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Anorexia nervosa has received a great deal of attention in the popular media in recent years. This disorder is listed under the category of disorders of childhood or adolescence in DSM-III. Anorexia consists of extreme weight loss due to a reduction in eating. It occurs most frequently in female adolescents; only about 1 in 10 people with anorexia are male. The disorder is believed to be rate, but one study found an incidence of 1 case out of 200 adolescent girls.
Anorexia begins when the adolescent starts to diet.
The person often has major problems in self-esteem and concerns about physical appearance. Weight reduction may be one way for the person to feel in control of her or his behavior, and to improve self-esteem ( Lager, 2003). However, for anorexics, dieting gets out of hand. They develop an unreasonable fear of eating, and often suppress hunger by engaging in repetitive activity such as frequent exercising. When anorexics must eat because others (e.g., parent) demand it, they often will induce vomiting after meals to get rid of the food ingested.
Even though the anorexic begins to waste away and develops such physical problems as cessation of menstruation (for girls), constipation, and imbalances in body chemistry, she or he is often unconcerned about the life-threatening aspect of the behavior (Darby, 2001). Anorexics continue to perceive themselves as heavier that they really are, and some continue to avoid eating until they die from starvation. Death may occur in up to 15 percent of anorexics.
This paper intent to: (1) understand what anorexia nervosa really means and its effects; (2) know the measures for managing anorexia; (3) be aware of the use of pharmacologic agents to stimulate appetite in the terminally ill and; (4) be familiar of the factors influencing nutritional status in varied situations.
Anorexia Nervosa is a psychiatric disorder characterized by an aversion to food and a resulting extreme loss of weight. It is most common in teenage girls and young women. The victims, although not necessarily overweight, become obsessed with a fear of obesity and deliberately subject themselves to a starvation diet (see “Anorexia Nervosa Overview.” eMedicineHeath. Emergency Care + Consumer Health). The resulting malnutrition typically leads to constipation, vomiting, low body temperature, low blood pressure, and amenorrhea (cessation of menstruation). Victims can lose up to 25 percent of their body weight and, if untreated, may die.
Treatment for anorexia consists of hospitalization along with psychotherapy and counseling. Victims are either fed intravenously or are placed on a high-calorie, high-protein diet supplemented by large doses of vitamins.
A. What are an anorexia nervosa and its effects?
At the other end of the spectrum from obesity is anorexia nervosa, an eating disorder associated with self-imposed starvation. The already underweight person continues to restrict food intake, often to the point where death is a genuine concern.
One of the most distinguishing traits of people who have anorexia nervosa is that they do not see themselves as thin (Halmi, 2004). When they look in a mirror, they actually perceive themselves to be overweight or gaining weight. In the latter case they may go out and jog 5 miles or stay up all night jumping jacks. The resulting weight loss and attendant physical stress often lead to an absence of menstruation among females, and the person may look pallid and gaunt.
Anorexia is a puzzling disorder. Why would an otherwise healthy young person starve to death? Although some explanations of anorexia have focused on biological causes (a possible malfunction of the hypothalamus which could lead to a lack of desire for food), current views focus on problems in the family which may lead to anorexic behavior. The parents of anorexic adolescents are often very controlling and attempt to order their children’s lives to a greater extent than do parents of non-anorexics. Furthermore, the families are often filled with conflict between family members. Anorexic behavior may be an extreme, distorted attempt by the adolescent to control at least one aspect of her or his own behavior.
Treatment of anorexia usually involves several different emphases. If the weight loss is life threatening, medical intervention (e.g., intravenous feeding) is necessary. The reinstitution of eating behavior and achieved using behavioral approaches; however, these gains are often short-lived. Most treatment programs report success rates as high as 86 percent. However, anorexia still results in death for some individuals.
A. Measures for managing Anorexia
Anorexia is a common problem in the seriously ill. The profound changes in the patient’s appearance and his or her concomitant lack of interest in the socially important rituals of mealtime are particularly disturbing to families. The approach to the problem varies depending on the patient’s stage of illness, level of disability associated with the illness, and desires. Although causes of anorexia may be controlled for a period of time; progressive anorexia is an expected and natural part of the dying process. Anorexia may be related to or exacerbated by situational variables (eg, the ability to have meals with the family versus eating alone in the “sick room”), progression of the disease, treatment for the disease, or psychological distress. The patient and family should be instructed in strategies to manage the variables associated with anorexia.
B. Measures for Managing Anorexia
There are many ways in how to manage the patient who suffers from anorexia nervosa and it is divided into two measures, the medical interventions and patient and family tips.
a) Medical Interventions
The medical group initiates measures to ensure adequate dietary intake without adding stress to the patient at mealtimes and assess the impact of medications (eg,chemotherapy, antiretroviral) or other therapies (radiation therapy, dialysis)that are being used to treat the underlying illness. It administers and monitors effects of prescribed treatment for nausea, vomiting, and delayed gastric emptying and encourages patient to eat when effects of medications have subsided and assess and modify environment to eliminate unpleasant odors and other factors that cause nausea, vomiting, and anorexia.
Remove items that may reduce appetite (soiled tissues, bedpans, emesis basins, clutter). This medical group assesses and manages anxiety and depression to the extent possible (see “Anorexia Nervosa: Treatment.” Mental Health. MayoClinic.com). It also assesses for constipation and/or intestinal obstruction and prevents and manages constipation on an ongoing basis, even when the patient’s intake is minimal. Furthermore, it provides frequent mouth care, particularly following nourishment, ensure that dentures are properly taken care, and administer and monitor effects of topical systematic for oropharyngeal pain.
b) Patient and Family Teaching Tips
The family reduces the focus on “balanced” meals; offer the same food as often as the patient desires it and increase the nutritional value of meals. For example, add dry milk powder to milk, and use this fortified milk to prepare cream soups, milkshakes, and gravies. Allow and encourage the patient to eat when hungry, regardless of usual meal times. Eliminate or reduce noxious cooking odors, pet odors, or other odors that may precipitate nausea, vomiting, or anorexia and keep patient’s environment clean, uncluttered and comfortable (Halmi, 2004).
Make mealtime a shared experience away from the “sick” room whenever possible. Reduce stress at mealtimes. Avoid confrontations about the amount of food consumed. Reduce or eliminate routine weighing of the patient. Encourage patient to eat in a sitting position; elevate the head of the patient’s bed. The family plan meals (food selection and portion size) that the patient desires. Provide small frequent meals if they are easier for patient to eat. Encourage adequate fluid intake, dietary fiber, and use of bowel program to prevent constipation (Wrede-Seamn, 1999).
C. Use of pharmacologic agents to stimulate appetite in the terminally ill
A number of pharmacologic agents are commonly used to stimulate appetite in anorectic patients. Commonly used medications for appetite stimulation include dexamethasone (Decadron), cyproheptadine (Periactin), megestrol acetate (Megace), and dronabinol (Marinol). Dexamethasone initially increases appetite and may provide short-term weight gain in some patients. However, therapy may need to be discontinued in the patient with a longer life expectancy, as after 3 to 4 weeks corticosteroids interfere with the synthesis of muscle protein. Cyproheptadine may be used when corticosteroids are contraindicated, such as when the patient is diabetic. It promotes mild appetite increase but no appreciable weight gain.
Megestrol acetate produces temporary weight gain of primarily fatty tissue, with little effect on protein balance. Because of the time required to see any effect from this agent, therapy should not be initiated if life expectancy is less than 30 days. Finally, dronabinol is not as effective as the other agents for appetite stimulation in most patients. Although the use of these agents may cause temporary weight gain, their use is not associated with an increase in lean body mass in the terminally ill. Therapy should be tapered or discontinued after 4 to 8 weeks if there is no response (Wrede-Seamn, 1999).
D. Factors Influencing Nutritional Status in varied Situations.
One sensitive indicator of the body’s gain or loss of protein is its nitrogen balance. An adult is said to be nitrogen equilibrium when the nitrogen intake (from food) equals the nitrogen output (in urine, feces, and perspiration); it is a sign of health. A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth, such as occurs during pregnancy, childhood, recovery from surgery, and rebuilding of wasted tissue. Negative nitrogen balance indicates that tissue is breaking down faster than it is being replaced. In the absence of an adequate intake of protein, the body converts protein to glucose for energy. This can occur with fever, starvation, surgery, burns, and debilitating diseases. Each gram of nitrogen loss in excess of intake represents the depletion of 6.25 g of protein or 25 g of muscle tissue. Therefore, a negative nitrogen balance of 10g/day for 10 days could mean the wasting of 2.5 kg (5.5 lb) of muscle tissue as it is converted to glucose for energy.
When conditions that result in negative nitrogen balance are coupled with anorexia (loss of appetite), they can lead to malnutrition.
In conclusion, the prevailing belief among clinical psychologists has been that anorexia arises out of an unstable self-concept. Thus, the commitment to diet and weight control is seen as an attempt to establish a firm sense of identity (Bhanji, 1999). In addition, there is the possibility that this illness, which in about 85 percent of cases occurs in adolescent females, indicates a rejection of traditional feminine roles. Even career patterns play a role. In certain occupations where there is a premium on being thin—for example, ballet dancing—the incidence of clinical anorexia may be great as 50 percent. Further, it has been suggested that malfunctioning neurons in the hypothalamus may alter the metabolism and feeding patterns of people with anorexia nervosa (Leibowitz 2003). At present, however, the empirical support for underlying neurological disturbances is scant (Logue, 1999).
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