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Physiology

Dental Problems, Barter Syndrome, Weight Control & More

Eating Disorders and Dental Problems: Some of the common signs and symptoms of dental problems associated with eating disorders include:

  • Erosion of dental enamel
  • Thermal hypersensitivity (cold/hot sensitive)
  • Salivary gland enlargement
  • Dryness of the mouth and decreased salivary flow
  • Redness of the throat and palate
  • Reddened, dry, and cracked lips and fissures at angles to the lips

Before TreatmentRepeated vomiting exposes teeth to gastric acids which erode tooth enamel, the hard protective covering of the tooth. Teeth may become rounded and soft and/or amalgam fillings may start to protrude above a tooth’s surface. Before TeethThe teeth weaken and become susceptible to the worst possible invasiveness. Decay, crumbling, fracturing, falling out – all occur with this insidious disease.

Widespread cavities over a short period of time are a significant problem for anorexic/bulimic patients. The problem is two-fold: those patients that binge on high-calorie, high-carbohydrate foods and then purge run the greatest risk of decay. The sugar in the foods set up an acid-attack on the enamel, while the act of purging bathes the teeth in hydrochloric acid from the stomach. This acid not only contributes to decay, but can also erode the teeth and fillings. The chronic bulimic patient will need numerous fillings over and over again, and have eroded enamel on the tongue-side of the teeth.

Associated with poor dental hygiene and damage to teeth and gums is the potential of greater risk of having an infection.

With the intervention of eating disorder specialists and a professional dental team, individuals can be helped to prevent further damage to their teeth and to have damaged and worn teeth replaced.

On a regular basis The Center calls upon the services of Dr. Brian McKay of Advanced Cosmetic & Laser Surgery to help our clients who have dental problems. Dr. McKay’s team steps in to create a functional and beautiful smile design that effectively replaces damaged and worn teeth. The results speak for themselves. Happy smiling people back on the road to improved self-esteem and a cure.

After dental work“The hard work necessary to overcome this disease is absolutely incredible. It is truly gratifying and humbling to me to play a role in helping make sufferers of Bulimia ‘whole again. After Dental WorkTheir smiles light up their entire being and touch me every time.”
Dr. Brian McKay

To learn more about the services of Advanced Cosmetic & Laser Surgery, go to www.acld.com.


Barter Syndrome:
Chronic Metabolic Alkalosis
The causes of chronic metabolic alkalosis are often evident on the initial assessment of the patient with a careful history and physical examination. In the absence of blood gas measurements, an increase in the anion gap favors metabolic alkalosis over respiratory acidosis as a cause of hypochloremic hyperbicarbonatemia. Urinary electrolyte measurements prior to therapy, especially chloride and potassium concentrations are important when the diagnosis is not obvious or the patient is concealing information (bulimia, diuretic or laxative abuse).

Weight Control and Obesity
While gorging on twinkies and mozzarella sticks most likely will help you put on pounds, diet is not the only factor in obesity. Researchers now are identifying a number of mechanisms in the brain that control weight and, if they go out of synch, may lead to an excess reserve of body fat. By piecing together the system, researchers hope to develop more effective treatments that have less side effects than current medications.

Environmental And Behavioral Factors Associated With Decreased Female Fertility
Reproductively speaking, we live in an increasingly hostile environment. There are frequent new revelations about factors that negatively affect the female reproductive system. Infertility has been estimated to afflict between 15-30% of the population in industrialized countries.

Estrogen’s Influence on the Brain
For years, estrogen was regarded only for its influences on a woman’s reproductive functions. Now research shows that it has a wider, more complex role. It turns out that estrogen boosts a variety of brain abilities including memory. Researchers hope that a clearer understanding of how the hormone carries out its brain functions will lead to treatments that could protect against ailments of old age.

Causes of Eating Disorders – Biochemistry
To understand eating disorders, researchers have studied the neuroendocrine system, which is made up of a combination of the central nervous and hormonal systems. The neuroendocrine system regulates multiple functions of the mind and body. It has been found that many regulatory mechanisms are, to some degree, disturbed in people with eating disorders.

Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and binge eating
Journal of the American Dietetic Association,  August, 1994

Onset of an eating disorder typically follows a period of restrictive dieting; however, only a minority of people who diet develop eating disorders. Those who do are emotionally and psychologically vulnerable when they develop the self-destructive behaviors characteristic of an eating disorder (eg, practicing unsafe dieting techniques, taking unproven diet products, and maintaining arbitrary standards of weight). As purveyors of food, nutrition, and health information, registered dietitians should identify and inform health professionals and the lay public of the dangers of fad diets and diet products and should educate the public regarding healthful weight ranges and weight stabilization methods. Dietitians should also discuss risk factors for developing an eating disorder. Such interventions may play an important part in the treatment and prevention of eating disorders (1-3).

Diagnostic criteria for anorexia nervosa and bulimia nervosa are stated in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (4) (DSM-IV). (See the Figure for a listing of the criteria). Although considered to be mental disorders, eating disorders are remarkable for their nutrition-related problems. In anorexia nervosa, nutrition-related problems include refusal to maintain a minimally healthy body weight (ie, 85% of that expected), dramatic weight loss, fear of gaining weight even though underweight, preoccupation with food, and abnormal food-consumption patterns (4). In bulimia nervosa, problems include recurrent episodes of binge eating, a sense of lack of control over eating, compensatory behavior after binge eating to prevent weight gain (eg, self-induced vomiting, abuse of laxatives or diuretics, fasting) (4). For a person with either diagnosis to recover fully, issues concerning food-intake patterns, food- and weight-related behaviors, body image, and weight regulation must be resolved (5,6). The registered dietitian is the logical member of the treatment team to address these issues with people recovering from anorexia nervosa and bulimia netrosa.

Eating disorders are complex disorders involving two sets of issues and behaviors: those directly relating to food and weight and those involving the relationships with oneself and with others. The name “eating disorder” is somewhat misleading in that it implies that the essence of the problem is disordered eating and suggests that the solution is to learn to eat normally again. If changes in food- and weight-related behavior alone are the focus of treatment, interventions are likely to be counterproductive rather than therapeutic. Thus, registered dietitians who treat persons with eating disorders should be cognizant of the psychological and nutritional aspects of eating disorders throughout the recovery process. Health care professionals who work with patients throughout their recovery process will benefit from familiarizing themselves with the process of nutrition care.

POSITION STATEMENT

It is the position of The American Dietetic Association (ADA) that nutrition education and nutrition intervention be integrated into the team treatment of patients with anorexia nervosa, bulimia nervosa, and binge eating during the assessment and treatment phases of outpatient and/or inpatient therapy.

MEDICAL NUTRITION THERAPY

Medical nutrition therapy, as defined by ADA, is the use of specific nutrition services to treat an illness, injury, or condition. It involves: (a) assessment of the patient’s nutritional status, and (b) treatment, which includes diet therapy, counseling, or use of specialized nutrition supplements. Medical nutrition therapy for eating disorders is a collaborative process in which the registered dietitian and the recovering person work together to change the patient’s food- and weight-related behaviors. Typically, this is a lengthy process because emotional and psychological issues may make these changes extremely difficult (6).

The process of medical nutrition therapy has two phases with regard to treating eating disorders: the education phase and the experimental phase (6). All registered dietitians have the qualifications to provide nutrition care during the education phase. However, only registered dietitians with additional training and experience in the treatment of eating disorders are qualified to do the nutrition interventions of the experimental phase.

The primary focus of the education phase is to provide nutrition information to the person with the eating disorder. The interactions between the registered dietitian and patient are often brief and factual in nature; thus, a very limited relationship develops in which it would be inappropriate to discuss subjects such as the emotions generated by attempts to change body weight.

In the experimental phase, the registered dietitian has a special interest in long-term, relationship-based counseling and is a member of a multidisciplinary treatment team (6). In addition to formal education in dietetics, the dietitian involved in this phase should have been trained in basic counseling skills through a combination of course work and/or supervision by a psychotherapist. This approach could be called “psychonutritional.” Ongoing supervision by and communication with a psychotherapist who may be part of the treatment team are strongly advised if the registered dietitian is to discuss emotional issues related to behavior change or weight. In some work settings, the registered dietitian may be called a “nutrition therapist” (6).

The Education Phase

The focus of the education phase is to provide a foundation of information that will make it possible for the patient to make notable changes in food- and weight-related behaviors during the experimental phase. The education phase has the following five primary objectives.

* Collect relevant information Nutrition assessment of this heterogeneous population should include a comprehensive history of weight changes, eating and exercise patterns, and purging behaviors. A detailed history helps the dietitian quantify behaviors and nutrient intake patterns, identify the effect of behavior on patient lifestyle, and direct treatment plans and goals (6-11).

* Establish a collaborative relationship between the person with the eating disorder and the registered dietitian Nutrition intervention involves forming a therapeutic alliance with the patient that will enable her or him to talk about and later resolve food fears and to develop realistic goals for weight and behavior change. The initial nutrition interview and history itself can be a therapeutic experience as it allows the patient to discuss secretive behaviors and food fears openly with a supportive and understanding health care provider. The interview should be performed in a nonjudgmental manner to help establish trust and collaboration with the patient (6,7,12,13).

* Define and discuss relevant principles and concepts of food, nutrition, and weight regulation Understanding why and how the body responds to starvation, binge eating, purging, and/or restriction is typically necessary before a person will risk making behavioral changes (9). Bodily responses to starvation include: symptoms of starvation, the effects of starvation and partial starvation on metabolic rate, ability to differentiate hydration shifts from muscle and fat weight shifts, abnormal and normal hunger, a healthy weight range for the individual, the way in which food- and weight-related behaviors change during the process of recovery, minimum food intake needed to stabilize weight and metabolic rate, optimal food intake for health, and the concept of and/or a carefully estimated set-point for weight.

* Present examples of hunger patterns, typical food intake patterns, and the total caloric intake of a person who has recovered from an eating disorder This technique is an additional means of helping the person with the eating disorder think about the changes she or he will eventually need to make to recover fully (6).

* Educate the family Involving family members in the recovery process will increase their understanding of the eating disorder and their support for treatment. The registered dietitian can help decrease family frustration at mealtimes by relieving the family of the responsibility for monitoring food intake or changing food-related behaviors. Concrete suggestions on meal planning, nutrient needs, and strategies for dealing with inappropriate food- and weight-related behaviors should be offered cautiously in conjunction with therapy. That allows the family to work toward a supportive rather than a confrontational environment around food. The dietetics practitioner plays an important role in educating the family and significant others on the nutrition needs of the patient and the effect of starvation on patient behavior (6,14,15).

Gastric compliance in bulimia nervosa
Bulimia nervosa (BN) is a psychiatric illness characterized by eating binges followed by inappropriate behavioral attempts to compensate for the binges, usually vomiting or laxative abuse. Patients with BN have disturbances in the development of satiety during a meal as well as disturbances in functions of the upper gastrointestinal tract such as slowed gastric emptying, impaired gastric accommodation reflex and blunted cholecystokinin release.

The present study examined gastric compliance and sensory responses to gastric distention in women with BN and controls. Sixteen women with BN and 13 healthy control subjects swallowed an inflatable bag that was placed in the proximal stomach. The bag was inflated to produce increasing steps of pressure against the stomach wall, before and after consumption of a 200 ml (200 Kcal) liquid meal. Pressure and volume were recorded for 2-min periods, beginning at 0 mm Hg pressure and increasing in steps of 2 mm Hg until subjects reported discomfort, gastric volume reached 600 ml, or pressure reached 20 mm Hg. At each pressure step subjects made sensory ratings. Gastric compliance was calculated as the slope of the best-fit straight line of each subject’s gastric volume vs. gastric pressure. There was a significant postmeal increase in gastric compliance in both groups of subjects but there was no difference in compliance between patients with BN and controls. Patients with BN appeared to have diminished sensitivity to gastric distention. In conclusion, although other studies have described gastrointestinal abnormalities associated with BN, the current study found gastric compliance of patients with BN to be normal.

The Center provides Specialized Nutritional Supplements for those suffering with an eating disorder. Visit A Place of Hope On-Line Store

Pediatrics for Parents,  August, 2003
Anorexia and heart problems
Anorexia and impaired heart function often go hand in hand. A recent study of 41 anorexic girls who were given a cardiac exercise stress test found that over half had significant cardiac impairment or cardiac abnormalities. These girls had no symptoms or other indications of heart problems. Three had potentially life-threatening electrocardiogram changes and irregular heart beats.

In the group of girls with heart problems, 18 were trained athletics. Although they tended to have less impairment, 40% still had moderate or severe decreased function of the heart when tested.

The finding of heart abnormalities in girls with anorexia is not new. The importance of the study is the finding that many of these problems become apparent only during exercise testing.

The most common cardiac abnormality found was bradycardia–an abnormally slow heart rate. Sadly, many of the girls thought their slow heart rates were a sign of physical fitness rather than a sign of their malnutrition.

Unfortunately, providing these girls with information about their heart problems or the risk of heart problems caused by anorexia did little to change their behaviors. Most wanted to know when they could resume exercising.

Family Practice News. 5/15/03.

Anorexia May Lead to Emphysema
HealthDay,  December, 2003

The malnutrition that results from the eating disorder anorexia nervosa may cause emphysema.

That startling finding comes from a Canadian study presented Dec. 3 at the Radiological Society of North America’s annual meeting in Chicago.

Researchers used a new method of assessing computed tomography (CT) scans to analyze the lungs of 14 anorexia patients and found the malnutrition in these patients changed the physical structure of their lungs.

“There is a reduction in the amount of lung tissue in patients with anorexia nervosa,” lead author Harvey O. Coxson, an assistant professor of radiology at the University of British Columbia and an investigator at Vancouver Coastal Health Research Institute at Vancouver General Hospital, says in a prepared statement.

“It is unclear whether these structural changes are permanent, but if they are, early therapy is important.

Regional Osteopenia In Women With Anorexia Nervosa
Nutrition Research Newsletter,  Jan, 2001

Anorexia nervosa is highly prevalent among US women and is associated with substantial bone loss. Bone loss in women with the disorder is multi-factorial. It is related in pan to estrogen deficiency and to direct effects of undernutrition. A study recently published in Annals of Internal Medicine measured bone mineral density (BMD) at several skeletal sites to determine the prevalence rates and predictive factors of regional osteopenia and osteoporosis in a large community-based sample of women with anorexia nervosa.

Women (n=130, 98% white) with anorexia nervosa underwent a 3-hour outpatient visit at the General Clinical Research Center of the Massachusetts General Hospital in Boston. Height, weight, age at menarche, time since last menstrual period, previous estrogen use, fracture history, frame size, and dietary intake were determined. BMD was determined using x-ray absorptiometry. At each skeletal site measured, patients were categorized as having normal BMD, osteopenia, or osteoporosis, according to World Health Organization criteria.

Osteopenia and osteoporosis, respectively, were seen at the anterior-posterior spine in 50% and 13% of patients, at the lateral spine in 57% and 24% of patients, and at the total hip in 47% and 16% of patients. No differences in BMD were observed between patients with anorexia nervosa alone and patients with anorexia nervosa and concomitant bulemia nervosa. Twenty-three percent of the patients were currently estrogen users and 58% were previous estrogen users. BMD did not differ at any site according to current or previous estrogen use.

Patients with primary amenorrhea (n=7) weighed less and had lower BMD at all sites than patients with secondary amenorrhea (n=123). Total calcium intake was not correlated with BMD at any site. Fifty-seven percent of patients were receiving calcium supplements, 53% were receiving a multivitamin containing 400 IU of vitamin D, and 43% were receiving both. BMD did not differ in patients receiving nutritional supplements. Weight was a significant independent predictor of BMD at all skeletal sites. Age at menarche was a significant independent predictor of BMD measured by anterior-posterior spinal densitometry. Time since last menstrual period was a significant predictor of BMD in the anterior-posterior and lateral spine.

These findings demonstrate the high prevalence and profound degree of site-specific bone loss in women with anorexia nervosa. The data suggests that patients with anorexia are at a markedly increased risk for fracture at many skeletal sites. A relatively high percentage of patients reported a previous history of fracture. BMD was reduced by at least 1.0 SD at one or more skeletal sites in 97% of women with fractures, but fracture sites were not correlated with the location of osteopenia. Lateral BMD was reduced to a greater extent that BMD at the anterior-posterior spine. More than 90% of the patients in this highly representative sample of young anorectic women demonstrated significant bone loss at one or more skeletal sites. Current weight is the best and most consistent predictor of BMD at several skeletal sites. Screening for bone loss and counseling women with anorexia nervosa about the adverse effects of low weight on the skeleton is of utmost importance.

S. Grinspoon, E. Thomas, S. Pitts, E. Gross et al. Prevalence and Predictive Factors for Regional Osteopenia in Women with Anorexia Nervosa. Ann Intern Med 133(10): 790-794 (Nov 2000) [Correspondence: Dr. Grinspoon, Neuroendocrine Unit, Bulfinch 457b, Massachusetts General Hospital, Boston, MA 02114].

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