Increasing number of individuals is being diagnosed with eating disorders, as social media and western culture portray thinness as signs of happiness and well-being. Individuals with eating disorders are obsessed with food, body image, and weight loss. Depending on the severity and duration of their illness, they may display physical symptoms such as weight loss, amenorrhea, loss of interest in sex, low blood pressure, depressed body temperature, chronic and unexplained vomiting and the growth of soft, fine hair on the body and face.

1. Eating disorders - Malnutrition for women

2. Review Article
Eating disorders e Malnutrition for women
Sugami Ramesh*
Clinical Psychologist, Apollo Hospitals, Bangalore 560076, India
a r t i c l e i n f o
Article history:
Received 22 January 2014
Accepted 30 January 2014
Available online 12 March 2014
Keywords:
Eating disorder
Anorexia nervosa
Bulimia nervosa
Binge eating
EDNOS
a b s t r a c t
Increasing number of individuals is being diagnosed with eating disorders, as social media
and western culture portray thinness as signs of happiness and well-being.
Individuals with eating disorders are obsessed with food, body image, and weight loss.
Depending on the severity and duration of their illness, they may display physical symp-
toms such as weight loss, amenorrhea, loss of interest in sex, low blood pressure,
depressed body temperature, chronic and unexplained vomiting and the growth of soft,
fine hair on the body and face.
There are four types of behavioral manifestations occurring from eating disorders:
a) Anorexia nervosa b) Bulimia nervosa c) Binge eating disorder d) Eating disorder not
otherwise specified.
Today’s theorists usually apply a multidimensional risk perspective to explain eating dis-
orders, and identity several key factors that place a person at risk for an eating disorder: soci-
ety’s emphasis on thinness, family environment, ego deficiencies and cognitive disturbances,
mood disorders and biological factors (including hypothalamic reactions to excessive dieting).
Treatments for anorexic nervosa include increasing caloric intake and restoring the per-
son’s weight quickly. The next step is to address the underlying psychological problems, so that
improvement maybelasting,by employing a mixture ofindividual, group andfamily therapies.
Treatments for bulimia nervosa focus on eliminating the binge-purge pattern and
addressing the underlying causes of the disorder. Often several treatment strategies are
combined, including individual insight therapy, group therapy, behavioral therapy and
antidepressant medications.
Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Anorexia nervosa and bulimia nervosa are characterized by
severe disturbances of eating behavior. The salient feature of
anorexia nervosa (AN) is a voluntary restriction of food intake
relative to caloric requirements leading to an inappropriately
low body weight. Bulimia nervosa (BN) is characterized by
recurrent episodes of binge eating followed by abnormal
compensatory behaviors, such as self-induced vomiting. AN
and BN are distinct clinical syndromes but share common
features. Both disorders occur primarily among previously
healthy young women who become overly concerned with
body shape and weight. Many patients with BN have past
histories of AN, and many patients with AN engage in binge
* Tel.: þ91 9845226939.
E-mail address: sugami.ramesh@gmail.com.
Available online at www.sciencedirect.com
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a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 8 e2 3
http://dx.doi.org/10.1016/j.apme.2014.01.006
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. eating and purging behavior. In the current diagnostic system,
the critical distinction between AN and BN depends on body
weight: patients with AN are, by definition, significantly un-
derweight, whereas patients with BN have body weights in the
normal range or above. Binge eating disorder (BED) is a more
recently described syndrome characterized by repeated epi-
sodes of binge eating, similar to those of BN, in the absence of
inappropriate compensatory behavior. (18 Edition Harrisons’s
principles of Internal Medicine chapter 79 page 636).
2. Eating disorders
Eating disorders affect both the mind and the body. It was first
identified as a medical condition by the British physician Dr.
William Gull in 1873. The incidence of eating disorders
increased substantially throughout the twentieth century and
in 1980 the American Psychiatric Association formally classi-
fied these conditions as mental illnesses.
Mental and psychological factors can affect your nutrition,
with depression being a common cause of weight loss and
malnutrition in adults. Stress and anxiety can also cause you
to eat less or more than you need. Dementia and confusion
can impair an adult’s desire to eat and their ability to feed
themselves by interfering with choosing which foods to eat,
getting food into the mouth and chewing.
3. Diagnosis
Individuals with eating disorders are obsessed with food, body
image, and weight loss. They may have severely limited food
choices, employ bizarre eating rituals, excessively drink fluids
and chew gum, and avoid eating with others. Depending on
the severity and duration of their illness, they may display
physical symptoms such as weight loss, amenorrhea, loss of
interest in sex, low blood pressure, depressed body tempera-
ture, chronic and unexplained vomiting and the growth of
soft, fine hair on the body and face.
4. Types of eating disorder
There are four types of behavioral manifestations occurring
from eating disorders. The American Psychiatric Association
has classified the same as following1
:
e) Anorexia nervosa
f) Bulimia nervosa
g) Binge eating disorder
h) Eating disorder not otherwise specified.
Sketches of Miss A & Miss B published in Sir William
Gull’s seminal work “Anorexia Nervosa” in 1873. Miss A
& Miss B were referred to Gull between 1866 and 1868 and
are one of the world’s first anorexia nervosa case studies.
Under Gull’s observation, the two young women seem to
have made significant recovery.
Source: http://en.wikipedia.org/wiki/Anorexia_nervosa
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 8 e2 3 19

4. 5. Anorexia nervosa
Anorexia nervosa has been diagnosed as an intentional weight
loss of 15% or more of normal body weight. The anorexic
displays an inordinate fear of weight gain or becoming fat,
even though he or she may be extremely thin. He/she might
intake limited food being unaware or inconstant denial of
their weight loss. This illness peaks mostly in individuals aged
between 12 and 13 & at age 17. Among women of menstruating
age, menstruation ceases due to weight-related declines in
female hormones. This illness has two subtypes:
1. The Resisting Type
2. Binge eatingepurging Type
6. Bulimia nervosa
Bulimia nervosa can be defined as a condition where an in-
dividual indulges in repeated episodes of bingeing followed by
compensatory behaviors to prevent weight gain. These
include vomiting, diuretic & laxative abuse, fasting, or
excessive exercise. Like the anorexic, the individual has an
unusual concern about body weight and weight loss. But un-
like the anorexic, he/she is acutely aware of this condition and
has a greater sense of guilt and of self-control. It largely de-
velops during the late teens and early twenties.
Classification2
A The purging type e which employs laxatives, diuretics,
or self-induced vomiting to compensate for bingeing
A The nonpurging type e which relies on behaviors such
as excessive exercising or fasting to offset binges.
Bulimia nervosa affects 15e50% of individuals partici-
pating in diet programs and often develops after substantial
diet-related weight loss. A clinical diagnosis also requires
three or more of the following behaviors:
A Eating at an unusually rapid pace
A Eating until uncomfortably full
Source: http://www.womenshealth.gov/publications/our-publications/fact-sheet/bulimia-nervosa.html
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 8 e2 320

5. A Eating large quantities of food in the absence of physical
hunger
A Eating alone out of shame
A Feelings of self-disgust, guilt, or depression subsequent
to bingeing episodes.
7. Eating disorder not otherwise specified
Eating disorder not otherwise specified is used to diagnose
individuals whose eating disorders are equally as serious as
anorexia nervosa, bulimia nervosa, or binge eating disorder,
but do not meet all of the diagnostic criteria for these illnesses.
For example, a female who fulfills all of the criteria for anorexia
but is still having regular menstrual periods; individual with all
signs of bulimia who binges and purges less than twice a week.
8. Risks
8.1. Environmental
Early childhood environment & parenting play a major role
in individuals getting affected by this illness. Sufferers
report dysfunctional family histories, with parents who
were either emotionally absent or overly involved in their
upbringing. As a result, these children may not tolerate
stress well, have low self-esteem and have difficulty in
interpersonal relationships. Children who have been
abused physically, sexually or psychologically are also
highly vulnerable to eating disorders, particularly bulimia3
.
Those raised by eating-disordered parents may be at
heightened risk due to repeated exposure to maladaptive
food-related behaviors.
8.2. Social & biological
Professions, activities, and dietary regimens that emphasize
food or thinness may also encourage eating disorders.
Example e Athletes, ballet dancers, models, actors, diabetics,
vegetarians and food industry professionals may have higher
rates of disordered eating than the general population. Low
levels of serotonin, a neurotransmitter involved in appetite
regulation and satiety may be indicative of a predisposition to
pathological eating behaviors.
Source: http://weightmatters.co.uk/eating-disorders/binge-eating-disorder/
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 8 e2 3 21

6. 8.3. Psychological
50e75% diagnosed with eating disorders suffer from
depression, a mental illness also associated with abnor-
malities in serotonin balance. Psychiatric disturbances,
such as bipolar depression, obsessive-compulsive disorder,
seasonal affective disorder, post-traumatic stress disorder,
attention-deficitehyperactivity disorder and addictive be-
haviors are also common in people with eating disorders.
8.4. Causes
Westernized culture portrays thinness as a coveted physical
ideal associated with happiness, vitality, and well-being4
.
Endless images of unrealistically thin models and actors in all
forms of media further promote body dissatisfaction. Eating
disorders are most likely to develop during the mid to late
teens, a period of considerable physical, psychological, and
social change.
There are two common milestones that can trigger disor-
dered eating, especially in those with a biological
predisposition:
A The occurrence of a traumatic event, such as the death
of a loved one or a divorce.
A Adoption of a strict diet, which may be even more
pivotal than a personal trauma.
8.5. Treatment modalities
Treatment modalities can be based on a combination of psy-
chotherapy, medication and nutritional counseling. The goals
of these treatments include5
:
1. Restoration of healthy body weight
2. Correction of medical complications
3. Adoption of healthful eating habits
4. Treatment of maladaptive food-related thought processes
& co-existing psychiatric conditions
5. Prevention of relapse
Survey indicating increasing dissatisfaction with their bodies
among men & women during 1972 and 1987. Probably the
trend could be the same today as well. Source: Rodin, 1992,
p.57
Nutrition is so important to prevent health issues and live a
better life. Why women continue to ignore it?
Source: Weiss, 1991; Calorie Control Council national survey, 1991; Smith et al., 1990; Britton, 1988, Rosen & Gross, 1987, Cash et
al., 1986
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 8 e2 322

7. Depending on the severity of the illness, therapy may be
conducted on an outpatient, day treatment, or inpatient basis
along with medication.
Conflicts of interest
The author has none to declare.
r e f e r e n c e s
1. The American Psychiatric Association-https://www.apa.org/
helpcenter/eating.aspx.
2. Barlow DH, Durand VM. Abnormal psychology : an integrative
approach. 3rd ed. Belmont, CA: Wadsworth/Thomson Learning;
2002.
3. Rohde P, Ichikawa L, Simon GE, Ludman EJ, et al., Associations
of child sexual and physical abuse with obesity and depression
in middle-aged women, Child Abuse Negl.; 32: 878e887.
4. Barker PJ. Psychiatric and Mental Health Nursing: The Craft of
Caring. Hodder Arnold; 2003.
5. Treatment of Patients With Eating Disorders, Third Edition
http://psychiatryonline.org/content.aspx?
bookid¼28&sectionid¼1671334.
How Family and Friends Can Help
Michael Levine
1. Write down specific instances of person’s problem-
atic behaviors or attitudes.
2. Educate yourself and other family members about
eating disorders, and about the nearest resources
offering professional and expert treatment.
3. Get support and advice from people you trusteclergy,
social workers, friends, family physicians. Don’t
isolate yourself from people who care about you and
who can help. Attend a support group.
4. Arrange for family and friends to speak confiden-
tially with the person about the specifics and con-
sequences of his or her disordered eating and
weight management practices. Try to remain
calm, caring and non-judgmental. Avoid giving
simplistic suggestions about nutrition or self-
control.
5. Communicate directly to the person the seriousness
of your concern, your conviction that treatment is
necessary, and your willingness to provide
emotional, financial and other practical support.
6. Exercise responsibility, authority and authoritative
wisdom in obtaining treatment for (a) minors with
eating disorders and (b) anyone who is suicidal, very
sick, or out of control.
7. Reaffirm the importance of yourself and your other
family members. Don’t allow your life to be disrupted
by emotional upheavalearguments, threats, blame,
guilt, bribes, resentment e concerning issues of food,
weight and eating.
8. Sustain the person’s sense of importance and dignity
by encouraging decision-making and personal re-
sponsibility. Don’t be manipulated into shielding the
person from the consequences of the disorder,
including separation from you.
9. Be patient: recovering is a long process because
treatment must address the physical, psychological
behavioral, social and cultural dimensions of com-
plex disorders.
10. Love your relative or friend for himself or herself, not
for appearance, health, body weight or achievement.
Encourage healthy feelings and interests, and avoid
talking about appearance, eating habits and weight.
11. Remember that families (by themselves) neither cause
nor cure eating disorders, but they can make a major
contribution to recovery and future development.
Dwelling on guilt or causes is counterproductive.
12. Remember that compassion is “bearing with” a per-
son in distress, not suffering unduly because of their
injustices or unwillingness to get help.
Source: (Levine, 1988)
Nobody can go back and start a new beginning, but anyone can
start today and make a new ending
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 8 e2 3 23

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