Executive Summary

Case studies contribute more focused analyses which, in the context of human loss and damage, demonstrate the effectiveness of response strategies and prevention measures and identify lessons about success in disaster risk reduction and climate change adaptation. The case studies were chosen to complement and be consistent with the information in the preceding chapters, and to demonstrate aspects of the key messages in the Summary for Policymakers and the Hyogo Framework for Action Priorities.

The case studies were grouped to examine types of extreme events, vulnerable regions, and methodological approaches. For the extreme event examples, the first two case studies pertain to events of extreme temperature with moisture deficiencies in Europe and Australia and their impacts including on health. These are followed by case studies on drought in Syria and dzud, cold-dry conditions in Mongolia. Tropical cyclones in Bangladesh, Myanmar, and Mesoamerica, and then floods in Mozambique are discussed in the context of community actions. The last of the extreme events case studies is about disastrous epidemic disease, using the case of cholera in Zimbabwe, as the example.

The case studies chosen to reflect vulnerable regions demonstrate how a changing climate provides significant concerns for people, societies, and their infrastructure. These are: Mumbai as an example of a coastal megacity; the Republic of the Marshall Islands, as an example of small island developing states with special challenges for adaptation; and Canada's northern regions as an example of cold climate vulnerabilities focusing on infrastructures.

AN is a disease, like asthma is a disease. It is not dieting, a strong wish to be thin, or malingering. People afflicted with AN have within their minds two realities. One reality is a normal and healthy one. Just like you and I, those who suffer from AN want to be happy, healthy, and normal. The other reality is best understood as a phobia, a state of immense fear and concern. In AN, the phobia is that of loss of control, leading to obesity. Just like a phobia of going outside, AN has far-reaching implications. The phobia of personal obesity leads to changes in exercise, eating, unusual behaviors, and AN almost constant state of fear, anxiety, and inability to cope with life. The weight loss that results from this phobic state can be life-threatening.

What causes anorexia nervosa?

Anorexia is a disease that occurs in about one in 100–200 women and about two in 1000 men. The onset of AN is preceded by weight loss. The weight loss may have occurred for any reason, e.g. dieting, travel, diarrhea, or after surgery. AN also requires a certain genetic make-up. AN cannot occur in those who do not have a genetic predisposition to the disease. Even with a genetic predisposition and weight loss, other factors, such as social, environmental, family, or psychological stressors, may be necessary for the disease to manifest itself.

Special considerations for history taking in eating disorder patients

Leave your office to meet the patient and observe their behavior with those who have accompanied them. Note their state of affect and ability to walk, then gait, weakness, and unsteadiness.

Certain elements of the history, such as those related to abuse or sexual issues, may best be left to a subsequent interview when rapport has been developed.

Instruct the patient to change in a private area, to keep on their underwear, and to wear the gown open to the back. Examining the patient while fully dressed may lead to failure to observe the degree of emaciation and other physical signs. It is preferable to perform the physical examination in the presence of a female trusted by the patient. Do not do rectal, pelvic, or breast examination as part of an eating disorder assessment physical examination.

Mental status examination

General appearance and behavior

Does the patient appear physically unwell, anxious, or depressed? Is he or she emaciated, or are they wearing clothes that obscure their figure? Is the patient restless? Many anorexic patients are unable to sit still or even sit, even when asked to do so, and continually jiggle their feet.

Speech

Is the patient communicative, or do they answer only briefly and reluctantly. Does the patient set out to justify their reasons for dieting? Do they avoid eye contact when asked potentially confrontational questions about eating, exercise, vomiting, or laxative abuse?

The medical symptoms and signs of AN and, although less serious, of other eating disorders are part of the illness, and hence it is more appropriate to think of them as medical manifestations rather than merely complications. Although the disorder usually starts in adolescence, its course is often prolonged; AN patients may be ill for many years, and the majority of severely ill AN patients are in early or mid adult life. Hence, AN is a matter of concern for adult physicians as well as for pediatricians and adolescent medicine specialists. Figure 4.1 shows a mnemonic that is useful for remembering the physical signs of eating disorders.

Manifestations result from starvation or from the behaviors adopted to induce it. They are not indicative of underlying pathology. The inexperienced clinician who undertakes unnecessary investigations to exclude all possible causes for each abnormal finding is doing the patient a disservice by delaying appropriate treatment. Rather, all clinicians should be aware of the wide range of physical abnormalities that are commonly found in anorexic patients (Table 4.1). Many of these abnormalities, such as decreased serum concentrations of gonadotropins and steroid sex hormones, alterations to the peripheral metabolism of thyroid hormone, and raised circulating concentrations of cortisol and growth hormone, are best regarded as physiological adaptations to the state of starvation and do not require treatment. However, some medical complications are not only clinically important but are also life-threatening; these require special attention.

Introduction

Caring for patients with dieting disorders can be one of the most challenging and rewarding roles for nurses. However, even for the most experienced clinician, it can also be frustrating, anxiety-provoking, and emotionally draining, and nurses must be aware of the potential for burnout and emotional over- or underinvolvement.

Nurses become many things to a patient with AN, most essentially someone who is familiar with the patient's feelings, ideas, emotions, routines, rituals, and behaviors. Nurses need to be skilled in recognizing and interpreting the physiological and psychological signs, symptoms, and complications of the disorder. It is imperative that they develop AN empathic, non-judgmental approach, and that they maintain clear professional boundaries — yet a nurse's job is to challenge fixed and unrealistic beliefs and to assist in the development of motivation to change, so it is necessary to form a strong and trusting bond. As well, nurses provide information, act as role models, and support the patient and their family through the recovery process.

In order to fulfill this challenging and difficult role, nurses need education, clinical supervision, support from management and administration, collaboration and communication with other nursing colleagues, and recognition from other members of the treatment team that the nurse's role is valuable and vital.

A team approach is vital for effective treatment of eating disorders. The specialist clinical dietitian, as part of the team, is the most qualified person to provide accurate education about nutrition, weight gain, weight maintenance, the resumption of normal eating, and the nutritional methods of avoiding the refeeding syndrome.

Nutrition treatment is not as simple as applying AN educational formula and handing out a diet sheet. Nutrition intervention is complex, and eating disorder patients are resistant to nutritional treatment. Compliance may be reduced by perceived coercion, psychiatric comorbidities such as borderline personality disorders, self-harm, and suicidality, and ethical issues such as the need to report at-risk children to the law. Dietary change may be dependent on the patient's psychological progress.

The objectives of this chapter are to:

• Review the range of dietetic interventions that are professionally acceptable to dietitians.

• List some methods of dealing with the emotional issues that are likely to occur during treatment.

• Promote self-care (supervision) for all dietitians working with eating disordered patients.

• Discuss distinctions between specialist and non-specialist dietitians.

Clinical boundaries

Discuss the therapeutic limitations of nutrition counseling and make clear the need for concurrent psychotherapy at the first interview.

Professional boundaries

• Work as a member of a team: before initiating any nutrition intervention, make certain that a doctor is following the patient medically on a regular basis and that psychological therapy is being carried out by a qualified practitioner. Emphasize the link between the patient's eating disorder and their emotional health in the dietetic sessions. Set AN upper limit of six dietetic sessions with a patient who is not engaged in a psychological intervention. This is to avoid clouding the dietetic intervention with emotional issues, to encourage psychological treatment, and to protect the patient against inadequate treatment.

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