This web site was partially supported by the
Health Resources and Services Administration, Maternal and Child Health Bureau
through grant number 6T76-MC00011
Disorders during Adolescence: Nutritional Problems and Interventions
Jane Mitchell Rees, PhD, RD, CD
Departments of Health Services and Pediatrics
Maternal Child Health and Adolescent Medicine
University of Washington, Seattle, WA 98195
Chapter 4 Initial Stage of Anorexia Nervosa in
[Table of Contents]
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 nervosa
are 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 herself 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
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
Initial Stage: Timely recognition of
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
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.
This Web Site is a reference for health care professionals, students and
educators; it is not intended to provide advice or treatment to people with
eating disorders. If you have an eating disorder or disturbed eating
patterns, consult a qualified physician who specializes in eating disorders.