Chapter 4: Initial Stage of Anorexia Nervosa in Adolescence

Initial Stage: Common physical symptoms

In the initial stage of anorexia nervosa, physical symptoms are linked to body weight loss, food restriction, excessive exercise, interrupted menses, and inadequate nutritional status.

Initial Stage: Weight preoccupation

Females are typically hypersensitive to developing breasts and hips. Appearance of these adult female sexual characteristics causes panic among vulnerable adolescents. In some cases adolescents with anorexia nervosaare overweight when the disorder begins. They may recall a chance statement about their weight by a relative or close friend, or a suggestion about a weight reduction plan by a health professional, as the trigger for their initial food restricting behavior.

Initial Stage: Dietary behaviors

The adolescent with anorexia nervosa usually develops a personal philosophy about her diet, limiting herself by eating food only from certain categories and in certain ways. She especially limits total food energy and fat consumption, and may manipulate the fiber, fluid or sodium content of her diet. In addition, she may force herself to vomit or misuse laxatives and/or diuretics to rid her of ingested food energy and body fluids. Vomiting may follow episodes of binge eating, and be followed in turn by fasting.

Initial Stage: Exercise habits

The type and amount of activity they engage in also varies but teenagers with anorexia nervosa ritually perform excessive calisthenics and other strenuous activities. They are drawn to high risk and solitary activities rather than team sports (They often deny fatigue and may limit rest and use stimulants). They are so frequently involved in junior and senior high school athletics and dancing that coaches and teachers should be educated about the disorder. Knowledgeable adults, teachers and coaches recognize an eating disorder is developing when a student exercises to her/his detriment, training compulsively beyond reasonable endurance while rapidly losing or maintaining an unhealthy weight.

Initial Stage: Menses

It is well known that adolescents (as well as older women) in a state of starvation are amenorrheic. Psychological changes and physical stress interfere with endocrine regulation of the menstrual cycle. Cessation of menses occurs in about one third of adolescents with anorexia nervosa before they have lost sufficient weight and body fat to cause the interruption, however. Further, amenorrhea often lasts beyond the point when they have regained close to normal weight and body fat. This indicates both physical and psychological aspects of the disorder contribute to the complicated mechanisms underlying amenorrhea. It is also clear that malnourished young women will not experience menarche. When energy is inadequate to fuel all body processes both males and females shunt the scarce resource to life-supporting, as opposed to reproductive, functions.

Initial Stage: Nutritional status

In the initial phase of anorexia nervosa, semi-starvation does not appear to effect the body measurably other than through weight loss. Stored fat and muscle components as well as the total body register the loss. The short-term nature of the starvation apparently does not lead to the same synergism between malnutrition and infection seen in populations chronically in semi-starving conditions. Deficiencies in specific nutrients have not been reported, possibly because the catabolic state decreases requirements. The increased demand for nutrients (especially minerals) in adolescence is reason to be concerned about sub-clinical and long-term deficiencies, however. Symptoms of severe starvation may become apparent if weight loss continues unchecked. Nutritional problems listed in the Crisis section undermine basic health, indicating a life-threatening crisis.

Initial Stage: Intervention strategies

When anorexia nervosa first appears, a team of experts will need to assess the situation and determine the most appropriate treatment. Initial actions will be planned to avert a serious threat to health. All members of the family will need to work with the therapeutic team to accomplish this goal.

Initial Stage: Timely recognition of symptoms

Recognizing the symptoms of anorexia is the most important early intervention strategy. Friends, school personnel, family and health professionals who are alerted by developing problems can take steps to initiate treatment. Younger people do not always fulfill all the diagnostic criteria of an eating disorder. The possibility of a disorder should not be dismissed if all symptoms do not perfectly fit. Symptoms, attitudes and behaviors that are detrimental to health should be treated whenever they are identified. See Eating Disorders not Otherwise Specified described in Prevalence, Chapter 1.

Initial Stage: Psychotherapy

Individual and family psychotherapy by experienced mental health care providers will enable both the affected adolescent and her family to adopt more appropriate attitudes and behaviors. In therapy, families learn to support the physical and psychological development of their children. With support the adolescent can give up harmful habits as she matures.

Initial Stage: Medical nutritional therapy

Initially, the nutritionist on the health care team will assess and monitor the adolescent's nutritional status, helping to determine her overall state of health in order to establish a diagnosis and therapeutic goals. The nutritionist will also begin to correct the adolescent's misunderstandings about nutrition and help her modify her eating habits to meet her physical needs. Nutritional counseling should take advantage of the adolescent's ability to change rather than impose a rigid system of dietary planning by a professional. A strong and more directive stance will need to be taken if no readiness for change can be identified.
The disorder should not be defined as solely a nutritional problem, although nutritional counseling is an important component of comprehensive therapy. Refocusing, through psychotherapy, on primary emotional and interactional problems rather than the power struggle over food and exercise patterns will often enable the adolescent to gradually abandon her compulsive striving for thinness. She can begin to devote her energy to recovery.

Initial Stage: Progressing from initial to crisis stage

Avoidance of intervention or lack of progress during initial therapy usually leads to physical and mental deterioration. With this crisis stage of anorexia nervosa, intervention must be directed toward both the psychological and physiological symptoms, which are severe.

Website link for chapter 4:

http://faculty.washington.edu/jrees/ch4ian.html

References

• American Dietetic Association: Anorexia and Bulimia Nervosa Medical Nutrition Therapy Protocol. Chicago, ADA, 1998.
• Brown, S and Bnoifazi, DZ: An overview of anorexia and bulimia nervosa and the impact of eating disorders on the oral cavity. Compend Contin Educ Dent 1993,14:1594-1608.
• Center for Disease Control, National Center for Health Statistics. 2000 CDC Growth Charts; United States.
• Cromer BA, McClean CS, & Heald FP. A critical review of comprehensive health screening in adolescents. J Adolesc. Health. 1992 Mar;13(2 Suppl):1S-65S. Review.
• Fisher, MF, Golden, NH, Katzman, DK et al: Eating disorders in adolescents: A background paper. J Adolesc Health 1995,16:420-437.
• Frisancho, RA: Anthropometric Standards for the Assessment of Growth and Nutritional Status. Ann Arbor, U Michigan Press, 1993.
• Gurney, JM and Jelliffe, DG: Arm anthropometry in nutritional assessment: nomogram for rapid calculation of muscle circumference and cross-sectional muscle fat areas. Am J Clin Nutri 1973,26:912.
• Hazelton, LR and Faine, MP: Diagnosis and dental management of eating disorder patients. Int J Prosthodont 1996,9:65-73.
• Katzman, DK & Zipursky, RB: Adolescents with anorexia nervosa: The impact of the disorder on bones and brain. Ann NY Acad Sci. 1997;817:127-137.
• Kohn, MR, Golden, NH, and Shenker, IR: Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. J Adol Health 1998;22:239-243.
• Golden NH, Katzman DK, Kreipe RE, Stevens SL, Sawyer SM, Rees J, Nicholls D, Rome ES. Eating disorders adolescents. A position paper of the Society for Adolescent Medicine. J Adolesc Health. 2003;33:496-503. [ Society of Adolescent Medicine, Position Paper on Adolescent Eating Disorders ]. Accessed January 4, 2009.
• Rome ES, Ammerman S, Rosen DS, et al: Children and Adolescents With Eating Disorders: The State of the Art. Pediatrics 2003; 111: e98-e108. [Link to article in ePediatrics (pdf file)]. Accessed January 4, 2009.
• Seidel, HM, Ball, JW, Dains, JE and Benedict, GW: Mosby’s Guide to Physical Examination, 2nd Edition. St. Louis, Mosby Year Book, 1991, pg 83.
• Shebendach, JE & Reichart-Anderson P.: Eating disorders. In Mahan, LK and Escott-Stump, MA: Krause’s Food Nutrition, and Diet Therapy, 10th Edition, Philadelphia, WB Saunders Co, 2000. Chapter 24.
• Shebendach, JE, Golden, NH, Jacobson, MS, et al: Indirect calorimetry in the nutrition management of eating disorders. Int J Eat Disord 1995,17:59-66.
• Shebendach, JE, Golden, NH, Jacobson, MS, et al: The metabolic responses to starvation and refeeding in adolescents with anorexia nervosa. Ann NY Acad Sci 1997,817:110-119.
• Schebendach, J, Nussbaum, MP: Nutrition management in adolescents with eating disorders. Adolescence Med 1992, 3:541-558.
• Striegel-Moore, RH: Risk factors for eating disorders. Ann NY Acad Sci 1997,817:110-119.