulin dependent person intentionally restricts or limits insulin doses, directly affecting weight loss patterns. Without sufficient available insulin to assist in glucose metabolism, the human body will begin metabolizing fat and muscle for energy. The hyperglycemic state is, in essence, starving the blood cells of necessary energy for proper functioning. This “self-induced” hyperglycemic state results in serious weight loss. Diabulimia is also known as an “eating disorder in diabetes mellitus Type 1.” (16) 

• Physical Signs and Symptoms of diabulimia may include any of the following (related to chronic, recurring states of diabetic ketoacidosis): 

• • Unexplained weight loss 

• • A hemoglobin level is excess of 9.0 percent or higher 

• • Polyuria, polyphagia 

• • Feeling faint or dizzy 

• • Nausea and vomiting, stomach cramps 

• • Erosion of tooth enamel 

• • Recurrent urinary tract infections/vaginal infections  

• • Extremely dry skin (due to dehydration) 

• • Slow healing of wounds 

• • Irregular menstrual periods 

• Mental Health/ Behavioral Signs and Symptoms that may indicate diabulimia (17): 

• • Intentionally avoiding routinely scheduled doctor appointment/ laboratory tests 

• • Increasing neglect of basic diabetes related self-care management (medication adherence, glucose monitoring, carbohydrate counting) 

• • Medication noncompliance (not filling routine insulin prescriptions, not administering routine insulin boluses) 

• • Visible discomfort/hesitancy in testing blood glucose level and/or administering insulin in the presence of others 

• • Increased interest (hyper focused interest) in calorie counting/dieting (to intentionally limit calorie intake) 

• • Anxiety and depression over diabetes ongoing self-care 

• Treatment: As noted in previous sections, the treatment of this eating disorder is also multifaceted (with medical, psychological and nutritional components) and requires a multidisciplinary team. Treatment involves a multipronged approach, with counselors, nurses, nutritionists, psychologists and endocrinologists. The focus of this mental health treatment plan will involve the identification of triggers as well creating effective behaviors to address these triggers. A variety of therapies are available and often utilized in this instance. They include the following: 

• • Cognitive behavior therapy (CBT) 

• • Group therapy 

• • Family based therapy (FBT) 

• Contributing Factors: In addition to concerns about weight gain in diabetes, other factors (triggers) may be contributing to this behavior, such as: 

• • Diabetes distress (having difficulties with the daily requirements of diabetes self-care and management) 

• • A history of past trauma 

• • A need or desire to be in “control” of the situation (the “situation” in this case may be a chronic medical condition) (18) 

• Statistics: The National Eating Disorders Association (NEDA) has reported the following statistics regarding diabulimia:  

• • 30% to 35% of women with diabetes have restricted insulin in order to lose weight. 

• • 1 in 6 men with diabetes experience diabulimia. 

• • Adolescent women with T1D are 2.4 times more likely to have a diagnosable eating disorder and 1.9 times more likely to have a sub-threshold eating disorder. 

Orthorexia 

Orthorexia is an “unhealthy focus on healthy eating”. A person thought to have orthorexia appears obsessed with food quality, often to a degree that can affect overall health and well-being. The term was first coined in 1996 by Dr Steven Bratman, who stated the term orthorexia is a “fixation on righteous eating”. Although it is not considered a true “medical term”, it is often used to describe a person who rejects a variety of food due to beliefs that it is not “pure enough”. Eventually, these thoughts on food quality progress to avoiding full meals that do not meet their rigid food standards. (19) 

• Symptoms: Orthorexia symptoms, much like previously mentioned eating disorders, revolve around food and control: 

• • Anxiety over food quality 

• • Avoidance of eating food prepared by others (fear over food preparation and ingredients not being good enough) 

• • Fear over food related illnesses 

• • Refusal to eat a variety of foods 

• • Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, all animal products) 

• • Hypercritical of others food choices 

• • Hyper focused on food research (nutrition label reading, meal planning, calorie counting) 

• • Preoccupation with one’s own dietary regimen 

• • Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available 

• • Unusual interest in what other people are eating  

• • Physical signs and symptoms of malnutrition (to include weight loss, muscle wasting, hair loss, vitamin and mineral deficiency) 

• Causes and Risk Factors: The following three groups reflect possible causes for eating disorders, although risk factors may be different for each person.  

• • Biological- having an immediate family member or close relative with an eating disorder may directly influence one’s own outcome 

• • Psychological – having a history of anxiety/ depression, dissatisfaction with one’s own body/ body dysmorphia, feeling the need to achieve perfectionism 

• • Cultural/ societal- having a multigenerational family trauma history, having a personal history of suffering from body shaming/ bullying tactics in society 

• Treatment: Although there is no clinical treatment specifically related to orthorexia, many experts agree to treat orthorexia as a variant of anorexia and/ or obsessive-compulsive disorder. The treatment regimens, therefore, are utilized to restore weight as needed to maintain a healthy range, reintroduce a variety of food options and lower anxiety levels associated with food choices. A multidisciplinary team approach, including physicians, therapists and nutritionists are optimal. (20) Orthorexia treatment options include: 

• • Behavior modification- addressing current behavioral patterns and changing those that are considered ineffective 

• • Cognitive reframing – identifying habits or beliefs that cause stress and work on ways to replace them with less stressful actions and behaviors 

• • Relaxation exercises (deep breathing, guided imagery, yoga and tai chi practices, other forms of meditation) 

Healthcare Strategies for Patients with Eating Disorders 

Nursing Assessments and Interventions 

• Avoiding weighing a patient unless medically necessary; consider weighing patient at end of medical visit; consider weighing patient facing away from scale (backwards) 

• Acknowledging changes in healthy behaviors more so than changes in actual body weight 

• Staff education on weight stigma, motivational interviewing, active listening, and patient focused interviewing techniques  

• Investigating physical symptoms that may be related to malnutrition on all patients, regardless of actual body weight (evaluation of symptoms such as cold intolerance, palpitations, dizziness, menstrual irregularity) 

The following additional suggestions are listed to obtain the most accurate weight assessment, across the board, for all patients in a healthcare setting. By initiating these suggestions for all patient care, there is the perception of a caring, nonjudgmental atmosphere weight positivity and inclusivity. (21) 

• Obtain height and weight at each visit 

• Measure height without shoes 

• Weigh patients wearing gowns 

• Ask the patient to void (urinate) before weighing 

• Avoid making comments about a person’s weight, including acknowledgment of a significant weight loss or a weight gain. Never “congratulate” someone who has lost weight by telling them they “look great,” as you may actually be complimenting an eating disorder, serious illness, or severe depression. Research has shown that such remarks, albeit meant to be supportive, may further exacerbate an eating disorder.  

The following list of physical assessment findings are often present in patients with anorexia nervosa (22): 

• Subjective complaints of dizziness, cold intolerance, weakness or fatigue 

• Abdominal discomfort, constipation and /or diarrhea 

• Swelling of arms and legs 

• Tooth and gumline erosion from repeated attempts at vomiting 

• Callus formation on hands (knuckles) from repeated attempts at vomiting 

Laboratory Tests 

As a diagnosis of anorexia nervosa is made off of clinical observations (and not a single, confirmatory diagnostic test), there are no “set” laboratory tests; the physical evaluation and laboratory testing should be patient specific and guided by individual physical findings. The following list is a baseline, general recommendation of laboratory testing to assist with a suspected diagnosis of anorexia nervosa (as well as to rule out other disease processes). (23) 

• Complete blood count (to check for low blood counts reflective of anemia) 

• Electrolyte/ metabolic profile (to check for hyponatremia, hypokalemia, underlying dehydration; other electrolyte imbalances) 

• Urinalysis (to check for underlying infection, or undiagnosed kidney disease/ renal dysfunction) 

• Serum/urine pregnancy test in female patients of childbearing age 

• Complete thyroid profile (to rule out under/overactive thyroid functioning 

• Hormone panel (serum prolactin and FSH {follicle stimulating hormone} studies) (to rule out other causes for irregular/missed menstrual periods) 

Diagnostic Tests 

• Radiologic Studies: Chest Xray to rule out rib fractures and pneumomediastinum (suggestive of repetitive forced, vomiting episodes) 

• Echocardiology Studies: Rule out decreased ventricular mass and mitral valve prolapse (resulting from the loss of cardiac muscle due to extreme malnutrition) 

• Electrocardiology Studies: Evaluate the presences of potential cardiac dysrhythmias (tachycardias, bradycardias, ST-segment elevation, T-wave abnormalities). The finding of a QT-interval prolongation is a serious finding, indicating higher risk for possible life-threatening cardiac dysrhythmias. QT- interval prolongation can occur as the results of severe electrolyte disturbances (hypokalemia and hypomagnesemia).  

Medications 

Although family therapy treatment is considered the leading form of treatment for patients with eating disorders, there are several options available that usually improve symptoms and lower the risk of relapse. The use of medications, in the recovery period of a person with an eating disorder, has been met with questions. The use of antidepressants and antipsychotics may address symptoms (of comorbid psychiatric diagnoses), improve mental health status, and even promote weight gain, but most are considered simply as adjunct therapy, and must be part of a larger plan of care. A person with an eating disorder should never be treated solely with medication. (24, 25) 

• Antidepressants 

• • May be effective in the clinical treatment of comorbid conditions such as depressions, anxiety, and obsessive- compulsive disorders 

• • May worsen preexisting gastrointestinal issues (constipation and gastroparesis) often present in patients with anorexia nervosa 

• • Recommended as adjunctive therapy in addition to nutrition stabilization and ongoing psychotherapy 

• Antipsychotics 

• • May be used in the clinical treatment of comorbid conditions such as the anxiety and associated rigid behaviors associated with eating disorders 

• • May be used to promote weight gain 

• Selective Serotonin Reuptake Inhibitors 

• • Generally tolerated in anorexic patient population, but requires gradual dose increases and frequent monitoring. Electrolyte imbalances, such as hypokalemia (often present in patients with eating disorders), can heighten the risk of arrhythmias.  

Mental Health Therapies 

Mental health therapies to treat eating disorders include: (26, 27) 

• Family-Based Treatment (FBT) 

• • Leading treatment for adolescent patients experiencing eating disorders 

• • Family members are involved in sessions to learn about eating disorder 

• • Focuses on empowering parents to assist recovery of child 

• • Addresses eating disorder as separate from patient 

• • Up to 20 sessions is recommended  

• Cognitive-Behavioral Therapy (CBT) 

• • Most favorably used therapy for treating eating disorders 

• • Focuses on normalizing eating patterns and other related behaviors 

• • Addresses distorted views on body weight, shape, and appearances 

• • Up to 40 sessions over a 40-week program 

Management of Refeeding Syndrome 

The term refeeding is simply the process of food intake after a period of malnutrition or starvation. Refeeding syndrome may occur during the attempts at reintroduction of food and fluids, and is potentially fatal in severely compromised patients. (28) 

Sudden shifts in levels of hydration and serum electrolytes can result in the following serious symptoms: 

• Difficulty breathing 

• Extreme fatigue and weakness 

• Heart dysrhythmias progressing to heart failure 

• Changes in mentation; confusion 

Risk Factors for Refeeding Syndrome: 

• A starting BMI below 16% (extremely underweight)   

• Weight loss of more than 15 percent of body weight in the past 3 to 6 months 

• Consumption of little to no food for greater than 10 or more consecutive days 

• Baseline blood tests reveal low serum phosphate, potassium, or magnesium levels 

Treatment Goals: 

• Replacement of essential fluids and electrolytes 

• Replacement of calories (maximum 1000 calories a day/ 20 calories per kilogram of body weight) 

• Refeeding may take upwards of 10 days with continued monitoring after treatment 

Case Scenario 

Your patient has been admitted to the hospital for severe dehydration due to a confirmed eating disorder (bulimia). They failed outpatient, individualized therapy, and has been sent to the hospital for stabilization. Laboratory results indicate severe electrolyte imbalances. The patient wants to go home, and promises to consume “a lot of electrolyte replacement drinks” and rehydrate themselves.  

• What would you tell this patient about severe dehydration (and rehydration attempts) in an eating disorder? 

• How would you explain the concept of “refeeding” in a hospital setting for a severe bulimic condition? 

• What concerns do you have over the monitoring of this patient during treatment? 

• Would you include “daily weights” for this patient?  

• Would you take any special “precautions” or actions when weighing this patient? 

Self-Management of Eating Disorders 

In addition to formal group and family therapy sessions, anorexia self-help management may provide additional support to the recovering anorexia nervosa patient. Self-help tips can include the following (in no particular order) (29, 30, 31):  

• Practicing gratitude on a daily basis 

• Refocusing inner dialogue to reflect better food and body image choices 

• Self-modification of once rigid behaviors/habits 

• Setting realistic goals that focus on health and well-being 

The practice of self-care also reduces one’s perception of distress/disconnect in the world of eating disorders, which can easily lead to burnout and self-compassion fatigue. The practice of self-care strategies, coupled with formal professionally guided therapy, offers the best outcomes.  

Self-care is not selfish; rather it assists in the healing/recovery process. Additional self-care practices can include such practices as: 

• Proper sleep hygiene 

• Well balanced, nutritionally dense dietary intake 

• Setting boundaries in both professional and personal life 

• Adherence/ compliance with medical appointments, therapy sessions, medication regimen 

• Cleaning and organizing physical surroundings to promote inner calmness 

Additional behaviors that can help the person recovering from anorexia nervosa include: 

• Setting realistic goals in all areas of one’s life (keeping scheduled appointments, taking prescribed medications, getting proper night’s sleep, achieving food/fluid intake targets) 

• Wear comfortable clothing that makes you feel good about yourself 

• Pamper yourself – schedule small rewards for yourself 

• Relaxation/ mindfulness exercises like meditation and yoga to let your mind relax; will aid in recovery

Conclusion

Anorexia nervosa, and its associated eating disorders, continue to be associated with the highest mortality rates. Early identification, prompt emergency treatment and ongoing therapies offer the best multidisciplinary approach to successful weight stabilization and optimal physical health and mental well-being. For more information and education, please check out the following external websites.  

• Eating Recovery Center    

• • https://www.eatingrecoverycenter.com/ 

• National Association of Anorexia Nervosa and Associated Disorders (ANAD) 

• • https://anad.org/ 

• National Eating Disorders Association 

• • https://www.nationaleatingdisorders.org/ 

• Multi-Service Eating Disorders Association 

• • https://www.medainc.org/get-help/find-a-treatment-center/ 

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