The pandemic we are currently experiencing has brought, as we all know, an increase in anxiety, depression, and distress among people struggling with eating disorders. Requests for help from ANEB (Anorexia and Bulimia Quebec) have more than doubled in the past year, reaching an increase of up to 131%.

Isolation, loss of routine, the desire to maintain control, and time spent on social media have had a definite impact on changes in their habits and relapses, as well as on the obsession that accompanies these disorders.

According to Dr. Mimi Israel, head of the psychiatry department at the Douglas Institute and associate professor in the Department of Psychiatry at McGill University, "Eating disorders most often occur during adolescence, so parents must be careful about the messages they convey. They should not appear obsessed with food, should not pressure children by talking about their weight or stigmatizing them for unhealthy eating habits. Self-esteem is paramount. What matters is not our appearance or our weight, but who we really are."

Here is the first article in a series on eating disorders.

Definition of anorexia nervosa

Anorexia nervosa is an eating behavior disorder recognized and listed in the Diagnostic and statistical manual of mental disorders fifth edition (DSM-5), which defines and categorizes mental disorders. This disorder is characterized by the desire to be thin, fear of obesity, body image distortion, and restriction of food intake, leading to weight loss and low body weight.

Different types of anorexia nervosa

There are two types of anorexia nervosa: the restrictive type and the binge-eating/purging type.

In the first case, individuals limit their food intake and may have excessive physical activity. They do not regularly have binge-eating episodes or purging behaviors.

In the second case, in addition to reducing their food intake, individuals regularly have binge-eating episodes, where they eat frantically, followed by purging behaviors, where they induce vomiting or take various laxatives (e.g., laxatives, diuretics, enemas).

Etiology of anorexia nervosa

The causes of anorexia nervosa are unknown. One of the only recognized risk factors is being female. However, other factors could also promote the development of this disease, such as having previously followed a diet or having an excessive concern about weight. There may also be genetic predispositions and social factors. Indeed, many individuals affected by this disease come from middle or upper classes. Finally, the valorization of thinness in Western society could also play a role in the development of this disease.

Symptoms of anorexia nervosa

Symptoms of anorexia nervosa may include bloating, abdominal pain, and constipation. Anorexic individuals may also have a low heart rate, low blood pressure, low body temperature, excessive body and facial hair, edema, and may present with depression. In women, cessation of menstruation is common. In individuals suffering from the binge-eating/purging type of anorexia who frequently induce vomiting, symptoms may also include erosion of dental enamel and inflammation of the esophagus. Anorexia nervosa can also cause hormonal changes, such as a decrease in sex hormones (estrogen and testosterone) and an increase in cortisol. These changes can lead to decreased bone density, increasing the risk of osteoporosis. Significant weight loss can also affect body fluids and electrolytes, which can cause dehydration and fainting. Finally, in severe cases of anorexia nervosa, all major organs of the body can be affected.

Diagnosis of anorexia nervosa

Diagnostic criteria for anorexia nervosa include:

• Restriction of food intake leading to low body weight
• Fear of gaining weight or obesity
• Distortion of body image and/or denial of the severity of the illness

Treatment of anorexia nervosa

Treatment of anorexia nervosa generally requires the intervention of a multidisciplinary team including several health professionals, such as doctors, psychologists, psychiatrists, and nutritionists. The initial goal of treatment is to restore weight. This phase of treatment may require hospitalization. During this phase, individuals also receive psychiatric and nutritional recommendations. Then, long-term treatment begins and mainly includes psychotherapy aimed at normalizing eating behavior and weight. This therapy lasts between one to two years after weight recovery. In adolescents, family therapy may also be part of the treatment. Regular follow-ups with various health professionals (doctors, psychologists, nutritionists, etc.) also take place throughout the treatment. Finally, medications may also be prescribed.

Nutritional approach for anorexia nervosa

The primary goal of anorexia nervosa treatment is to restore weight. Weight restoration is done through nutritional supplementation. Ideally, solid foods are used orally, but liquid supplements can also be used. In some severe cases, tube feeding may also be required. The rate of weight gain can vary depending on the severity of weight loss. In very severe cases, a more gradual weight gain may be required to prevent refeeding syndrome. This syndrome refers to a set of complications that can occur with too rapid weight restoration in individuals with very significant underweight. During weight restoration, it is also recommended to stop physical activity, as it can prevent weight gain. Finally, calcium and vitamin D supplements are often prescribed for people with decreased bone mass.

Once weight is restored, long-term treatment aims to normalize eating behavior and weight. During this phase of treatment, individuals generally undergo behavioral therapy and have regular follow-ups with a team of health professionals including a nutritionist. The nutritionist can intervene to establish a meal plan, provide dietary recommendations, and offer nutritional education to help normalize weight.

Nutritional education for anorexia nervosa

In the case of anorexia nervosa, the nutritionist's role is notably to provide education on normal eating. This education may include the following recommendations:

• Plan three regular meals per day.
• Consume normal portions.
• Expand the food repertoire. People with anorexia nervosa often consume a small variety of foods.
• Avoid slimming or diet foods.
• Discourage adopting vegetarianism or veganism, which can often be used to mask food intake restriction.
• Avoid frequent weighing. Limit weigh-ins to those done during follow-ups with health professionals.
• Teach how to keep a food diary.
• Educate and reassure individuals about gastrointestinal symptoms that may occur at the beginning of refeeding. These symptoms subside after a few weeks of refeeding.

References

1. https://quebec.huffingtonpost.ca/entry/troubles-alimentaires-demandes-aide-aneb_qc_60185fdac5b63b0fb2836d08
2. https://www.merckmanuals.com/fr-ca/accueil/troubles-mentaux/troubles-des-conduites-alimentaires/anorexie-mentale
3. https://www.merckmanuals.com/fr-ca/professional/troubles-psychiatriques/troubles-du-comportement-alimentaire/anorexie-mentale
4. https://www.merckmanuals.com/fr-ca/accueil/les-faits-en-bref-troubles-mentaux/troubles-des-conduites-alimentaires/anorexie-mentale
5. https://www.unlockfood.ca/fr/Articles/Adolescence/Quand-la-nourriture-et-le-poids-corporel-prennent-toute-la-place---coup-d%E2%80%99%C5%93il-sur-les-troubles-de-l%E2%80%99alimentation.aspx
6. https://www.inserm.fr/information-en-sante/dossiers-information/anorexie-mentale
7. Coughlin, Janelle W., et al. Modern Nutrition in Health and Disease, by A. Catharine Ross, Wolters Kluwer/Lippincott Williams & Wilkins, 2014, pp. 1324–1325.

Article written by:

Marie-Noël Marsan, written in 2021.