Post by Mel on Dec 30, 2005 17:48:34 GMT -5
Nutritional Management of Bulimia Nervosa: Common Concerns and Considerations
Leanne Wagner, Dietician in Private Practice, Brisbane
Unlike anorexia nervosa, bulimia nervosa is often a secret disorder, remaining hidden for many years before sufferers seek help. The characteristic features of bulimia nervosa - strict dieting, binge eating, and compensatory behaviours such as vomiting or laxative misuse, can produce a variety of physical consequences that, if present, need early recognition and ongoing monitoring. In particular, consideration needs to be give to symptoms of the starvation syndrome, delayed gastric emptying, fluid and electrolyte balance, and bowel changes that sufferers may experience.
Starvation Syndrome
When people are starved a number of physical and physiological changes may take place. In bulimia nervosa the focus is often on the bingeing and purging. It is easy to forget that the sufferer may have extended periods of food restriction between binges, or that the purging may mean that the food is not absorbed. In addition, excessive exercise may mean that insufficient energy is consumed for weight maintenance. In all, while the sufferer may appear in the healthy weight range, they may in fact be starved (starvation in the midst of plenty).
The effects of starvation are many :
Preoccupation with food.
Sufferers may think, dream, and talk about food incessantly. They may hoard food, collect recipes, love preparing elaborate meals and become quite agitated if some of the meal is left by those served.
Unusual eating habits.
People with bulimia nervosa may take a long time to eat their meal and become ritualistic about the order in which the meal is eaten. They may drink large quantities of fluids, chew lots of gum or smoke more heavily. Unusual combinations of foods may be eaten and condiments may be used excessively.
Mood swings and personality changes.
Sufferers may be moody, depressed, irritable and withdraw socially. Sleep can be disturbed and there can be difficulty in concentrating, and with decision making, comprehension and memory. There may be difficulty coping with changes in routine, and rigid, obsessional thinking.
This may make the management of bulimia nervosa difficult. While a flexible, healthy eating plan may be recommended, initially this might be very difficult for the person to achieve due to the effects of starvation. Information needs to be clear and written down ( even at the risk of being seen as a rigid "diet" to follow). Suggestions may need to be explained several times as memory and concentration can be effected. As the effects of starvation reverse with refeeding and reduction in the binge/purge cycle, the eating plan can then be made more flexible and new foods can be encouraged.
Delayed Gastric Emptying
One of the physical consequences of starvation is a delayed gastric emptying, that is, food sits in the stomach for longer than usual. It can be worse in those that have used vomiting as a way of purging after binges. The delay in gastric emptying means that the sufferer may feel considerable discomfort and bloating after eating relatively small amounts of food and may find compliance with a healthy eating plan difficult. Small, frequent snacks can help reduce the feeling of fullness however some sufferers may find this does not help. Medications such as cesopride can help gastric emptying and can be of valuable assistance in short term.
Fluid And Electrolyte Balance
When vomiting and laxative abuse are used as a means of purging there can be problems with fluid balance and electrolyte imbalances. In some cases this can produce a life-threatening situation. The levels of potassium, magnesium, phosphate, calcium, sodium and chlorides may be low and there may be volume depletion and dehydration. Hypokalaemic alkalosis may occur secondary to starvation, dehydration, vomiting and/or laxative abuse. Oedema may occur in starvation and is not uncommon in refeeding resulting in artificially large weight gains. The chemical changes may result in heart rhythm irregularities (with ECG changes), muscle weakness, cramps and spasms and epileptic fits.
It is essential to have full blood tests to assess the degree of electrolyte disturbance and when necessary appropriate supplements prescribed (e.g. K + where hypokalemia exists or remains an ongoing risk).
Be aware that normal electrolytes seen in one test may become abnormal in a very short period, for example, after a period of frequent bingeing and purging, and regular testing is recommended.
Bowel Changes
After laxative abuse a number of bowel problems may be seen in people with bulimia nervosa. Lactose intolerance may occur and there may be irritable bowel syndrome. On cessation of the laxatives, constipation is common. Apart from the wind and pain, the sufferer may feel very bloated and reluctant to eat. It is essential to ensure an adequate fluid intake and emphasise the importance of regular, high fibre meals and snacks.
Haemorrhoids and rectal prolapse may occur as a consequence of the constipation. Less frequently the bowel may not return to normal function or a megacolon may exist. While a high fibre diet is usually recommended, ever increasing amounts of bran are not advisable. Apart from the effects on binding essential minerals such as iron and calcium, the extra bran may only worsen the bloating, wind and abdominal distension. Laxatives that stimulate the bowel are to be avoided and osmotic agents such as Epsom salts or Sorbitol may be recommended (often with a fibre supplement such as Metamucil or Fibrogel).
A referral to a gastroenterologist may be needed when bowel function does not return to normal with a high fibre/fluid intake, regular meals and snacks and cessation/reduction of the laxative abuse.
Leanne Wagner, Dietician in Private Practice, Brisbane
Unlike anorexia nervosa, bulimia nervosa is often a secret disorder, remaining hidden for many years before sufferers seek help. The characteristic features of bulimia nervosa - strict dieting, binge eating, and compensatory behaviours such as vomiting or laxative misuse, can produce a variety of physical consequences that, if present, need early recognition and ongoing monitoring. In particular, consideration needs to be give to symptoms of the starvation syndrome, delayed gastric emptying, fluid and electrolyte balance, and bowel changes that sufferers may experience.
Starvation Syndrome
When people are starved a number of physical and physiological changes may take place. In bulimia nervosa the focus is often on the bingeing and purging. It is easy to forget that the sufferer may have extended periods of food restriction between binges, or that the purging may mean that the food is not absorbed. In addition, excessive exercise may mean that insufficient energy is consumed for weight maintenance. In all, while the sufferer may appear in the healthy weight range, they may in fact be starved (starvation in the midst of plenty).
The effects of starvation are many :
Preoccupation with food.
Sufferers may think, dream, and talk about food incessantly. They may hoard food, collect recipes, love preparing elaborate meals and become quite agitated if some of the meal is left by those served.
Unusual eating habits.
People with bulimia nervosa may take a long time to eat their meal and become ritualistic about the order in which the meal is eaten. They may drink large quantities of fluids, chew lots of gum or smoke more heavily. Unusual combinations of foods may be eaten and condiments may be used excessively.
Mood swings and personality changes.
Sufferers may be moody, depressed, irritable and withdraw socially. Sleep can be disturbed and there can be difficulty in concentrating, and with decision making, comprehension and memory. There may be difficulty coping with changes in routine, and rigid, obsessional thinking.
This may make the management of bulimia nervosa difficult. While a flexible, healthy eating plan may be recommended, initially this might be very difficult for the person to achieve due to the effects of starvation. Information needs to be clear and written down ( even at the risk of being seen as a rigid "diet" to follow). Suggestions may need to be explained several times as memory and concentration can be effected. As the effects of starvation reverse with refeeding and reduction in the binge/purge cycle, the eating plan can then be made more flexible and new foods can be encouraged.
Delayed Gastric Emptying
One of the physical consequences of starvation is a delayed gastric emptying, that is, food sits in the stomach for longer than usual. It can be worse in those that have used vomiting as a way of purging after binges. The delay in gastric emptying means that the sufferer may feel considerable discomfort and bloating after eating relatively small amounts of food and may find compliance with a healthy eating plan difficult. Small, frequent snacks can help reduce the feeling of fullness however some sufferers may find this does not help. Medications such as cesopride can help gastric emptying and can be of valuable assistance in short term.
Fluid And Electrolyte Balance
When vomiting and laxative abuse are used as a means of purging there can be problems with fluid balance and electrolyte imbalances. In some cases this can produce a life-threatening situation. The levels of potassium, magnesium, phosphate, calcium, sodium and chlorides may be low and there may be volume depletion and dehydration. Hypokalaemic alkalosis may occur secondary to starvation, dehydration, vomiting and/or laxative abuse. Oedema may occur in starvation and is not uncommon in refeeding resulting in artificially large weight gains. The chemical changes may result in heart rhythm irregularities (with ECG changes), muscle weakness, cramps and spasms and epileptic fits.
It is essential to have full blood tests to assess the degree of electrolyte disturbance and when necessary appropriate supplements prescribed (e.g. K + where hypokalemia exists or remains an ongoing risk).
Be aware that normal electrolytes seen in one test may become abnormal in a very short period, for example, after a period of frequent bingeing and purging, and regular testing is recommended.
Bowel Changes
After laxative abuse a number of bowel problems may be seen in people with bulimia nervosa. Lactose intolerance may occur and there may be irritable bowel syndrome. On cessation of the laxatives, constipation is common. Apart from the wind and pain, the sufferer may feel very bloated and reluctant to eat. It is essential to ensure an adequate fluid intake and emphasise the importance of regular, high fibre meals and snacks.
Haemorrhoids and rectal prolapse may occur as a consequence of the constipation. Less frequently the bowel may not return to normal function or a megacolon may exist. While a high fibre diet is usually recommended, ever increasing amounts of bran are not advisable. Apart from the effects on binding essential minerals such as iron and calcium, the extra bran may only worsen the bloating, wind and abdominal distension. Laxatives that stimulate the bowel are to be avoided and osmotic agents such as Epsom salts or Sorbitol may be recommended (often with a fibre supplement such as Metamucil or Fibrogel).
A referral to a gastroenterologist may be needed when bowel function does not return to normal with a high fibre/fluid intake, regular meals and snacks and cessation/reduction of the laxative abuse.