Eating Disorders in Teens

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Eating Disorders in Teens

• Maj Anisha Abraham, MD, MPH

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Objectives

• To identify the risk factors for eating disorders
• To perform an evaluation of the physical,
  emotional and nutritional status of a teen
• To establish the diagnosis of anorexia or bulimia
• To manage a patient with an eating disorder using
  a multi-disciplinary team

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The Drive for Thinness

• 63 of women feel that body weight determines
  how they feel
• Americans spend 33 billion dollars on dieting and
  diet-related products
• The average female starts dieting at age 9yrs

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The Drive for Thinness

• Started when Twiggy replaced Marilyn Monroe in
  the 60s
• The average woman is 54 and 140 lbs
• The average model is 511 and 117 lbs

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Scope of the Problem

• The incidence of eating disorders has increased
  five times since 1955
• More than 1/2 of high school girls have dieted
• Anorexia is the third most common chronic disease
  in teens

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Scope of the Problem

• 10-50 of teens engage in binge eating or
  vomiting
• 1-5 have bulimia .5-1 develop anorexia
• 1 in 5 females 19-25yrs have an eating dx

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Culture and Eating Disorders

• One anthropological study found
• when women are more financially dependent and
  marital ties are paramount, the standard is to be
  curvaceous
• When independence for women is possible, the
  standard for female attractiveness is towards
  thinness

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Culture and Eating Disorders

• There is an increase in eating disorders among
  Black, Hispanic and Asians
• Linked to the pressure to integrate and be a
  smart,beautiful and thin career woman
• In Argentina, China, and Japan similar pressures
  have developed

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Eating Disorders in the Military

• Study by Mayo researchers at Madigan Army
  Medical Center 8 of active duty women were
  reported to have eating dxs compared to 1-3 in
  general population
• Study conducted among active duty males in the
  Navy 2.5 of male doctors were anorexic and
  11 were bulimic (Mcnulty, 1994)

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Eating Disorders in the Military

• Anorexia-1.3(Army), 1.1(Navy), and 0.8(AF)
• Bulimia-4.3(Army), 5.2(Navy), 9.3 (AF)
• Diet pill usage in the Army-8.6(year-round)
• Increased by 3.9 at PT time
• Vomiting,laxative use and diurectic use showed
  similar patterns

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Risk Factors for Eating Disorders

• Ethnic and socioeconomic status
• Cultural influence
• Low self-esteem/perfectionistic
• Difficulties with communication, separation and
  conflict resolution w/ family

• Anxiety or depressive disorder
• Family history
• A drive to excel in sports
• Early puberty
• Winter season
• Sexual Abuse

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Case1-Eating Disorders

• Ellen is a 14 yo Caucasian female w/ a 6 mo hx of
  wt loss who is referred to you by her primary
  care provider. Her last visit to the physicians
  office was over 6 mos ago for a camp physical at
  which time she was doing well.
• Her wt was 53kgs and her ht was 160cm. Her mother
  brought her into the doctors last month because
  she was losing weight and becoming isolated and
  withdrawn. The primary care provider was
  surprised at her appearance.

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Case1-Eating Disorders

• She appeared cachetic and pale. Her wt was 40kgs
  and her height was 160 cm. He followed her over
  the next four weeks and she continued to lose
  weight. The family physician did a preliminary
  work up and refers her to you.

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Case1-Eating Disorders

• Ellen was angry about having to come into the
  hospital for an evaluation as she did not feel
  that anything was wrong with her. The patient
  tells you that she was in good health till 6 mos
  ago when following a move with her family to a
  different city, she voluntarily restricted her
  intake and began a regular strenuous exercise
  program.

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Case1-Eating Disorders

• Her mother was concerned because she was no
  longer eating breakfast and only eating a small
  salad and a cup of tea for dinner. As she lost
  increasing amounts of weight, her appetite
  diminished and she found it easier to diet. She
  seems neither surprised nor concerned when she is
  told that has lost over 25 of her body weight.

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Case1-Eating Disorders

• What further information do you need to help
  understand Ellens problem?
• What further evaluation would help you to make
  the diagnosis?
• How will you manage Ellen?

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The Interview

• Perception of illness
• History of Illness
• Weight and height
• Body image
• Means of weight control

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The Interview

• Menstrual Function
• Past Medical History
• Family History
• Psychosocial History

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Differential Diagnosis

• Depression,OCD
• CNS tumors
• Endocrinologic disorders-IDDM, Hyperthyroidism,
  Addisons
• GI disorders-IBD,malabsorption
• Chronic infections,SLE,Malignancy

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Diagnostic Criteria-Anorexia

• Refusal or inability to maintain body weight over
  a minimum normal weight
• Intense fear of gaining weight despite being
  underweight
• Disturbance in perception of body shape
• Absence of three consecutive menstrual cycles

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Diagnostic Criteria-Bulimia

• Minimum of 2 binge-eating episodes weekly for 3
  months/recurrent binge eating
• A feeling of lack of control over binge-eating
  behavior
• Regular use of self-induced vomiting,
  laxatives,diuretics,strict dieting,fasting,or
  vigorous exercise to prevent weight gain
• Disturbance of body shape perception

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Diagnostic Criteria-Eating Disorder Not Otherwise
Specified

• All of the criteria for Anorexia Nervosa are met
  except the individual has regular menses or
  weight is in the normal range.
• All of the criteria for Bulimia Nervosa are met
  except binges less than twice a week or less than
  3 months.
• 3. Binge eating disorder- recurrent episodes of
  binge eating in the absence of the regular use of
  purging,etc

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Physical examination

• Vital signs
• Weight and height percentiles, BMI and weight
  percentile for ht
• HEENT-dental erosion,parotid swelling
• Thyroid
• Cardiovascular-poor cap refill,bradycardia
• Breasts-loss of fat

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Physical examination

• Genitourinary-tanner stage
• Abdominal-organomegaly
• Skin-color,loss of fat,edema,lanugo,bruises on
  mcp joint
• Mental state-apathy, depression,
  anxiety,obsessive-compulsive

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Laboratory evaluation

• CBC
• Urine dip
• Electrolytes,BUN,creatine, Ca,Mg,Phos
• T4 and TSH,serum protein and albumin
• EKG
• ?Stool for occult blood, ESR
• ?FSH,LH,Prolactin

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Management-Mild Stage

• Set goal weight-usually BMIgt18
• Refer to nutritionist
• Aim for wt gain of .5-1 kg weekly
• Check weights with gown,pt facing away from scale
  and empty bladder.
• Check hr,temp,and urine PH. If phgt7metabolic
  alkalosis
• Consider calcium and iron supplementation
• Reevaluate regularly

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Ways to Develop a Good Body Image

• Question whether there is one ideal body shape
• Cultivate the ability to appreciate uniqueness
• Take care of your body
• Surround yourself with people who feel good about
  their body

• Learn to respect internal cues
• Value body movement and competence
• Cultivate role models with appearances that are
  not the ideal
• Bond with friends on issues other than dieting

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Management-Moderate Stage

• Set goal weight
• Refer to psychology/ psychiatry and nutrition
• Provide structure to daily activities and meals.
• Consider restriction of excercise
• Increase calories by 200 every 2-3 days
• Follow up frequently
• Stress medical markers of starvation, consequence
  of failure to gain wt to patient

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Indications for Hospitalization

• Electrolyte abnormalities
• hypokalemia,hypophosphatemia
• Physiologic decompensation
• Temp lt36 degrees
• Pulse lt 45
• Altered mental status
• Acute medical complications
• arrhythmias,syncope,seizures

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Indications for Hospitalization

• Inability to break cycle as outpatient
  (gt3-6mos)
• Acute psychiatric emergency- ie.suicidal
• Rapid or excessive weight loss
• gt10 in 2moss
• weight lt75 for IBW

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Medical Therapy

• Bulimia
• Fluoxetine is the only drug which is
  approved-60mg/day. Use w/ CBT
• Anorexia-
• TCAs may improve wt gain/has side effects
• SSRIs showed no change vs placebo on
  hospitalized AN patients
  Did improve weight for outpt wt recovered
  patients

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Medical Concerns in Eating Disorders

• Cardiac-,bradycardia, arrythmias
• Pulmonary-pneumomediastinum
• GI-Delayed emptying, constipation,SMA
  syndrome,Mallory-Weiss tear,dental erosion
• Metabolic-Osteoporosis (consider OCPs, bone
  density), increased cholesterol, low bg,
  hypercarotenemia

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Medical Concerns in Eating Disorders

• Hematologic-Leukopenia, anemia, thrombocytopenia,
  decreased ESR, low wbcs
• Dermatologic-Lanugo,dry skin,brittle
  nails,acrocynanosis
• Other-ammenorhea-need 90 of IBW to reestablish
  menses

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Prognosis

• Associated with length of illness
• Worsening occurs in 15-25 of patients
• Mortality is 5 for anorexia
• Poorer prognosis for bulimia with hx of sexual
  abuse,coexistent personality disorder or
  depression,substance abuse

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Summary

• Eating disorders are common in teens
• Screen for eating disorder risk factors
• Check physical exam for evidence of
  abnormalities,consider routine labs
• Rule out organic disease, use criteria to
  diagnose anorexia/bulimia
• Use a team approach in treating eating disorders!

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QUESTIONS?