Revised Eating disorders- Every meal is an opportunity to choose recovery.

Revised Eating disorders- Every meal is an opportunity to choose recovery.

• 1.
  EATING DISORDERS: PRESENTER: MSRITIKA SONI
• 2.
  EATING DISORDERS: Look inthe mirror. What do you see? Is it the real you or just another "me"?
• 3.
  INTRODUCTION  Nutrition isrequired to sustain life, the most individuals require nutrients from eating balanced food.  The HYPOTHALAMUS contains the appetite regulation center with in the brain. This complex neural system regulates the body’s ability to recognize when it is hungry and when it has been stated.  When it is disturbed, lead to eating disorder.
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  WHAT IS ANEATING DISORDER?  Eating disorders are mental illnesses that cause serious disturbances in a person’s everyday diet.  It can manifest as eating extremely small amounts of food or severely overeating.  leading to severe changes.
• 5.
  EATING DISORDER  Eatingdisorders are characterized by severe form of disturbances in eating pattern / behavior leading to life threatening conditions.
• 6.
  CLASSIFICATION: ICD-10  TheICD10 codes for eating disorders fall under the category F50. Here are some key codes: • F50.0: Anorexia nervosa • F50.1: Bulimia nervosa • F50.2: Binge eating disorder • F50.9: Eating disorder, unspecified.
• 7.
  ICD-11 CLASSIFICATION Eating disorder-BlockL1-6B8  6B80- Anorexia nervosa  6B81- Bulimia nervosa  6B82- Binge –eating disorder  6B83- Avoidant-restrictive food intake disorder  6B84- Pica  6B85- Rumination-regurgitation disorder  6B8Y- Other specified feeding or eating disorders  6B8Z- Feeding or eating disorders, unspecified
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  TYPES OF EATINGDISORDERS  Anorexia Nervosa  Bulimia Nervosa
• 9.
   Obesity  BingeEating Disorder  Psychogenic vomiting  Not Otherwise Specified (NOS)
• 10.
  EPIDEMIOLOGICAL FACTOR  Theincidence of Anorexia Nervosa has increased in the past 30 years both in the united states and in western Europe. Studies indicate a prevalence rate among young women in the united state of approximately 1 percent . Anorexia nervosa occurs predominantly in females 12-30 years.  More prevalent in higher socio-economical groups.  Bulimia nervosa is more prevalent than anorexia nervosa, with estimates up to 4 percent of young women.  Onset occurs in early childhood and late adolescent .
• 11.
   Obesity hasbeen defined as a body mass index (BMI= weight/height(2) of 30 or greater. In the united state, statistics indicate that, among adults 20 years of age or older, 68 % are overweight.
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  ANOREXIA NERVOSA: WHATIS IT?
• 13.
  ANOREXIA NERVOSA  Anorexia:Prolonged loss of appetite.  Nervosa : Indicates that the loss is due to emotional reason.  Body image: a subjective concept of one’s physical appearance based on the personal perceptions of self and the reactions of others.
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  ANOREXIA NERVOSA:  Anorexianervosa happens when one is obsessed with becoming thin that they reach extreme measures and this leads to extreme weight loss.
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  DEFINITION  Anorexia nervosais characterized by excessive food restriction, irrational fear of gaining weight and a distorted body self-perception which leads to excessive weight loss.
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  ICD-11 CLASSIFICATION  Eatingdisorder-Block L1-6B8  6B80- Anorexia nervosa  6B80.0- Anorexia nervosa with significantly low body weight  6B80.1- Anorexia nervosa with dangerously low body weight  6B80.2- Anorexia nervosa in recovery with normal body weight  6B80.Y- Other specified anorexia nervosa  6B80.Z- Anorexia nervosa, unspecified
• 17.
  Prevalence and Incidence A.N is found all around the world but prevalence is significantly higher in developed countries.  At any given point in time between 0.3-0.4 % of young women and 0.1% of young men will suffer from anorexia nervosa.  Overall prevalence is 0.3-1% in women and 0.1- 0.3 % in men.
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  TYPES OF ANOREXIANERVOSA  Restricting type: individual has not engaged in recurrent episodes of binge –eating or purging behavior (self –induced vomiting or the misuse of la, laxatives, diuretics or enemas). In this weight loss by excess starvation or rigid exercise.  Binge-eating / purging type: individual has engaged in recurrent episodes of binge-eating or purging behavior (self –induced vomiting or the misuse of laxatives, diuretics or enemas).
• 19.
  CHARACTERISTIC FEATURES  Anorexianervosa is characterized by a morbid fear of being obese. This fear does not decrease even if body becomes very thin and underweight.  The term anorexia was actually a misnomer.  It was initially believed that anorexics didn't experience sensation of hunger .  However, research indicates that they do indeed suffer from pangs of hunger, and it is only with food intake of less than 200 calories per day that hunger sensation actually ceases.
• 20.
   Significant lossof weight occurs, usually more than 25% of the original weight. The final weight is usually 15% less than the minimum limit of normal weight or the Quetelet’s body-mass index (BMI) of 17.5 or less.  No known medical illness, which can account for the weight loss , is present.  Absence of any other psychiatric disorder.
• 21.
  Symptoms includes:  Extremefear of gaining weight or becoming fat , even when underweight o Gross distortion of body image  Preoccupation with food, and refusal to eat food.  Weight loss due to less intake of food and extensive exercising  Poor sexual adjustment.( often conflict about being a female and fear of pregnancy)  Up to 50% of anorexics have bulimic episodes. Characterized by rapid consumption of large amount of food in a short period, when alone , called binge eating. Due to intense guilt attempt to remove eaten food by:  purging behavior such as Self induced vomiting and abuse of laxative or diuretics also may occur.
• 22.
   Others symptoms: hypothermia, edema, lanugo, and variety of metabolic changes.  Yellow dry skin  Obsessed with food . E.g.: hoard or conceal food, talk about food and recipes or prepare food for others.  Feeling of depression, anxiety .  Confusion, poor memory, judgment  Loss of bone strength, osteoporosis  Extreme sensitivity to cold  Death may occur due to hypokalemia ( by self induced vomiting), dehydration, malnutrition, CCF.
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  ANOREXIA NERVOSA: WARNING SIGNS Dramatic weight loss  Refusal to eat certain foods or food categories.  Consistent excuses to avoid situations involving food  Excessive and rigid exercise routine  Withdrawal from usual friends/relatives
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  HEALTH RISKS WITHANOREXIA NERVOSA  Heart failure  Kidney failure  Low protein stores  Digestive problems
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  SEVERITY OF ANOREXIA NERVOSA Levelof severity of the disorder can be determined by calculating BMI.  Level-1: Mild (BMI >17)  Level-2: Moderate (BMI 16-16.99)  Level-3: severe (BMI 15-15.99)  Level-4: Extreme (BMI <15)
• 26.
  COMPLICATIONS OF ANOREXIA NERVOSA Bone weakening  Decrease in white blood cells, which lead to increased risk of infection  Low potassium levels in the blood, which may cause dangerous heart rhythms  Severe dehydration and malnutrition  Seizures due to fluid or sodium loss from repeated diarrhea or vomiting  Thyroid gland problems and tooth decay
• 27.
  DIAGNOSTIC CRITERIA Acc. ToDSM-5:  Restriction of energy intake as per the body requirements that leads to significantly low body weight.  Extreme fear of gaining weight or persistent behavior that interferes with weight gain, even though at a significantly low weight.  Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self evaluation.
• 28.
  DIAGNOSTIC CRITERIA Acc. ToICD-11:  Significantly low body weight for the individual’s height, age, developmental stage that is not due to another health condition or to the unavailability of food .  BMI <18.5 kg/m2 in adults.  Rapid weight loss (>20 % of total body weight within 6 months) .  Failure to weight gain as expected  Low body weight is accompanied by a persistent pattern of behaviors to prevent restoration of normal weight , involved in restricted eating, purging behavior (self induced vomiting , misuse of laxatives) , associated with fear of weight gain.  Low body weight or shape is central to the person’s self evaluation.
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  BULIMIA NERVOSA: WHATIS IT?
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  BULIMIA NERVOSA  Bulimia: excessive, insatiable appetite (Hunger)  Nervosa: Indicates that due to emotional reason.
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  BULIMIA NERVOSA  BulimiaNervosa is an episodic, uncontrolled , compulsive, rapid ingestion of large amount of food over a short period of time (bingeing), followed by inappropriate compensatory behavior to rid the body of the excess calorie(purging)
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  BINGE AND PURGECYCLE  Strict dieting  Craving  Binge –eating  Purging  Shame and disgust – leads to strict dieting and restart the cycle.
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  BINGE AND PURGECYCLE
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  Prevalence and Incidence Lifetime prevalence of bulimia nervosa is 1 % .  Prevalence among women is 1.5 % and 0.5% of young men will suffer from bulimia nervosa.  The onset is often during adolescence, between 13 and 20 years of age.  Adolescents have self-imposed perfectionism and compulsivity issues in eating compared to their peers.
• 35.
  CHARACTERISTIC FEATURES  Earlyteens or adolescents  Intense fear of being obese. There may be history of anorexia nervosa.  Body image disturbance  Persistent preoccupation with eating, and an irresistible craving for food.  Episode of binge eating  No known medical illness  Absence of psychiatric disorder.
• 36.
   Recurrent episodesof binge eating. An episode of binge eating is characterized by both of the following:  A) eating in a discrete period of time  B) a sense of lack of control over eating during the episode.
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   Attempt to‘counteract’ the effects by inappropriate compensatory behavior in order to prevent weight gain, self induced vomiting ;misuse of laxatives, diuretics, enemas, fasting, or excessive exercise.  The binge eating and inappropriate compensatory behavior occurs, at least twice a week for 3 months.  Specific types:  Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self- induced vomiting or the misuse of laxative, diuretics, or enemas.  Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting, or excessive exercise.
• 38.
  PHYSICAL SIGNS ANDSYMPTOMS  Calluses or scars on the knuckles or back of the hands from sticking fingers down the throat to induce vomiting over long period of time (Russell’s sign).  Bulimics who are capable of “hand free purging” induce the vomiting by the use of pen, tooth brushes).  Puffy ‘chipmunk’ cheeks / faces (sialadinosis-swollen salivary glands due to repeated exposure to stomach acid) caused by repeated vomiting.  Discolored teeth from exposure to stomach acid when throwing -up.  They may have normal weight or slightly overweight.  Frequent fluctuations in weight due to alternating episodes of binge –eating and purging.
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  RUSSELL’S SIGN
• 40.
  PUFFY ‘CHIPMUNK’ CHEEKS/ FACES (SIALADINOSIS
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  DISCOLORED TEETH
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  Discolored teeth
• 43.
  SEVERITY OF BULIMIA NERVOSA(DSM-5) Mild : an average of 1-3 episodes of inappropriate compensatory behaviors per week.  Moderate : an average of 4-7 episodes of inappropriate compensatory behaviors per week.  Severe : an average of 8-13 episodes of inappropriate compensatory behaviors per week.  Extreme : an average of 14 or more episodes of inappropriate compensatory behaviors per week.
• 44.
  BULIMIA NERVOSA: WARNINGSIGNS  Wrappers/containers indicating consumption of large amounts of food  Frequent trips to bathroom after meals  Signs of vomiting e.g. staining of teeth, calluses on hands  Excessive and rigid exercise routinely.  Withdrawal from usual friends/relatives
• 45.
  HEALTH RISKS WITHBULIMIA  Dehydration and electrolyte imbalance  Dental problems  Stomach rupture  Menstruation irregularities  Mood disorder, anxiety disorder, substance abuse etc.
• 46.
  COMMON MEDICAL COMPLICATIONS  Weightgain  Abdominal pain, bloating, swelling of the hands and feet  Chronic sore throat, hoarseness  Acid reflux or Ulcers  Ruptured stomach or esophagus  Loss of menstrual period  Chronic constipation from laxative abuse
• 47.
  DIAGNOSTIC CRITERIA Acc. ToDSM-5:  Recurrent episodes of binge –eating that is characterized by-eating large amount of food in a discrete period of time (within 2 hours period) and a sense of lack of control over eating during the episodes .  Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self induced vomiting, misuse of laxatives, diuretics, fasting or excessive exercise.  The binge-eating and inappropriate compensatory behaviors both occur, at least once a week for 3 months.  Self-evaluation is improperly influenced by body shape and weight.
• 48.
  DIAGNOSTIC CRITERIA Acc. ToICD-11:  Frequent, recurrent episodes of binge eating (once a week or more over a period of at least one month).  Binge –eating episode.  Binge-eating is accompanied by repeated inappropriate compensatory behaviors aimed at preventing weight gain .  Preoccupied with body shape or weight, strongly influenced by self-evaluation.  Marked distress about pattern of binge –eating and inappropriate compensatory behavior or significant impairment in important areas of functioning.  Low body weight or shape is central to the person’s self evaluation.
• 49.
  BINGE EATING DISORDER: WHATIS IT?
• 50.
  BINGE EATING DISORDER Binge eating is disorder in which someone eats a lot amount of food at a time but they don't vomit.
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  DEFINITION  It ischaracterized by loses control over her eating. Unlike bulimia nervosa, periods of binge eating are not followed by purging and excessive exercise or fasting.  As a result people with binge eating disorder are often overweight or obese. They have risk of developing cardiovascular disease and high blood pressure. They also experience guilt, shame and distress about their binge eating, which can lead to more binge eating.
• 52.
  BINGE EATING DISORDER: WARNINGSIGNS  Wrappers/containers indicating consumption of large amounts of food  MAY be overweight  MAY eat throughout the day with no planned mealtimes
• 53.
  HEALTH RISKS WITH BINGEEATING DISORDER  High blood pressure  High cholesterol  Gall bladder disease  Diabetes  Heart disease  Certain types of cancer
• 54.
  PREDISPOSING FACTOR  Biologicalinfluences:  Genetics- on the basis of family history  Chromosome abnormality: 1,2,13 • Neuroendocrine abnormalities : - primary hypothalamic dysfunction in anorexia nervosa - Elevated cerebrospinal fluid, cortical levels (proteolysis) (released in response to stress or low blood-glucose concentration). - Impairment of dopaminergic regulation(brain dopamine receptors –known for controlling movement, also for weight and feeding behavior) • Neurochemical influences: - Neurotransmitter serotonin and nor epinephrine - High level of endogenous opioids in the spinal fluids.
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   Psychological influences: -Personality traits- Perfectionist, overachievers, neuroticism, negative emotionality, obsessive compulsiveness.  Low self-esteem  Feelings of inadequacy or failure  Feeling out of control  Response to change (puberty)  Response to stress  Personal illness  breakup.
• 56.
   Psychodynamic influences: Earlyand profound disturbances in mother –infant interactions may results in retarded ego development in child.  Troubled family and personal relationships  Difficulty in expressing emotions and feelings  History of being teased or ridiculed based on size or weight  History of physical or sexual abuse  Social acceptance of thinness  Mass media- TV, magazines, advertising influences.
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  • Family andsocial pressure: - Participation in any activity: Gymnastic , modeling  Cultural pressures that glorify thinness and place value on obtaining the perfect body  Narrow definitions of beauty that include only women and men of specific body weights and shapes.  Cultural norms that value people on the basis of physical appearance and not inner qualities and strengths.
• 58.
  PSYCHODYNAMICS  Predisposing factorssuch as genetics, hypothalamic dysfunction, unresolved childhood conflict in mother-child relationship.  Underdeveloped ego  Precipitating factors, stressful situations, failure to fulfill social expectations  Distorted cognitive self-assessment  Use of maladaptive coping mechanisms (distortion, denial, regression, rationalization)  Abnormal eating behavior
• 59.
  OBESITY  Obesity hasbeen defined as a body mass index (BMI= weight/height2) of 30 or greater.  The following formula is used to determine extent of obesity in individual:  BMI=Weight (kg) Height (m)2  BMI range for normal weight is 18.5-24.9  Overweight= BMI of 25.0-29.9  Obesity= BMI of 30.0 or greater  American average women has BMI= 26  Fashion models=18  Anorexia nervosa=17.5
• 60.
  RISKS:  Hyperlipidemia  Diabetesmellitus  Workload on heart and lungs is increased
• 61.
  PREDISPOSING FACTORS TO OBESITY Biological influences: -Genetics: - Physiological factors: lesions in the appetite and satiety centers in the hypothalamus may contribute to overeating and obesity. -hypothyroidism( thyroid helps in metabolism of calories). - Lifestyle factors: sedentary life style, ingestion of greater no. of caloric food. - Psychosocial influences: obese individual have unresolved dependency needs and are fixed in the oral stage of psychosexual development.
• 62.
  TREATMENT MODALITIES:  Behaviormodifications along with cognitive therapies helps the patient to confront irrational thinking and strands to modify distorted and maladaptive cognitions about body image and eating behaviors. Providing positive reinforcement.  Individual therapy  Family therapy  Psychopharmacology: fluoxetine, clomipramine, chlorpromazine, olanzapine ( antipsychotic), other antidepressants: imipramine, desipramine, amitriptyline etc.  Hospitalization: with adequate nursing care for food intake and weight gain.
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  GENERAL MANAGEMENT  Identificationof psychosocial stressors.  Environmental manipulation to deal with stress.  Teaching coping skills.  Psychotherapy
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  PURGING DISORDER  Purgingdisorder is characterized by recurrent purging (self-induced vomiting, misuse of laxative, diuretics or enemas) to control weight or shape in the absence of binge eating episodes that occurs in people with normal or near- normal weight.
• 65.
  RUMINATION SYNDROME  Ruminationsyndrome or merycism is an underdiagnosed chronic condition characterized by effortless regurgitation of most meals following consumption. There is no vomiting, nausea, heartburn, odours or abdominal pains associated with the regurgitation.
• 66.
   Rumination syndromeis a condition in which recently swallowed food comes back up into the mouth without nausea, retching, or vomiting. The food is then either re-chewed, re- swallowed, or spit out. It is a functional gastrointestinal disorder, meaning it occurs because of abnormal function rather than a structural disease.
• 67.
  Symptoms • Effortless regurgitationof undigested food within 10–30 minutes after eating • Food tastes relatively normal because it has not yet been digested • Re-chewing and swallowing or spitting out the regurgitated food • Feeling of pressure or fullness in the upper abdomen before regurgitation • Bad breath • Weight loss or poor weight gain (especially in children or severe cases) • Nutritional deficiencies in prolonged cases
• 68.
  Causes  The exactcause is not always known, but it may be associated with: • A learned, involuntary habit of contracting the abdominal muscles after meals • Stress or anxiety • Previous gastrointestinal illness • It can occur in infants, children, adolescents, and adults.
• 69.
  Diagnosis  Diagnosis ismainly based on the clinical history and symptom pattern. Doctors may perform tests to rule out other conditions, such as:  Repeated regurgitation of food for at least 1 month • Upper gastrointestinal endoscopy • Esophageal manometry • pH monitoring • Gastric emptying studies (if indicated)
• 70.
  Treatment  The maintreatment is behavioral therapy, especially: • Diaphragmatic breathing (abdominal breathing) during and after meals, which helps prevent regurgitation. • Habit-reversal training with a psychologist or therapist. • Stress management if anxiety is a contributing factor. • Nutritional counseling if there has been weight loss.  Medications are generally not very effective, although they may be used if another gastrointestinal condition is also present.
• 71.
  Complications • Weight loss •Malnutrition • Dental erosion • Social embarrassment • Reduced quality of life
• 72.
  PICA DISORDER  Picais an eating disorder characterized by the persistent craving and consumption of non-food items (such as clay or chalk) that have no nutritional value, often linked to nutritional deficiencies or mental health conditions.  For these actions to be considered pica, symptoms must persist for > 1 month at an age.
• 73.
  WHAT IS PICA? Pica is a psychologically compulsive eating disorder where individuals consume substances not intended as food, such as dirt, paint, hair, chalk, or ice, over a period of at least one month. The behavior is considered developmentally inappropriate and not part of culturally sanctioned practices. While occasional mouthing of objects is normal in children under two, pica is diagnosed when the behavior persists beyond this age or causes health risks
• 74.
  WHO IS AFFECTED? Pica can occur at any age but is most commonly seen in:  Young children, especially those over two years old  Pregnant women, often linked to nutritional deficiencies  Individuals with developmental or mental health conditions, such as autism spectrum disorder, intellectual disabilities, or schizophrenia. Certain environmental and psychological factors, including stress, trauma, maternal deprivation, or family instability, may increase the risk
• 75.
  CAUSES AND RISKFACTORS  The exact cause of pica is not fully understood, but several factors are associated with the disorder:  Nutritional deficiencies, particularly iron or zinc deficiency  Pregnancy, which may trigger cravings for non- food items  Mental health conditions or developmental disorders  Environmental stressors, such as poverty or neglect
• 76.
  COMMONLY INGESTED SUBSTANCES  Peoplewith pica may consume a wide range of non-food items, often focusing on one preferred substance, though multiple items can be involved. Common examples include: • Amylophasia- Consumption of starch • Coprophagy-Consumption of feces-animal feces • Geophasy- Consumption of soil, clay, chalk. • Hyalophagia-Consumption of glass • Consumption of dust or sand has been reported among iron-deficient patients. • Mucophagia-Consumption of mucus • Odowa- Soft stones eaten by pregnant women in Kenya • Consumption of paint. • Pagophagia- Pathological consumption of ice • Self-cannibalism-Rare condition where body parts may be consumed • Tricophagia- Consumption of hair or wool • Urophagia- Consumption of urine • Xylophagia- Consumption of wood or paper
• 77.
  HEALTH RISKS  Picacan lead to serious complications depending on the substances ingested:  Toxicity, such as lead poisoning from paint or contaminated soil  Gastrointestinal issues, including obstruction, perforation, or infection  Nutritional deficiencies, particularly iron deficiency anaemia  Parasitic infections from contaminated soil or feces
• 78.
  DIAGNOSIS  There areno laboratory tests for pica. Diagnosis is based on: • Clinical history of persistent non-food ingestion for at least one month • Exclusion of culturally accepted practices • Assessment for nutritional deficiencies, intestinal blockages, or toxic exposure
• 79.
  Treatment  Treatment focuseson addressing underlying causes and preventing harm: • Nutritional supplementation for deficiencies (iron, zinc) • Behavioral therapy, including cognitive-behavioral approaches to reduce cravings • Aversive therapy, oral taste (lemon) smell sensation ( ammonia) and physical sensation ( water mist in face) • Environmental modifications, such as keeping non-food items out of reach • Positive reinforcement • Discrimination training between edible and inedible items, with negative consequences. • Physical restraints and behavior modification: Self- protection devices that prohibit placement of objects in mouth. • Time-out contingent on pica being attempted • Overcorrection, with attempted pica resulting in required washing of self, disposal of nonedible objects and chore-based punishment. • Negative practice- Non-edible object held against patient’s mouth without allowing ingestion.
• 80.
  • Monitoring andmedical care for complications like poisoning or gastrointestinal issues  In children, pica often improves with age, but persistent cases, especially in those with developmental disorders, may require ongoing support
• 81.
  NURSING MANAGEMENT: NURSING ASSESSMENTFOR ANOREXIA NERVOSA
• 85.
  NURSING INTERVENTION  Foranorexia nervosa:  Imbalanced nutrition/deficient fluid volume less than body requirements related to refusal to eat/ drink, severe fear of obesity self-induced vomiting , abuse of laxatives as evidenced by loss of weight, poor muscle tone, dry mucous membrane.  Interventions: 1. Dietitian will determine number of calories required to provide adequate nutrition. 2. Weight patient daily. Keep strict record of intake and output.
• 86.
   Stay withpatient during established time for meal(usually 30 min) and for at least 1 hours following meals.  If excessive weight loss occurs due to deterioration in nutritional status, tube feedings will be initiated.  Encourage the patient to explore and identify the true feelings and fears that contribute to maladaptive eating behavior.  FOR BULIMIA NERVOSA: 2. Imbalanced nutrition more than body requirements : 1. Encourage the patient to keep a diary of food intake. 2. Discuss feelings and emotions associated with eating. Formulate an eating plan that includes food from the required food groups with low-fat intake.
• 87.
   Plan aprogressive exercise program tailored to individual goals and choice. Exercise may enhance weight loss by burning calories, reducing appetite, increasing energies etc.
• 88.
   With inputfrom the client, formulate an eating plan with emphasis on low intake food.  Provide instruction about medications to assist with weight loss. Appetite suppressant drugs: phentermine and other that have weight loss as a side effect e.g. : fluoxetine, topiramate.
• 89.
  NURSING INTERVENTIONS: FOR THEPATIENT WITH OBESITY  Assess the patient’s feeling and attitude about being obese. Obesity and compulsive eating behavior may have deep rooted psychological implications such as compensation for lack of love or nurturing.  Determine the patient’s motivation for weight loss and set goals. The individual may harbor repressed feelings of hostility, which may be expressed inwardly on the self.  Help the patient identify positive self-attributes. Focus on strengths and past accomplishment unrelated to physical appearance.  Group therapy : support groups – increase motivation 