Nurse’s Guide to Caring for Patients With Eating Disorders
Eating disorders can lead to serious health issues and be fatal. Find out how nurses can recognize warning signs and manage care to help patients successfully recover.
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Eating disorders (EDs) do not discriminate. People of all ages, ethnicities, backgrounds, and genders can suffer from an ED. They start from painful thoughts or emotions and, if left untreated, lead to severe health problems, even death. Early detection and proper treatment are critical to a successful outcome.
"Nurses interact with patients who might not otherwise be detected as having an eating disorder," Cassandra Godzik, the associate dean for Regis College School of Nursing states. "EDs are usually practiced in secrecy, behind closed doors of the bathroom, such as in binging/purging ED, because shame and guilt are associated with this mental health illness."
She continues, "Patients might show up in the physician's office, and nurses are the first to ask patients questions about their holistic health (think appetite, sleep, exercise behaviors, etc.)."
Explore this guide to learn more about EDs and your role as a nurse.
Fast Facts About Eating Disorders
28.8 million Americans will experience an eating disorder in their lifetime.*
Approximately 10,200 deaths were associated with eating disorders between 2018 and 2019.**
Of people with an eating disorder, less than 6% are medically diagnosed as "underweight."
** Deloitte Access Economics: Social and Economic Cost of Eating Disorders in the United States of America
The Role of Nurses When Caring for Patients With Eating Disorders
Nurses play an essential role in identifying destructive eating patterns and providing physical and emotional care for patients from detection to recovery. The goal is to have a manageable multidisciplinary, holistic approach to care.
Monitoring nutritional status, electrolyte balance, weight, and activity, while keeping watch over diuretic/laxative use, make up important aspects of a nurse's role.
Patients also need emotional support, as they face deep pain and traumatic thoughts. Nurses can gain trust through active listening, empathy, and positive reinforcement. They can foster independence and educate patients and loved ones.
Establishing goals to ensure the patient maintains awareness, practices healthy coping techniques, and adopts a positive body image and sense of self-worth is a priority.
Godzik identifies the role of the nurse when caring for patients with EDs to include:
- Active listening
- Availability and being present
- Open, honest communication
- Time for the patients to reflect on the best approach for recovery
- Multidisciplinary approach to care and serving as an advocate
- Staying nonjudgmental
How to Recognize an Eating Disorder
Nurses are often the initial point of contact for patients. As a result, they can recognize an ED through routine assessments of vital signs, weight, and dietary/eating trends.
Physical and emotional signs can warn nurses of eating disorders. Physical presentations include cardiac irregularities, elevated blood pressure, hair loss, weight fluctuations, fainting, tooth decay, skin breakdown, and bruised/callused knuckles.
Emotional or behavioral indicators may include depression, impulsiveness, obsessiveness, perfectionism, isolation, bathroom visits after meals, stashing food, excessive exercise, or concealed eating.
Who Is at Risk of Developing an Eating Disorder?
Researchers believe ED stems from a combination of biological, psychological, and sociocultural factors. The road to recovery begins with identification of the underlying cause and risk factors.
The National Eating Disorders Association and the National Alliance of Mental Illness identify risk factors for developing ED. Biological influences include dieting, a family member with an ED or mental condition, and Type 1 diabetes. Teens/young adults and women tend to be more at risk.
Psychological factors include distorted body image, perfectionism, obsessive-compulsiveness, anxiety, or social phobia. Social effects involve diet fads, our culture's "ideal" body type, overprotective parents, being bullied, and certain activities like gymnastics or dancing.
Although there are identifiable risk factors, an ED can present itself regardless of age, race, socioeconomic class, body type, or gender. For example, eating disorders are not always visible. Clearing any misconceptions or preconceived ideas can prevent misdiagnosis.
Types of Eating Disorders
EDs are not unhealthy choices in dietary habits. They are a detrimental attempt to manage emotional issues. Just as there are many risk factors for why someone may develop an eating disorder, there are also different types of eating disorders.
Some of the most common EDs include anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), avoidant-restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED), and unspecified feeding or eating disorder.
According to the National Institute of Mental Health (NIMH), AN is "characterized by a significant and persistent reduction in food intake, leading to extremely low body weight in the context of age, sex, and physical health; a relentless pursuit of thinness; a distortion of body image and intense fear of gaining weight; and extremely disturbed eating behavior."
AN has a high incidence of morbidity and mortality because of medical complications associated with self-starvation or suicide.
AN can present at any age, but it is more common in adolescent females with the median age of onset at 18 years old. Other risk factors include a transition or major life event, trauma or abuse, dieting, genetics, or culture. An extreme drive for perfectionism or obsessive-compulsive disorder can accompany AN.
Symptoms of AN can present as physical signs of starvation or behavioral changes. Some more common symptoms include severe restricted eating, emaciation, extreme fear of weight gain, wearing baggy clothes, and distorted body image.
The NIMH characterizes BN as "binge eating (eating large amounts of food in a short time, along with the sense of a loss of control), followed by a type of behavior that compensates for the binge, such as purging (e.g., vomiting, excessive use of laxatives, or diuretics), fasting, and/or excessive exercise."
BN typically starts in the late teens or early adulthood and is more common in women. The median age of onset is 18 years old. Other risk factors can be genetic or familial predisposition, a previous traumatic event, dieting, distorted body image, or psychological issues, such as depression and anger.
BN symptoms may include callused/bruised knuckles, weight fluctuations, irregular periods and dental problems. Isolation, fainting, dry skin, hoarding food, or excessive exercise are also signs to look for.
The NIMH says that BED is the leading eating disorder in the U.S. It is "characterized by recurrent binge-eating episodes, during which a person feels a loss of control and marked distress over his or her eating. Unlike bulimia nervosa, binge-eating episodes are not followed by purging, excessive exercise, or fasting. As a result, people with binge-eating disorder often are overweight or obese."
BED is more prevalent in females, with the highest incidences occurring for those ages 45-59 years, followed by 19-29. The median age of onset is 21.
Other risk factors can be genetic or familial predisposition, psychological issues like depression or anger, substance misuse, distorted body image, and a previous traumatic event. Dieting and boredom are also factors. Symptoms of BED may include eating even when full, concealed eating, eating large amounts of food, frequent dieting, and feelings of shame, depression, disgust, and guilt.
Other Eating Disorders
With avoidant-restrictive food intake disorder, a person limits their intake of food but does not have a distorted body image or fear of weight gain as seen with AN. Other eating disorders include unspecified feeding or eating disorders or specified feeding or eating disorders.
OSFEDs include purging disorders that entail purging but not binging. Night-eating syndrome involves waking up at night and consuming a large amount of food. A patient with pica disorder eats things that are not food. Rumination disorder involves regular regurgitation of food that is rechewed, reswallowed, or spit out.
Best Practices for Nurses When Caring for Patients With Eating Disorders
The role of the nurse is cyclical, from detection to recovery and ongoing monitoring. Godzik states, "Nurses collaborating with patients with ED should be cognizant that patients can certainly enter recovery from an ED. However, it is something that nurses should be monitoring on an ongoing basis."
Best practices for nurses include the following.
1. Conscious Language
Nurses must be conscientious when communicating with patients with ED. Refrain from commenting about their weight, appearance, and food/intake.
"Asking the patient about whether they want to be made aware of their weight is important," Godzik says.
"Also, healthcare providers like nurses should not make comments about weight changes of their patients ('Oh, wow, you lost so much weight. You look great!' … or 'I see you gained weight. What's going on in your life?')," Godzik continues. "Comments about appearance can be difficult for patients to hear if they've experienced ED behaviors in the past."
Options to promote constructive self-talk could be to compliment them on other positive qualities unrelated to appearance or highlight features they like about themselves.
2. Identifying Potential Triggers
A patient may face setbacks on their road to recovery. Identifying stressors can help minimize the chance of relapse. Patients can overcome obstacles with a relapse prevention plan that lists their triggers. They can also throw away their scale and create a healthy meal plan.
Godzik says that nurses should check in at each appointment about the patient's appetite and pay close attention to changes in vital signs, height, and weight. "Stressors in a patient's life can bring up feelings and emotions that might cause relapse for them."
However, Godzik notes that "it is important to keep in mind that patients recovering from ED can be sensitive to hearing or visualizing weight on the scale. Nurses … should be mindful that not all patients want to hear about their weight. It can be triggering for them and cause them to ruminate about their eating behaviors."
3. Collaborative Plan of Care
The nurse case/care manager promotes autonomy and accountability by offering guidance to allow the patient to play an active part in managing their ED. Guiding patients to recovery, nurses can help them develop a plan of care to include meals (for instance, small frequent meals with snacks), physical and social activity, and managing all aspects of healthier living.
4. Support and Resources
Nurses provide a safe environment with active listening, open communication, and empathy. As an advocate, nurses ensure a multidisciplinary and holistic team approach. They can provide referral options to patients and loved ones, such as information on support groups and other eating disorder resources.
What Are Common Treatments and Therapies for Eating Disorders?
Patients diagnosed with ED suffer deep emotional turmoil because of traumatic thoughts or events. As the patient confronts their trauma, the risk of ED behavior can increase. They are also at an increased risk for suicide, mental disorders, physical illnesses, or substance misuse. An integrated approach to treating eating disorder symptoms is best.
Common treatments for EDs include nutritional counseling or psychotherapies. Psychotherapy may entail group therapy, family therapy, and individual psychotherapy, such as cognitive behavioral therapy (CBT). Another method of treatment includes medications like antidepressants, antipsychotics, or mood stabilizers.
"The goals of treatment for a patient with an eating disorder need to be patient-centered or patient-driven, meaning that the patient and the nurse work to formulate shared goals for recovery."
Godzik says, "The goals of treatment for a patient with an eating disorder need to be patient-centered or patient-driven, meaning that the patient and the nurse work to formulate shared goals for recovery. Goals and outcomes are determined alongside the patient, versus telling the patient what to do."
Godzik states that treatment can involve family members or a patient's friends to support the patient. "It is a team effort."
"Some goals that might be generated during ED treatment," Godzik says, "can be (1) not engaging in ED behaviors (restricting calories, not binging, and purging) during the next week; (2) restoring weight to healthy body mass index limits; and (3) participating in group or individual therapy twice weekly."
More Than Just Food
Risk factors vary, making ED detection a challenge. The role as a nurse is crucial in identifying the risks and clinical presentation of EDs and managing the patient through recovery.
Continuing education helps nurses stay up to date on EDs. By applying knowledge and nursing tips in caring for patients with ED, nurses can play a significant role in a positive patient outcome.
Helpful Eating Disorder Resources for Nurses
MedlinePlus.gov offers information on the types of eating disorders and identifies the causes, risk factors, symptoms, and clinical presentation of the disorder. It also lists diagnostic testing and treatment options.
ANAD is the nation's leading nonprofit, providing free peer support services to anyone struggling with disordered eating and body image. Volunteers understand the journey through their own experience and recovery from EDs.
Eating disorder treatments at Cleveland Clinic include psychotherapy, such as CBT, the Maudsley approach or family-based treatment, medication, and nutritional counseling. An ideal plan would include a collaborative method of collective treatments.
A team of healthcare professionals developed these questions as a screening tool when assessing patients with ED:
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry that you have lost Control over how much you eat?
- Have you recently lost more than One stone (14 lbs.) in a three-month period?
- Do you believe yourself to be Fat when others say you are too thin?
- 5. Would you say that Food dominates your life?
Meet Our Contributor
Cassandra Godzik, Ph.D., APRN, PMHNP-BC, CNE
Dr. Cassandra Godzik is the associate dean at Regis College School of Nursing. During her time at Regis, she has worked as an RN in the adolescent personality disorder and adult female eating disorder units at McLean Hospital. She is also a psychiatric nurse practitioner working as a nurse manager/clinical educator at McLean. In this role, she assists people with psychiatric diagnoses in inpatient and residential settings.
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