# Fundamentals of Human Nutrition/Anorexia Nervosa
## An Overview of Anorexia Nervosa

Anorexia nervosa is an eating disorder that is characterized by weight loss (or lack of appropriate weight gain in growing children). The individuals that suffer from this disorder find it difficult to maintain an appropriate body weight relative to their size, age, height, and stature (1). Those who are anorexic, likely have a distorted body image that leads them to eliminate food from their diet Often their routine will consist of weighing themselves frequently, eating only small amounts, and only eating certain foods. Also some will exercise excessively, force themselves to vomit, or use laxatives to increase weight loss (4). It is also common for those with anorexia to have other mental illnesses including depression, anxiety, OCD, or substance abuse. Much of the time, people with anorexia will perceive themselves as heavier than they really are. We often see shows or movies about this disease where adolescent girls look into the mirror and see themselves as “fat” and in reality, they are severely underweight. Sometimes, however, a person with anorexia can accept the fact that they are very thin but cannot or will not accept the danger that they are putting themselves in. Generally, anorexia develops during adolescence, most often affecting women between the ages of 12-25 (2). However, anorexia is now known to affect both males and females, spanning all ages, socioeconomic, ethnic, and racial groups. Unfortunately, the diagnosis of anorexia has become more common over the past 20 years. This can be attributed to the increase in media in recent years. The media places a huge stressor on young girls to fit some kind of ideal image of a woman. An image in which women should have curves, but not be heavy, have thin legs but also have nice breasts and a butt. Even though anorexia has no single cause, experts believe that anorexia is a mental disorder influenced by biological, psychological, and environmental factors (3). To be diagnosed with Anorexia, there are criteria set by the DSM-5. The individual must restrict energy intake relative to requirements that causes them to have a significantly low body weight. They much have a significant fear of gaining weight or becoming fat even though they are severely underweight. This individual must also have a disturbance in the way their body weight or shape is experienced in accordance with a denial of the severity of their low body weight.The typical outline of a person with anorexia nervosa is usually an adolescent to young adult female who considers themselves a “perfectionistic”. However, is not unusual for these individuals to be attributed with having a low self-esteem based on body image distortion. Regardless of the general make up of this individual, weight control habits focused on reducing intake of calories is what helps to reduce their anxiety, stress, and negative mood by giving this person a sense of control in at least one aspect of her/his life. In a way, those that suffer from this disorder get a sense of accomplishment when weight is lost (2). Like all other eating disorders, anorexia nervosa is not an easy obstacle to overcome. Treatment can be challenging and relapse isn’t uncommon. Some medicinal treatments could include antidepressants, mood stabilizers, and antipsychotics if necessary. Though these are certainly helpful, effective treatment most often includes a form of therapy. These treatments will often try to dig deeper to locate the underlying emotional and mental health issues that may date back into the individuals early childhood and examines person’s self-perception and self-image (5). According to experts, the most challenging part of treating this disorder is getting the patient to understand that they have a serious mental illness (5). There lies a stigma around different disorders and diseases that may affect the individual’s ability to comprehend what is really going on. While there are several different routes to choose from when it comes to treatment for anorexia nervosa, there are a few essential steps to take. Most treatment begins with a one on one meeting with an eating disorder specialist. This psychologist has deep experience and training in helping those affected by this disorder and is an essential participant in this therapy. Another important step in this process is a physical examination by a medical doctor. This is a necessary step because it is important that the patient is informed of any physical problems can be dealt with if they are in danger of something worse happening. Of any psychological disorder Anorexia nervosa has the highest mortality rate (4). Though there are many treatment options available, not every individual is able to fully recover from this disorder. About 20% of people develop anorexia nervosa as a chronic disorder (4). According to the National Eating Disorders Association, at any given time, .3 to .4 percent of young women and .1 percent of men will suffer from Anorexia. In a study of 496 adolescent girls over a time span of 8 years, 5.2 percent of girls met criteria for some form of eating disorder. Because of the serious malnutrition associated with those who have anorexia, this disorder can lead to many other health defects down the road. These include impaired brain and nerve function, thinning of hair, cardiovascular complications, bone and muscle impairments, hormone disruption, skin problems kidney failure and even death if gone untreated for too long. Though someone with anorexia may be in denial about his or her condition, it is important to get that person to help in order to be able to attain a normal body weight and set them on the right path to recovery.

## Anorexia Nervosa: What is it?

Anorexia Nervosa, commonly referred to as anorexia, is an eating disorder in which an individual restricts his or her intake of calories. Those affected by this disorder lack many of the vital nutrients needed to complete everyday tasks. They are often characterized by their pronounced physical problems, such as thinning hair, visible bone protrusions and unhealthy dry and thin skin. People with anorexia often live with a poor body image, thinking they are too fat- when they are often of normal if not below average weight, and respond to such with excessive exercising, reduced food intake, calorie counting, vomiting after eating, increased water consumption or misusing diet aids (mayoclinic.org, 2014). They usually correlate their thinness with their self-worth, meaning that they presume that the thinner they get the more self-worth they will have, but in actuality this does not happen. Simply stated, anorexia can be identified as a mental problem, “an attempt to deal with perfectionism and a desire to gain control by strictly regulating food and weight.” (Anorexia nervosa)
As anorexia worsens, it can become all encompassing, affecting both physical and mental states. The disorder is often characterized by a lower than normal Body Mass Index (under 18.5 kg/m2). Due to this low BMI and lack of proper food intake, many are often found to have reached a point of severe malnutrition resulting in significant depletion of vitamins and minerals as well as fat and protein, thus impeding on normal body development. As the body begins to slow itself down to conserve the little energy it makes, it can lead to severe health consequences that can be life-threatening, such as osteoporosis, heart failure, kidney failure, and mental complications like depression and anxiety (Health Consequences of Eating Disorders). Some body systems are specifically affected such as digestive, integumentary, nervous and cardiovascular. As weight loss increases, it is common for those with anorexia nervosa to be prone to bruising and lanugo hair growth. Bloating, acute gastric pain and constipation are also present(Mehler,2001). Despite this weakening of the systems however, patients are not more predisposed to infectious disease than prior. Depending on the age, amenorrhea can also result or the menstruation cycle onset will even be delayed in females who have yet to begin their cycle. The extent of malnutrition that anorexia leads to can affect judgment as well, making it difficult to reason with the individual of their own current state.
Anorexia can overwhelm an individual’s life, as they dedicate their time to the time consuming exercises, frequent weigh-ins and more. As mentioned prior, vomiting is another form of losing weight, tying in to another eating disorder known as bulimia. It has been found that about half of individuals with anorexia suffer from bulimia(Mehler,2001). They may be seen cutting their food into smaller portions, eating slower as well as restricting themselves to certain foods. Due to the obsession component of this disorder, even after weight loss has occurred, individuals typically continue to control food and exercise regimens because of his or her inability to see any physical difference. In certain cases, anorexic patients use food and exercise to control an aspect of their lives. An anorexic individual may have large life changes surrounding him or her that cannot be controlled, so this control that anorexia entails may ease the anxiety that is being produced from everyday life.
Anorexia is one of the most common eating disorders and psychological diseases. It occurs most commonly in teenagers and those in their twenties, but can affect people in all age ranges. It can occur in both males and females; with females making the majority. Internationally, approximately 90-95% of those diagnosed with this disorder are girls and women. In the United States, about 0.5 – 1% of women suffer from anorexia nervosa, which accounts for at least 793,000 women (Anorexia nervosa). As every case is different, it is difficult to pinpoint an exact cause as many factors come into play, be it severe trauma, emotional stress before or during puberty, abnormalities in brain chemistry, i.e., serotonin, cultural/social environment, family history and so on (Ehrlich). What is known however is that the disorder is highly heritable and several other factors may play into its onset such as prenatal complications, gastrointestinal diseases and dysregulation of the neuroendocrine systems (Rikani, 2013). Comorbidities can also be found as well, depression, obsessive compulsive disorder and bipolar disordering being some of the more prominent ones (Herpertz-Dahlmann, 2009). Less commonly, type I Diabetes Mellitus, anemia and leukopenia can also occur (Mehler, 2001). Unfortunately, someone who has dealt with anorexia nervosa may continue to struggle with it for the rest of his or her life (Anorexia Nervosa Facts Sheet). Between 5-20% of these individuals struggling with anorexia will die due to the lack of food and essential nutrition, making this condition one with the highest death rates of any mental health condition (Anorexia nervosa). As they typically suffer from depression and other comorbidities as well, suicide is another frequent cause of death if not from the malnutrition.
Herpertz-Dahlmann. Adolescent eating disorders: definitions, symptomatology, Epidemiology and comorbidity. Child Adolesc Psychiatry Clin N Am. 2009, 18:31-47.
Mehler PS. Diagnosis and Care of Patients with Anorexia Nervosa in Primary Care Settings. Ann Intern Med. 2001;134:1048-1059. doi:10.7326/0003-4819-134-11-200106050-00011
Rikani AA, Choudhry Z, Choudhry AM, Ikram H, Asghar MW, Kajal D, Waheed A, Mobassarah NJ (2013). “A critique of the literature on etilogoy of eating disorders”. Annals of Neurosciences. 20 (4): 157-161. Doi:10.5214/ans.0972.7531.200409

## Signs

- Taking diet pills (also diuretics and laxatives)
- Excessive exercise, even when sick or hurt
- Being excessively thin
- Not eating or eating very little
- Weigh their foods/count calories
- Weighing themselves multiple times a day
- Depression
- Anxiety
- Obsessive disorders
- Physical development is stunted
- Kidney and heart problems
- Some people even become suicidal
If anorexia is not treated the person could develop severe, life altering problems that could eventually kill them. People that have this illness usually are treated before their symptoms become life-threatening. It can cause women that are pregnant to lose their child or bare a child that is severely malnourished and underweight. It affects the hormones of both men and women causing mild to severe mood swings.

## Symptoms

Anorexia Nervosa affects many bodily functions. If a young adolescent becomes anorexic, growth and development my slow or stop all together. If a young adolescent female becomes anorexic, her menstrual cycle may never start, or if the menstrual cycle does begin the cycle could cease to continue; this phenomenon is called amenorrhea. Anorexic patients may lose lean body mass and slow their basal metabolic rate. The cardiac systems may also be affected often leading to bradycardia (slow heart rate). In an attempt to stay warm, the body may start producing lanugo (soft hair that may help insulate the body). The body systems will react similarly to someone who is malnourished or starved, and multiple organs may stop functioning all together if the starvation continues (Whitney, 2015).

## Risk Factors

There are many risk factors that can increase the risk this disease. According to the Mayo Clinic (2014), the following are some of the typical risk factors for anorexia nervosa:
Biological sex: Women and girls are more likely to have anorexia. However, anorexia in men and boys has started to increase, presumably as a result of increasing pressures by society for men to have a certain physical appearance along with women.
Age: Anorexia is seen to be the most prevalent among teenagers. Teenagers are seen to be more susceptible to contracting anorexia due to the bodily changes that they undergo during puberty. During this time, teenagers are subjected to outside pressure from peers and can thereby be more sensitive to criticism about their body or weight. Although a person of any age can develop anorexia, anorexia is rare in people over 40.
Changes in Weight: Weight loss may be reinforced by positive comments, whereas weight loss may be reinforced by negative criticism. These comments may cause someone to either start an extreme diet or even starve themselves.
Transitions/Life Changes: A change in environment or social relationships can increase the risk of developing anorexia due to the emotional hardships transitions can cause.
Career or Hobby Choice: Those who work in or participate regularly in sports, acting, modeling, and dance are seen to have a higher risk of developing anorexia due to how these professions may increasingly continually suggest that a person involved in these must maintain a certain weight and appearance.
Media: TV, movies, and fashion magazines regularly perpetuate that being “skinny” is the norm by regularly featuring skinny actors and models. This may suggest to viewers that being thin is directly related to how popular and successful one is.
Anorexia is also seen as a genetic predisposition that may run in families. A girl whose brother or sister struggles with anorexia may be ten to twenty times more likely to develop anorexia herself when compared to girls who do not have a sibling with anorexia. In addition, the chemical makeup of the brain is also seen to be a risk factor for anorexia. Those with anorexia are typically seen to have increased levels of cortisol (hormone that brings about feelings of stress) and lower levels of norepinephrine and serotonin, which bring about feelings of well-being (Smith & Segal, 2015).

## Diagnosing Anorexia Nervosa

The main indication of anorexia is the refusal to keep a body weight at or greater than 85 percent of one’s expected body weight. This is defined by comparing one’s current body mass index to their predicted “normal” BMI. Another main sign of anorexia is a patient’s excessive uses of calorie restriction and exercising. A additional hallmark of diagnosing anorexia is an extreme fear of gaining weight or becoming overweight (Pritts & Susman, 2003).

## Treatment

Treatment of Anorexia Nervosa
Treating anorexia nervosa is a multi step process that includes different types of support. If someone is seriously affected by anorexia nervosa the first step is to “stop weight loss” at all costs (Whitney Rolfs, 2002). After the patient is hospitalized and weight loss has stopped any number of things could happen next.
These include: receiving intense medical care, restoring a healthy weight, psychotherapy, and medication.
Medical Care
Since those affected by anorexia nervosa can sometimes be is very serious physical condition the patient may require constant monitoring of their vital signs. Once the patient is in stable condition they may still need a “nasogastric tube” to eat that is placed through the nose and leads to the stomach (mayoclinic.org, 2014). From this medical care facility the primary care doctor responsible for the patient decides what further action must be taken. If the case of anorexia nervosa is less severe a mental health care provider will arrange what to do for their patient.
Restoring a Healthy Weight
When a patient with anorexia nervosa is in stable condition they should start to plan on getting back to their healthy weight. Patients may meet a nutritionist or dietician to learn how to plan a healthy diet (helpguide.org, 2015). Most of the time they will recommend trying to eat 3 times a day with snacks in between. They may even prescribe meal plans for the patient to follow. These meal plans are designed to give enough calories so that the patient is at a healthy weight. Another factor that can help return a patient to healthy weight is their family, friends, and coworkers. Having a healthy environment can ensure you return to a healthy weight.
Psychotherapy
Psychotherapy is a treatment that helps people with anorexia nervosa by reaching the root of their psychological disorder. There are 2 types of therapy. Family based therapy involves parents working with their own children who have the disorder (mayoclinic.org, 2014). These parents then feed and monitor their weight since they are unable to on their own. The next therapy is called individual therapy. Individual therapy involves a patient and a psychiatrist. The main goal is to train patients to eat regularly and promote healthy eating behaviors (mayoclinic.org, 2014). Next the psychiatrist tries to help change the patients distorted views about themselves.
Medications
Currently there are no drugs to treat anorexia nervosa because few have been found to be effective. However, doctors may choose to prescribe antidepressant drugs that can treat mental disorders commonly associated with anorexia nervosa such as depression or anxiety. Medication coupled with psychotherapy sessions seems to be particularly impactful.
References
"Anorexia Nervosa." Treatments and Drugs. N.p., n.d. Web. 02 Dec. 2015.
Smith, Melinda, and Jeanne Segal. "Anorexia Nervosa." : Signs, Symptoms, Causes, And Treatment. N.p., n.d. Web. 02 Dec. 2015.
Whitney, Eleanor Noss., and Sharon Rady. Rolfes. Understanding Nutrition. Belmont, CA: Wadsworth, 2002. Print.
Treatment
There are several treatments for anorexia, including hospitalization, psychotherapy, and medical care. Treatment is usually a “team approach” with the help of the families, doctors, therapists, and nurses. (Treatments and Drugs) Hospitalization is normally used if the person is in danger from their disease. Hospitals can give liquids to the patient, make sure they are eating, and can regulate the person’s body functions. They are admitted and monitored for changes in their health. People that are admitted usually have reached the point of heart issues, kidney issues, imbalances of their hormones and electrolytes. They can also be admitted for psychiatric problems to help regulate these problems. They begin therapy in the hospital for the disorder and they continue it once they have been discharged from the hospital.
Therapy is another option. If the patient has not reached the point of needing hospitalization then they go into therapy and begin to learn how to treat their illness. Therapists either bring in the families to help with the treatment process or they do it one-on-one. Both focus on how to treat the disorder and try to focus on the patient’s needs. The biggest problems during therapy is helping the person realize that anorexia is an illness and that their weight does not correlate to their self-worth in society. The largest factor to treating anorexia is keeping the person in remission. Many people lose their fight to the illness because they either do not stay in therapy long enough or they feel that they are not supported in their fight.

## Influences of Social Media and the Internet

We are constantly bombarded with images from social media that suggest what the ideal body should look like. Eating disorders continue to rise for both men and women. Pressure comes from sources around us to achieve an unrealistic body type, weight and figure. Constant connection to social media can worsen this problem for some individuals.
Anorexia is an eating disorder that many people struggle with every day. It is considered a psychological disorder and can require a variety of therapies to overcome it. Consider the number of people that have been diagnosed with anorexia or those that face symptoms of the disease. Then, think of the number of these people that use the Internet everyday. Most people do not realize it, but Internet and social media sites play a big role in the lives of those with anorexia.
Social media outlets like Facebook, Instagram, Pinterest and Tumblr often show photo of young men and women with bony, at times emaciated, bodies apparently glamorizing the disease. The Internet beautifies the ideals of eating disorders with these images. These sites are what teenagers and young adults use everyday and these types of photos add pressure to look a certain way. After seeing these pictures, many young people strive to attain these body types and it’s not healthy. In addition to social media sites, there are “pro-ana” websites. These websites are created in support of anorexia.
According to Mansour (2013), pro-ana websites glorify the dangerous weight loss that can occur with anorexia. The article provides direct quotes from a woman who personally struggled with anorexia and the hardships of these pro-ana websites. Mansour then goes on to mention some of the hash tags used with these images such as #thinspiration, #thinspo, #thighgap (Mansour, 2013). These words are what glorify anorexia, like Mansour (2013) mentions. She states, “If you’re at risk of an eating disorder” that these hash tags can trigger “devastating psychological illness” (Mansour, 2013). While these images are glorified by people, reposts and comments, they represent an ugly truth that so many people face in their everyday lives.
One of the biggest issues with these websites is that they possess inaccurate views of anorexia. Pro-ana websites almost applaud those with anorexia making it seem like a lifestyle choice instead of a psychological disorder (Mansour, 2013). The sites provide environments where there is constant competition (Mansour, 2013) in the same way social media outlets do. Another article titled “Totally In Control” taken from the Social Issues Research Centre directly quotes a pro-ana website that states: “‘This is a site for those who already have an eating disorder and do not wish to go into recovery’” (“Totally In Control”). This demonstrates that there are websites that support anorexia in such a way where it is made to seem like people make a conscious decision to be anorexic.
Another problem with these sites is that they do not offer help to those suffering. Instead, they reinforce a behavior that is unhealthy and detrimental to psychological and physiological health. The increasing Internet presence of pro-anorexia websites seems to have increased the presence of the disease in men, as Edmonds discusses in his article. The author mentions that although the disease was once thought to only harm women, researchers have found that the trend is now increasing among men (Edmonds, 2012). The disease tends to be most popular in young people (Edmonds, 2012) and is not something to be taken lightly. There is considerable pressure on young adults today to look a certain way from magazines, televisions shows, and maybe even from friends and family members. The last thing people suffering with anorexia need is another outlet to pressure them.
There will always be people that are unhappy with their bodies. We may not even ever fully eradicate eating disorders. Regardless, removing the pressure added from social media and existing pro-ana websites would certainly make a difference.

## References

Edmonds, R., G. (2012). A New Generation of Eating Disorders Eating Disorders – Not Only for Girls. African Journal of Psychiatry. Retrieved from http://www.omicsonline.com/open-access/JOP/JOP-15-450.pdf
Mansour, I. (2013). ‘Thinspiration’ Packages Eating Disorders as a Lifestyle Choice. Mashable. Retrieved from http://mashable.com/2013/12/05/thinspiration/#
Totally In Control. (n.d.). Social Issues Research Centre. Retrieved from http://www.sirc.org/articles/totally_in_control2.shtml

## References

Anorexia Nervosa Facts Sheet. (2009, June 15). [PDF Document]. Retrieved from http://womenshealth.gov/publications/our-publications/fact-sheet/anorexia-nervosa.html?from=AtoZ
Anorexia nervosa: Risk Factors. (2014, December 30). Retrieved November 30, 2015, from http://www.mayoclinic.org/diseases-conditions/anorexia/basics/risk-factors/con-20033002
Anorexia Nervosa | National Eating Disorders Association. (n.d.). Retrieved from https://www.nationaleatingdisorders.org/anorexia-nervosa
Anorexia nervosa. (2015, April 23). Retrieved from Web.
Anorexia nervosa fact sheet. (2012, July 16). Retrieved from Web.
Health Consequences of Eating Disorders. Retrieved from Web.
Pritts, S., & Susman, J. (2003). Diagnosis of Eating Disorders in Primary Care. American Family Physician, 67(2), 297-304. Retrieved November 29, 2015, from http://www.aafp.org/afp/2003/0115/p297.html
Smith, M., & Segal, J. (2015, August 1). Anorexia Nervosa. Retrieved November 30, 2015, from http://www.helpguide.org/articles/eating-disorders/anorexia-nervosa.htm#causes
Treatments and Drugs. (2015). Retrieved from Web.
Whitney, E., & Rolfes, S. (2015). Understanding Nutrition (14th ed.). Stamford: Cengage Learning.