Medical Aspects of Eating Disorders Richard Kreipe, M.D

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Medical Aspects of Eating Disorders

• Richard Kreipe, M.D.
• Professor of Pediatrics, Division of Adolescent
  Medicine, Golisano Childrens Hospital
• Medical Director, Eating Disorders
• Recovery Center of Western New York
• February 29, 2008

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The role of the physicians on the eating disorder
treatment team is to

• Identify the disorder.
• Rule out other causes.
• Monitor for consequences.
• Treat the disorder .

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• Identification of patients with eating disorders

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Determination of normal weight for height in
adults

• Predicted body weight method (PBW)
• Predict body weight based on height.
• Divide actual weight by predicted weight
• Example PBW for 5'6" woman is 130 lb. If actual
  weight is 110 lb., then patient is 85 of
  predicted weight.

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Determination of normal weight for height in
children and adolescents

• Growth chart
• Height
• Weight
• Body mass index for age

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Growth chart height and weight for age
Height
Weight
Age in years
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Growth chart body mass index for age
body mass index weight/height2
Age in years
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Symptoms of patients with anorexia nervosa

• Dizziness, weakness, fainting, fatigue
• Cold intolerance
• Hair loss
• Bloating, abdominal pain, heartburn,
  constipation, diarrhea
• Lack of menstrual periods
• Bone pain from stress fractures in athletes

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Physical examination anorexia nervosa

• Appearance of malnutrition
• Thin, loss of subcutaneous tissue, muscle
  wasting
• Skin pale, poor circulation, dry
• Hair dry, brittle, thinning
• Lanugo fine body hair as in newborns

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Physical examination anorexia
nervosa(continued)

• Low blood pressure
• Slow heart rate
• Orthostatic positional changes in heart rate
  and blood pressure
• Low body temperature

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Symptoms of patients with bulimia nervosa

• Feeling faint or fainting
• Depression and anxiety
• Bloody vomiting (unusual)
• Throat or upper abdominal pain
• Fatigue, weakness, difficulty concentrating
• Facial swelling around jaw

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Physical exam bulimia nervosa

• Signs of vomiting
• Enlargement of salivary glands
• Throat irritation
• Subconjunctival hemorrhages
• Upper abdominal tenderness
• Dental erosions

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Diagnosis

• Complete history and physical exam
• Screening lab work blood count, chemistry panel,
  thyroid-stimulating hormone, urinalysis
• Targeted lab work done based on findings

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• Differential diagnosis of eating disorders

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Differentiation of eating disorders from other
diseases

• Gastrointestinal disease
• Crohns disease, ulcerative colitis
• Celiac disease
• Endocrine disease
• Diabetes mellitus
• Hyperthyroidism

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Differentiation of eating disorders from other
diseases (continued)

• Pulmonary diseases
• Malignancy
• Chronic infection
• Central nervous system tumors

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Differentiation of eating disorders from other
diseases (continued)

• Psychiatric disorders
• Depression
• Obsessive compulsive disorder
• General anxiety disorder
• Panic disorder

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• Monitoring for
• consequences of
• eating disorders

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Metabolic consequences of eating disorders

• Lowered basal metabolic ratesuppressed
  metabolism
• Increased catabolismbreakdown of tissuemuscle,
  brain, bone
• 70 of weight loss is lean tissue, 30 is fat
• Decreased anabolismbuilding of tissue
• Electrolyte abnormalities
• Potassium, sodium, phosphorous
• Hypercholesterolemia early and
  hypocholesterolemia late

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Endocrine system consequences of eating disorders

• Lack of menstrual periods, estrogen deficiency
• Irregular menstrual periods
• Lowered testosterone levels
• Elevated cortisol levels
• Thyroid adaptation

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Bone consequences of eating disorders
osteoporosis

• Lack of normal bone density gains in adolescence
  and early adulthood
• Midlife osteoporosis if peak bone density is low
• Stress fractures
• Suppressed bone formation related to hormonal
  changes that affect calcium uptake into bone.

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Normal bone density growth
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Osteoporosis
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Gastrointestinal system consequences of eating
disorders

• Reduced intestinal movement and delayed stomach
  emptying
• Gastroesophageal reflux
• Gastric tears
• Dental erosions
• Elevated liver enzymes

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Cardiovascular consequences of eating disorders

• Decreased heart size
• Abnormal heart rhythms

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Hematologic consequences of eating disorders

• Bone marrow depression
• Anemia low red blood cell count
• Leukopenia low white blood cell count
• Thrombocytopenia low platelet count

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Behavioral and psychological consequences of
eating disorders

• Ancel Keys study of the effects of starvation on
  healthy young men showed that many psychological
  and behavioral symptoms of eating disorders were
  the result of the biology of starvation.
• Weight and caloric intake must be returned to
  normal in treatment process while psychological
  issues are also addressed.
• Binge eating is in part a physiologically based
  reaction to starvation.

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• Treatment of patients
• with
• eating disorders

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Improve nutritional status

• A subnormal weight cannot be healthfully
  maintained.
• Malnutrition cannot be corrected without adequate
  intake of carbohydrates, proteins, fats, and
  total calories.

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Improve nutritional status (continued)

• Malnutrition can be seen in patients who are
  normal or overweight and have restrictive eating,
  bulimia, or binge eating disorder.

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Coordinating with the treatment team

• Physician and medical staff have ongoing
  consultation with
• Dietitian
• Social worker/case manager (if separate from
  psychotherapist or other team member)
• Psychotherapist
• Psychiatrist
• Regularweekly or biweeklyappointments until
  weight gain is well established or symptoms have
  decreased.

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Management education

• Educate on
• Effect of malnutrition on the body metabolic,
  gastrointestinal, psychological.
• Normal body weight/acceptance of current body
  weight.
• Risks of purging behaviors.
• Long-term risks of being underweight.
• Use of blind weights, if applicable.

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Pharmacologic treatment

• Psychotropic medications
• SSRI medications decrease purging behaviors,
  address co-morbid conditions such as depression
  or anxiety.
• SSRI medications are not effective for promoting
  weight gain in anorexia nervosa.
• SSRI, tricyclics, and anticonvulsant medications
  being tried with binge eating disorder.
• Reference Devlin, M. J. (2005) Binge Eating
  Disorder 2005, 15th Annual
• Conference, Renfrew Center Foundation, Nov. 12.

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Pharmacologic treatment (continued)

• No evidence of effectiveness
• Appetite stimulants for weight gain
• Estrogen replacement

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Treatment plan

• Establish a relationship.
• Address the patients and familys concerns, even
  if different from our own.
• Set nutritional intake to support nutritionists
  recommendations.
• Monitor weight and medical status.
• Set treatment plan for
• expected rate of gain.
• weight or medical criteria for which
  hospitalization may be required.

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Treatment Adults

• Adults age 18 and over must agree to treatment.
• Health care for patients 18 and over is
  confidential.
• Signed release required for medical provider to
  discuss specifics with family.
• Confidentiality does not include a situation that
  is life-threatening.

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ManagementAnorexia Nervosa (continued)

• Osteoporosis
• Weight gain.
• Calcium 1,500 mg with Vitamin D 400 IU per day or
  four servings of calcium-rich food per day.
• Dexa scan if no menstrual period for six months
  to one year or prolonged malnutrition.
• Estrogen replacement does not treat osteoporosis
  in young women.
• Drugs like Fosamax used to increase bone density
  are not currently used in women before or during
  childbearing years because the safety profile is
  not known.

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Treatment Anorexia Nervosa

• Refeeding syndromefluid and electrolyte
  abnormalities that occur when a patient who is
  malnourished suddenly eats large amounts
• Occurs in patients less than 75 PBW.
• Usually occurs in first few days of a
  high-calorie diet.
• Prevent by starting with low caloric intake and
  increase slowly.
• Check electrolytes, especially phosphorous,
  frequently.

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Management Bulimia Nervosa

• Monitor for electrolyte abnormalities.
• Help patients stop laxative abuse.
• Discuss dental care.
• Discourage dieting in conjunction with treatment
  team members
• Eat three meals a day plus two snacks.
• Increase protein in diet.

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Indications for hospitalization in patients with
eating disorders

• Less than 75 of predicted body weight.
• Inability to eat.
• Changes in blood pressure, pulse, and temperature
  indicative of seriously compromised circulation
  and organ perfusion.
• Cardiac arrhythmias.

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Indications for hospitalization in patients with
eating disorders (continued)

• Serious serum electrolyte abnormalities
  potassium, phosphorous, sodium
• Esophageal tears
• Intractable vomiting
• Failure to improve despite intensive out-patient
  treatment
• Psychiatric instability Danger to self or
  others, e.g., suicide risk

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• The road to success is always under
  construction.

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References

• Garner, D. M., and Garfinkel, P. E. (1997)
  Handbook of Treatment for Eating Disorders, 2nd
  ed. New York Guilford Press.
• Kreipe, R. E., and Yussman, S. M. (2003) The
  Role of the Primary Care Practitioner in the
  Treatment of Eating Disorders. Adolescent
  Medicine 14(1).
• Levine, R. L. (2002) Endocrine Aspects of Eating
  Disorders in Adolescents. Adolescent Medicine
  13(1).
• Mitchell, J. E. et al. (2001) Combining
  Pharmacotherapy and Psychotherapy in Treatment of
  Patients with Eating Disorders. Psychiatric
  Clinics of North America 24(2).