Laboratory abnormalities in bulimia nervosa may include electrolyte imbalances such as hypokalemia, hypochloremic alkalosis, mild elevations of serum amylase, and hypomagnesemia and hypophosphatemia, especially in laxative abusers.

It is the frequency and intensity of the bingeing that separates anorexics from bulimics, even though both will restrict food consumption and many anorexics also binge and purge. Anorexics who purge and normal weight individuals who do not binge but vomit whenever they eat food they consider as too fattening are often improperly diagnosed with bulimia nervosa. Without binge eating the diagnosis of bulimia is incorrect. However the disorders do cross over into each other.

Dr. Marc Darrow, believes that most people with bulimia have thought patterns and experience symptoms similar to those with anorexia. The drive for thinness and the fear of being fat appear in both disorders, and while body image distortion is present in bulimia, it is usually not to the same degree as in anorexia nervosa.

Most people with bulimia restrict caloric intake such that they try to keep a weight that is too low for them to maintain without experiencing many of the symptoms of semi-starvation. Some bulimics are at or above normal weight but nevertheless experience starvation symptoms due to their continual efforts to restrict food intake. Individuals with bulimia nervosa live in a world between compulsive, or binge eating, and starving, pulled in both directions. Bulimics are often referred to as "failed anorexics"-they have repeatedly tried to control their weight by restricting intake and have been unable to do so. These individuals end up bingeing and then, out of anxiety and desperation, purge through self-induced vomiting, laxatives, or diuretics, or use other compensatory behaviors to make up for their binges, such as fasting, exercise, saunas, or other similar means. On the other hand, many individuals with bulimia describe themselves as binge eaters first who then resort to purging after dieting fails.

Purging and other compensatory behaviors often serve to calm down bulimics and ease their guilt and anxiousness about having consumed too much food or gained weight. As the disorder progresses, bulimics will purge or compensate for eating even normal or small amounts of anything they consider "bad" or "fattening" and, eventually, any food at all. Binges can eventually be quite extreme. Binges of up to 50,000 calories a day have been recorded.

Overall, it is important to understand that bulimia nervosa, which appears in the beginning to be related to dieting and weight control, eventually becomes a means of mood regulation in general. A bulimic finds solace in food and often in the purging itself. The act of purging becomes powerfully addictive, not just because it controls weight, but because it is calming, or serves as a way of expressing anger, or in some other way helps the individual cope.

Bulimics seem to be individuals who need help regulating or modulating mood states and therefore are more prone to use a variety of coping mechanisms such as drugs, alcohol, and even sex.

Social functioning and adjustment among individuals with bulimia vary. For one thing, unlike anorexics, bulimics are not easily identified by their unusually low weight and are able to be successful at work, in school, and in relationships, while keeping the bulimia a secret. Patients have disclosed their bulimia to therapists after successfully hiding it from everyone, including their spouses, sometimes for as long as twenty years. Some bulimics however become so entrenched in the disorder, bingeing and purging eighteen or more times per day, that they have little or no ability to perform on the job or in school and have marked difficulty with relationships.

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Eating Disorder Not Otherwise Specified

The Eating Disorder Not Otherwise Specified (EDNOS) category is for disorders of eating that do not meet the criteria for any specific eating disorder. In EDNOS, individuals engage in some form of abnormal eating, but do not exhibit all the specific symptoms required to diagnose an eating disorder. An individual with EDNOS may meet all the criteria of anorexia nervosa but manage to maintain normal weight while someone else may engage in purging behavior with less frequency or intensity than a diagnosed bulimic.

The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. The American Psychiatric Association uses the following clinical descriptions:

1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses.
2. All of the criteria for Anorexia Nervosa are met except that despite significant weight loss, the individual's current weight is in the normal range.
3. All of the criteria for Bulimia Nervosa are met except that the binge eating inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.
4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (for example, self induced vomiting after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
6. Binge eating disorder- recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa.

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Binge Eating Disorder Categories

Binge eating disorder (BED) is the newest clinically recognized eating disorder. The term was developed to describe individuals who binge eat but do not use extreme compensatory behaviors such as fasting or purging to lose weight. In the past, these individuals were often referred to as compulsive overeaters, emotional overeaters, or food addicts. Many of these individuals suffer from debilitating patterns of eating for self-soothing rather than following physiological cues to eat. This nonhunger eating, when done on a regular basis, produces weight gain and even obesity.

Some professionals are of the opinion that there are two distinct subcategories of binge eating: deprivation-sensitive binge eating and addictive or dissociative binge eating. Deprivation-sensitive binge eating appears to be the result of weight loss diets or periods of restrictive eating, both of which result in binge eating episodes. Addictive or dissociative binge eating is the practice of self-medicating or self-soothing with food unrelated to prior restricting. Many individuals report feelings of numbness, dissociation, calmness, or regaining of inner equilibrium after binge eating.

The American Psychiatric Association uses the following diagnostic research criteria:

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. Eating, in a discrete period of time (for example, within any two-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances; and

2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating).

B. The binge eating episodes are associated with three (or more) of the following:

1. 1. eating much more rapidly than normal,
2. 2. eating until feeling uncomfortably full,
3. 3. eating large amounts of food when not feeling physically hungry,
4. 4. eating alone because of being embarrassed by how much one is eating,
5. 5. feeling disgusted with oneself, depressed, or very guilty after overeating.

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least two days a week for six months. Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating.

E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (for example, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

Misconceptions

It is a common misconception that all people who are overweight or obese have binge eating disorder, but being overweight or obese does not imply the existence of binge eating disorder. To distinguish simple overeating from binge eating, it is important to understand the use of the word "binge". According to the Webster's Collegiate Dictionary, tenth edition, the word binge can be applied to anything where there is "an unrestrained or excessive indulgence." In binge eating disorder, the food is binged on in a discrete period of time with the individual reporting an inability to stop or to control the behavior.

Binge eating was first observed and reported in studies on obesity in the late 1950s. In the 1980s, additional studies on obesity and bulimia nervosa showed that many people in both populations have binge eating problems without the other criteria for bulimia nervosa. Then, in 1992, the term binge eating disorder was adopted at the International Eating Disorders Conference.

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Treatment and Levels of Care

The services available for the treatment of eating disorders can range from intensive inpatient settings, partial hospital and residential programs, to varying levels of outpatient care, the patient can receive general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy.

The American Psychiatric Association recommends that pretreatment evaluation of the patient is essential for determining the appropriate setting of treatment. Weight and cardiac and metabolic status are the most important physical parameters for determining choice of setting. Generally, patients who weigh less than approximately 85% of their individually estimated healthy weights have considerable difficulty gaining weight in the absence of a highly structured program. Those weighing less than about 75% of their individually estimated healthy weights are likely to require a 24-hour hospital program.

Once weight loss is severe enough to cause the indications for immediate medical hospitalization, treatment may be less effective, refeeding may entail greater risks, and prognosis may be more problematic than when intervention is provided earlier. Knowledge about gray matter deficits that result from malnutrition and persist following refeeding also point to the need for earlier rather than later effective interventions. Therefore, hospitalization should occur before the onset of medical instability as manifested by abnormal vital signs.

The decision to hospitalize should be based on psychiatric and behavioral grounds, including rapid or persistent decline in oral intake; decline in weight despite maximally intensive outpatient or partial hospitalization interventions; the presence of additional stressors--such as intercurrent viral illnesses--that may additionally interfere with the patient's ability to eat; prior knowledge of weight at which instability is likely to occur; and comorbid psychiatric problems that merit hospitalization.

Indications for immediate medical hospitalization include marked orthostatic hypotension with an increase in pulse of >20 bpm or a drop in blood pressure of >20 mm Hg/minute standing, bradycardia below 40 bpm, tachycardia over 110 bpm, or inability to sustain body core temperature (e.g., temperatures below 97.0¡ÆF). Most severely underweight patients, those with physiological instability, and many children and adolescents whose weight loss, while rapid, has not been as severe as in adult patients nonetheless require inpatient medical management and comprehensive treatment for support of weight gain.

Although most patients with uncomplicated bulimia nervosa do not require hospitalization, indications for hospitalization can include severe disabling symptoms that have not responded to adequate trials of competent outpatient treatment, serious concurrent general medical problems (e.g., metabolic abnormalities, hematemesis, vital sign changes, or the appearance of uncontrolled vomiting), suicidality, psychiatric disturbances that would warrant the patient's hospitalization independent of the eating disorders diagnosis, or severe concurrent alcohol or drug abuse.

Legal interventions, including involuntary hospitalization and legal guardianship, may be necessary to ensure the safety of treatment-reluctant patients whose general medical conditions are life-threatening. Decisions to hospitalize on a psychiatric versus general medical or adolescent/pediatric unit depend on the patient's general medical status, the skills and abilities of local psychiatric and general medical staffs, and the availability of suitable programs to care for the patient's general medical and psychiatric problems. Some evidence suggests that patients treated in eating disorders inpatient specialty units have better outcomes than patients treated in general inpatient settings that lack expertise and experience in treating patients with eating disorders.

Partial hospitalization and day hospital programs are being increasingly used in attempts to decrease the length of some inpatient hospitalizations; for milder cases, these programs are being increasingly used in place of hospitalization. However, such programs may not be appropriate for patients with lower initial weights (e.g., those who are less than 75% of average weight for height). In clinical practice, failure of outpatient treatment is one of the most frequent indications for more intensive treatment, either day/partial hospital or inpatient. In deciding whether to treat in a partial hospitalization program, the patient's level of motivation to participate in treatment and ability to work in a group setting should be considered.

Patients with high motivation to comply with treatment, cooperative families, brief symptom duration, and who are less than 20% below healthy body weight may benefit from treatment in outpatient settings, but only if they are carefully monitored and if they and their families understand that a more restrictive setting may be necessary if persistent progress is not evident in a few weeks (8-10). Careful monitoring includes at least weekly (and often two to three times a week) postvoiding gowned weighings, which may also include measurement of urine specific gravity together with orthostatic vital signs and temperatures. While patients treated in the outpatient setting can remain with their families and continue to attend school or work, these advantages must be balanced against the risks of failure to progress in recovery.

Anorexia Nervosa Recovery

A recent study by Drs. Strober, Freeman and Morrell, to assess the long-term course of recovery and relapse as well as predicators of outcome in anorexia nervosa tracked ninety-five participants, ages twelve to seventeen. They were selected from a specialized university treatment program, were assessed semiannually for five years, and were assessed annually thereafter over a period of ten to fifteen years. Recovery was defined in terms of varying levels of symptom remission maintained for no fewer than eight consecutive weeks. In this study:

• Full recovery was achieved in 75.8 percent;
• Partial recovery was achieved in 10.5 percent; and
• Chronicity, or no recovery, was evidenced in 13.7 percent.

By the end of the follow-up, most patients were weight-recovered and menstruating regularly. Nearly 86 percent of the patients met the study's criteria for partial, if not full, recovery, and roughly 76 percent achieved full recovery. Furthermore, none of the patients died from anorexia nervosa during the course of the study. It is important to note that relapse after recovery was relatively uncommon, while nearly 30 percent of the patients discharged from the treatment program prior to clinical recovery had relapses. It is also important to note that recovery took a substantial amount of time, ranging from fifty-seven to seventy-nine months. Other findings include:

• Among restrictors at intake, nearly 30 percent developed binge eating within five years of intake.
• No correlation between poorer outcome and longer duration of illness, lower minimum body weight, binge eating, vomiting, or prior treatment failure.
• Recovery time was lengthened significantly among patients with disturbances in family relationships.
• A compulsive drive to exercise present at the time of discharge was found to be a predictor of chronic outcome.
• Being asocial prior to the eating disorder was a statistically significant predictor of chronic outcome.
• Bulimia Nervosa Recovery

A recent study conducted by Drs Fichter and Quadfling assessed the two- and six-year course and outcome of 196 consecutively treated females with bulimia nervosa-purging type (BNP). Results showed that at the six-year follow-up, 59.9 percent achieved a good outcome, 29.4 percent an intermediate outcome, and 9.6 percent a poor outcome. Two persons were deceased, accounting for the remaining 1.1 percent. Over time, the general pattern of results showed substantial improvement during therapy, a slight decline during the first two years after treatment, and further improvement and stabilization from three to six years after treatment.

Other interesting findings from the six-year follow-up include:

• 20.9 percent had bulimia nervosa-purging type BN-P.
• 0.5 percent had bulimia nervosa-nonpurging type BN-NP.
• 1.1 percent shifted from bulimia nervosa to binge-eating disorder.
• 3.7 percent had anorexia nervosa.
• 1.6 percent were classified as eating disorder not otherwise specified (EDNOS).
• 2 patients died.
• 6 percent had a body mass index (BMI) of greater than 30.
• The majority (71.1 percent) showed no major DSM-IV eating disorder.

Impediments to Recovery

Pro-eating-disorder Web sites have proliferated on the Internet and encourage their users to view eating disorders as a "lifestyle choice" rather than an illness. These sites now outnumber pro-recovery sites five to one. Research conducted at Stanford University and Lucile Packard Children's Hospital in Palo Alto, Ca show that over 40% of patients that had been diagnosed with an eating disorder had visited such sites. Teens who frequent these sites were hospitalized three times more than nonusers, and nearly two-thirds of visitors to these sites used new weight loss or purging techniques they learned about through the sites.

The study reported that a typical "pro-Ana" (code for anorexia) or "pro Mia" (code for Bulimia) Web site personified the illness into a perfect person, "Ana," and provides their viewers with new methods of hiding their eating disorder behaviors, cheating on weigh-ins at the doctors office, and providing what the sites call "thinspiration"-glamour shots of thin women and celebrities, and specially designed goal-weight charts where they can report their "cw" and "gw" -current weight and goal weight.

Some sites even include a special food pyramid, with food placed at the narrow tip to be used sparingly while the bulk of the structure promotes large rations of water, diet soda, black coffee and cigarettes. Many sites sell merchandise such as red Ana bracelets, jewelry, t-shirts and other products. Carmen Mikhail, director of the eating disorders clinic at Texas Children's Hospital in Houston, Tx believes that the Ana movement plays on the tendency that people with eating disorders have toward "all or nothing at all." Ana is a role model to some, a goddess to others, the subject of drawings, prayers and even a creed. "She" tells them what to eat and mocks them when they don't lose weight. Some Web-sites encourage followers to make a vow to Ana and sign it in blood.

Dr. Martin Fisher, chief of the division of adolescent medicine at Schneider Children's Hospital in Manhasset, N.Y. fears that teens in recovery that have their parents and health professionals pushing against their disorder, that these sites support the side of the brain that says "yes" to the eating disorder. Those with an undiagnosed and untreated eating disorder may feel a sense of community with other victims which could spur the illness on.

Treatment can include writing goodbye letters to Ana or Mia to gain control over them. However it is easy for patients to fall back into the online world of Ana after they leave treatment.

Role of the Registered Dietitian

The Academy of Nutrition and Dietetics recommends that the Registered Dietitian assess the nutritional status, knowledge base, motivation, and current eating and behavioral status of the patient, develops the nutrition section of the treatment plan and supports the patient throughout the course of treatment. The registered dietitian addresses the food and nutrition issues, the behavior associated with these issues, and assist the medical team with monitoring lab values, vital signs, and physical symptoms associated with malnutrition. The psychotherapeutic issues are the focus of the psychotherapist or mental health worker.

Because of the complex biopsychosocial aspects of eating disorders, the AND recommends that the optimal assessment and ongoing management of these conditions appears to be with an interdisciplinary team consisting of professionals from medical, nursing, nutritional and mental health disciplines (1). Medical Nutrition Therapy provided by a registered dietitian trained in the area of eating disorders plays a significant role in the treatment and management of eating disorders. The registered dietitian, however, must understand the complexities of eating disorders such as comorbid illness, medical and psychological complications, and boundary issues. The registered dietitian needs to be aware of the specific populations at risk for eating disorders and the special considerations when dealing with these individuals.

The American Psychiatric Association guidelines recommend nutritional rehabilitation as a first goal in the treatment of anorexia and bulimia.

For patients diagnosed with an eating disorder there are two phases of the nutritional aspect of treatment.

1. The education phases, in which nutrition information is provided in a factual manner with little or no emphasis on the emotional issues.
2. The experimental phase, where the registered dietitian works in conjunction with other members of a treatment tea and builds a long-term, relationship-based counseling.

When working with eating disordered individuals, a treatment team is important because the psychological issues involved in the patient's eating and exercise patterns are so intertwined. The registered dietitian needs therapeutic backup and must be in regular contact with the therapist and other members of the team.

Dietitians should involve the patient in a discussion of the following topics:

• What kind and how much food the client's body needs
• Symptoms of starvation and of refeeding (the process of beginning to eat normally after a period of starvation)
• Effects of fat and protein deficiency
• Effects of laxative and diuretic abuse
• Metabolic rate and the effect of restricting, bingeing, purging, and yo-yo dieting
• Food facts and fallacies
• How restricting, bingeing, and taking laxatives or diuretics influence hydration (water) shifts in the body and thus body weight on the scale
• The relationship between diet and exercise
• The relationship of diet to osteoporosis and other medical conditions
• The extra nutritional needs during certain conditions such as pregnancy or illness
• The difference between "physical" and "emotional" hunger
• Hunger and fullness signals
• How to maintain weight
• Establishing a goal weight range
• How to feel comfortable eating in social settings
• How to shop and cook for self and/or significant others
• Nutritional supplement requirements

Case Studies

1. Gina is a 14 year-old 9th grade student in a large suburban high school.

When she started there 6 months ago, she had come from a small school where she had spent the previous 8 years. It has been a major challenge for her and she has had a hard time figuring out how to fit in. The few people she knew before starting there are not in any of her classes. The classroom work is also challenging and although she is generally keeping up, she has to work hard. She comes home every evening and spends most of the time in her bedroom, choosing to focus on her grades until she feels confident enough to try an extracurricular activity. Though she was quiet before, she seems to have become withdrawn as the year has progressed.

Her mother became very concerned about Gina's behavior when she noticed she was always napping during the dinner hour and she observed her eating only a few grapes for breakfast, cutting them in half with a knife before eating them. Gina's favorite clothes were looking baggy on her. When she went to her pediatrician, she found Gina had lost 20 pounds in the past year, had not changed in height, and Gina admitted her periods had stopped. Gina was given a diagnosis of anorexia.

Because her weight was 90% of a healthy body weight, the doctor recommended outpatient care including weekly visits with a psychotherapist and a registered dietitian who collaborate with the doctor to help Gina understand effective ways to deal with the dynamic changes often experienced in this phase of adolescence. Gina met with the dietitian weekly to understand her nutritional needs and how to eat to meet these needs. Establishing a trusting relationship between the professionals and Gina was key. Once this occurred, she talked easily with the dietitian. The dietitian worked with her to increase calories to an appropriate level for weight maintenance and gain, described the variety and portions of foods needed, helped her understand the symptoms of starvation and nutritional deficiencies, helped her to understand fluid shifts.

They worked on dispelling food myths and misinformation, did role play for eating meals out and meal preparation at home. Gina's meal plan consisted of 3 meals and 2 snacks daily; she was not to vary from the plan. Her family was also intimately involved in her therapy and observing for accountability with the meal plan. Deviations with the meal plan observed by the family were handled by the dietitian to reduce conflict at mealtimes in the home. Gina eventually regained the weight she had lost and grew in stature though the process was long term with relapses.

2. Sheila is a 22-year-old overweight (BMI=29), recent college graduate working as a preschool teacher.

She excelled in college earning honors in her program and great letters of recommendation from professors. She has a boyfriend who is very enamored of her, anticipating her needs, driving her from place to place. She is soft-spoken and very well liked by most who encounter her. She asked her primary care doctor for a referral to see a registered dietitian because she wanted to lose weight. When she met with the dietitian, just before the initial interview was finished, she asked to share something very private. She admitted that she had been bingeing and purging by vomiting for the past 3 years.

The dietitian worked with her to inform her of the benefit of letting the primary care doctor know about this. The dietitian gave her a meal plan with 3 meals and 3 snacks at an appropriate level for weight maintenance. The dietitian shared with her the observation that nutrition counseling and physician care is not usually enough for maximum patient benefit. Sheila did not keep her third scheduled appointment, did not return a phone call, and did not come back for care.

3. Janet is a 55-year-old, obese (BMI=35), female with type 2 diabetes, hypertension, and hyperlipidemia, all of which are poorly controlled.

She has lived with her elderly, infirmed parents for the past 5 years since a divorce. She works the night shift as a nurse's aid in a nursing home. Her days are spent taking care of her parents. She feels like her work never ends because her life at home is so similar to her job. Janet knows she is gaining weight but she ignores this fact. She has much pride in behavior she changed ten years before when she attended Alcoholics Anonymous and overcame her alcohol dependence.

She knows she struggles with eating but it sometimes seems to be the only activity that gives her pleasure. Her parents do not help the situation by continually making derogatory remarks about her weight and size, the kind they have made throughout her life. She cooks and eats with her parents, being careful to have small meals. When she eats at work however and other times when she is alone, she eats large quantities of food.

A few times a week she goes to 3 or 4 drive thru restaurants for the inexpensive breakfast foods, which she eats quickly but then feels terrible about after she finishes. After these fast food binges, she goes to a ladies room and brushes her teeth and washes her hands before heading home to prepare and eat breakfast with her parents. Janet knows her eating is out of control but she is not sure how to stop. An incident of blurred vision secondary to a high blood sugar level got her attention and caused her to see her physician, who adjusted her diabetes medication and suggested she work with a therapist and a registered dietitian.

Janet's dietitian realized from her assessment that Janet had binge eating disorder (Total calories on a binge day-3500 with 2000 from fast food bingeing), confirming this with the therapist. She worked to stabilize Janet's weight, blood sugar, blood pressure and cholesterol levels.

• She gave Janet a meal plan at a realistic calorie level given her medications and activities.
• She encouraged Janet to believe that all foods can fit into a healthful eating plan so that stigmas about "good" and "bad" foods could be dispelled.
• She encouraged Janet to pay attention to her hunger and fullness before and after meals.
• Janet identified activities she enjoyed that she could do for pleasure other than eating which included some walking for exercise.

Janet's episodes of binges diminished substantially, her physical health improved as did her mood.

Summary

The more that is learned about eating disorders the more it is realized that there are certain individuals predisposed to develop them. There are far more people with eating or body image problems than those with full-blown eating disorders. The registered dietitian must be aware of specific populations at risk for eating disorders and specific considerations when treating these patients. The registered dietitian plays a significant role in the treatment and management of eating disorders.

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