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EATING DISORDERS

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Title: EATING DISORDERS


1
EATING DISORDERS
  • Resmy Palliyil Gopi

2
OBJECTIVES
  • Discuss the signs and symptoms of eating
    disorders, the appropriate evaluation, and
    treatment options
  • Anorexia nervosa
  • Bulimia nervosa
  • Binge Eating Disorder
  • Eating disorder NOS

3
DSM-IV CRITERIA-Anorexia Nervosa
  • Refusal to maintain weight within a normal range
    for height and age (weight loss leading to
    maintenance of body weight less than 85 of that
    expected)
  • Intense fear of gaining weight or becoming fat,
    even though underweight.
  • Disturbance in the way in which ones body weight
    or shape is experienced, undue influence of body
    weight or shape on self-evaluation, or denial of
    the seriousness of the current low body weight.
  • In postmenarchal females, amenorrhea or the
    absence of at least three consecutive menstrual
    cycles.

4
SUBTYPES
  • Restricting
  • Restriction of intake to reduce weight
  • Binge eating/purging
  • May binge and/or purge to control weight
  • 50 of patients go through a phase during their
    illness when they binge eat.

5
Anorexia nervosa
  • Outstanding feature of AN is persistent and
    severe restriction of energy intake, delusion of
    being fat and obsession to be thinner.

6
SIGNS AND SYMPTOMS
  • Lanugo hair
  • Scalp hair loss
  • Early satiety
  • Constipation
  • Short stature
  • Osteopenia
  • Breast atrophy
  • Atrophic vaginitis
  • Primary or secondary amenorrhea
  • Delayed puberty
  • Dry skin
  • Cold extremities, acrocyanosis
  • hypothermia
  • Sinus bradycardia
  • Pitting edema
  • Weakness, fatigue
  • Cardiac murmurs
  • Fainting
  • Orthostatic hypotension

7
DSM-IV CRITERIA- Bulimia
  • Episodes of binge eating with a sense of loss of
    control
  • Binge eating is followed by compensatory behavior
    of the purging type (self-induced vomiting,
    laxative abuse, diuretic abuse) or nonpurging
    type (excessive exercise, fasting, or strict
    diets).
  • Binges and the resulting compensatory behavior
    must occur a minimum of two times per week for
    three months
  • Dissatisfaction with body shape and weight

8
Bulimia nervosa
  • Hallmark of BN is binge eating followed by
    compensatory methods to rid the body of effects
    of calories.
  • More likely to be impulsive, not only in eating
    behavior, but also in their use of drugs,
    alcohol, self mutilation, lying, stealing and
    other manifestations of personality disturbance.

9
SIGNS AND SYMPTOMS
  • Mouth sores
  • Pharyngeal trauma
  • Dental enamel erosions
  • Heartburn, chest pain
  • Esophageal rupture
  • Impulsivity
  • Stealing
  • Alcohol abuse
  • Drugs/tobacco
  • Muscle cramps
  • Weakness
  • Bleeding or easy bruising
  • Irregular periods
  • Fainting
  • Swollen parotid glands
  • hypotension

10
Binge Eating DisorderRESEARCH CRITERIA
  • Eating, in a discrete period of time, an amount
    of food that is larger than most people would eat
    in a similar period
  • Occurs 2 days per week for a six month duration
  • Associated with a lack of control and with
    distress over the binge eating

11
BED
  • Must have at least 3 of the 5 criteria
  • Eating much more rapidly than normal
  • Eating until uncomfortably full
  • Eating large amounts of food when not feeling
    physically hungry
  • Eating alone because of embarrassment
  • Feeling disgusted, depressed or very guilty over
    overeating

12
Eating Disorder NOS DSM-IV CRITERIA
  • All criteria for anorexia nervosa except has
    regular menses
  • All criteria for anorexia nervosa except weight
    still in normal range
  • All criteria for bulimia nervosa except binges lt
    twice a week or for lt 3 months
  • Patients with normal body weight who regularly
    engage in inappropriate compensatory behavior
    after eating small amounts of food (ie,
    self-induced vomiting after eating two cookies)
  • A patient who repeatedly chews and spits out
    large amounts of food without swallowing

13
EPIDEMIOLOGY
  • Incidence rates have increased in the past 25
    years More than 90 are females, more than 95
    are Caucasian, more than 75 are adolescents
  • Anorexia
  • Affects 1 of adolescent females
  • Age of onset is lower in AN 1216yrs
  • In AN females outnumber males 9 to 1
  • Bulimia
  • Occurs in 5 of older adolescents and young adult
    females.
  • Age of onset is 15-20yrs
  • In BN females outnumber males 5 to 1

14
Epidemiology
  • Eating Disorder NOS (ED-NOS)
  • Occurs in 3-5 of women between the ages of 15
    and 30 in Western countries
  • As minority culture groups assimilate into
    American society, rates increase
  • Binge Eating Disorder (BED)
  • Occurs more commonly in women
  • Depending on population surveyed, can vary from
    3 to 30

15
PATHOGENESIS
  • No consensus on precise cause
  • Combination of psychological, biological, family,
    genetic, environmental and social factors
  • Imbalance of neurotransmitters of which serotonin
    is the most extensively studied.

16
ASSOCIATED FACTORS
  • History of dieting in adolescent children
  • Childhood preoccupation with a thin body and
    social pressure about weight
  • Sports and artistic endeavors in which leanness
    is emphasized, young women with restrictive
    eating disorders and amenorhea referred to as
    female atheletic triad
  • Association of eating disorders and sexual abuse
  • Women whose first degree relatives have eating
    disorders 6 to 10 fold increased risk for
    developing an eating disorder

17
ASSOCIATED PSYCHIATRIC CONDITIONS
  • affective disorders
  • anxiety disorders
  • obsessive-compulsive disorder
  • personality disorders
  • substance abuse

18
Screening
  • Screening questions about eating patterns and
    satisfaction with body appearance should be asked
    to all preteens and all adolescents as part of
    routine pediatric health care

19
Questionnaire
  • What is the most you ever weighed? How tall were
    you then? When was that?
  • What is the least you ever weighed in the past
    year? How tall were you then? When was that?
  • What do you think you ought to weigh?
  • Exercise how much, how often, level of
    intensity? How stressed are you if you miss a
    workout?
  • Current dietary practices ask for
    specificsamounts, food groups, fluids,
    restrictions?
  • 24-h diet history?
  • Calorie counting, fat gram counting? Taboo foods
    (foods you avoid)?
  • Any binge eating? Frequency, amount, triggers?
  • Purging history?
  • Use of diuretics, laxatives, diet pills, ipecac?
    Ask about elimination pattern, constipation,
    diarrhea.
  • Any vomiting? Frequency, how long after meals?
  • Any previous therapy? What kind and how long?
    What was and was not helpful?

20
Questionnaire
  • Family history obesity, eating disorders,
    depression, other mental illness, substance abuse
    by parents or other family members?
  • Menstrual history age at menarche? Regularity of
    cycles? Last menstrual period?
  • Use of cigarettes, drugs, alcohol? Sexual
    history? History of physical or sexual abuse?

21
Questionnaire Review of symptoms
  • Dizziness, syncope, weakness, fatigue?
  • Pallor, easy bruising or bleeding?
  • Cold intolerance?
  • Hair loss, lanugo, dry skin?
  • Vomiting, diarrhea, constipation?
  • Fullness, bloating, abdominal pain, epigastric
    burning?
  • Muscle cramps, joint paints, palpitations, chest
    pain?
  • Menstrual irregularities?
  • Symptoms of hyperthyroidism, diabetes,
    malignancy, infection, inflammatory bowel disease?

22
SCREENING TOOL
  • Are you satisfied with your eating patterns? (No
    is abnormal)
  • Do you ever eat in secret? (Yes is abnormal)
  • Does your weight affect the way you feel about
    yourself? (Yes is abnormal)
  • Have any members of your family suffered with an
    eating disorder? (Yes is abnormal)
  • Do you currently suffer with or have you ever
    suffered in the past with an eating disorder?
    (Yes is abnormal)

23
PHYSICAL EXAM anorexia
  • Vital signs to include orthostatics
  • Skin and extremity evaluation
  • Dryness, bruising, lanugo
  • Cardiac exam
  • Bradycardia, arrhythmia, MVP
  • Abdominal exam
  • Neuro exam
  • Evaluate for other causes of weight loss or
    vomiting

24
PHYSICAL EXAM bulimia
  • All previous elements plus
  • Parotid gland hypertrophy
  • Erosion of the teeth enamel
  • Skin lesions on the fingers (Russels sign)

25
LABORATORY ASSESSMENT
  • Diagnosis is clinical, there is no confirmatory
    lab test
  • CBC, Electrolytes, UA, LFT, TSH
  • B-HCG, Serum prolactin, FSH, LH
  • EKG
  • Bone density

26
DIFFERENTIAL DIAGNOSIS
  • Malignancy, central nervous system tumor
  • Gastrointestinal system inflammatory bowel
    disease, malabsorption, celiac disease
  • Endocrine diabetes mellitus, hyperthyroidism,
    hypopituitarism, Addison disease
  • Depression, obsessive-compulsive disorder,
    psychiatric diagnosis
  • Other chronic disease or chronic infections
  • Superior mesenteric artery syndrome (can also be
    a consequence of an eating disorder)

27
Medical Complications Resulting From Purging
  • Fluid and electrolyte imbalance hypokalemia
    hyponatremia hypochloremic alkalosis
  • Use of ipecac irreversible myocardial damage and
    a diffuse myositis
  • Chronic vomiting esophagitis dental erosions
    Mallory-Weiss tears rare esophageal or gastric
    rupture rare aspiration pneumonia
  • Use of laxatives depletion of potassium
    bicarbonate, causing metabolic acidosis
    increased blood urea nitrogen concentration and
    predisposition to renal stones from dehydration
    hyperuricemia hypocalcemia hypomagnesemia
    chronic dehydration
  • Amenorrhea ,menstrual irregularities, osteopenia

28
Medical Complications From Caloric Restriction
  • Cardiovascular Electrocardiographic
    abnormalities low voltage sinus bradycardia
    (from malnutrition) T wave inversions ST
    segment depression (from electrolyte imbalances).
    Prolonged corrected QT interval is uncommon but
    may predispose patient to sudden death.
    Dysrhythmias include supraventricular beats and
    ventricular tachycardia, with or without
    exercise. Pericardial effusions can occur in
    those severely malnourished. All cardiac
    abnormalities except those secondary to emetine
    (ipecac) toxicity are completely reversible with
    weight gain.

29
Medical Complications From Caloric Restriction
  • Gastrointestinal system delayed gastric
    emptying slowed gastrointestinal motility
    constipation bloating fullness
    hypercholesterolemia abnormal liver function
    test results. All reversible with weight gain.
  • Renal increased BUN concentration (from
    dehydration, decreased GFR) with increased risk
    of renal stones polyuria with refeeding, 25
    can get peripheral edema attributable to
    increased renal sensitivity to aldosterone and
    increased insulin secretion

30
Medical Complications From Caloric Restriction
  • Hematologic leukopenia anemia iron deficiency
    thrombocytopenia.
  • Endocrine euthyroid sick syndrome amenorrhea
    osteopenia.
  • Neurologic cortical atrophy seizures.

31
AMENORRHEA
  • Secondary amenorrhea affects more than 90 of
    patients with anorexia
  • Caused by low levels of FSH and LH
  • Withdrawal bleeding with progesterone challenge
    does not occur due to the hypoestrogenic state
  • Menses resumes with 6 months of achieving 90 of
    IBW

32
REFEEDING SYNDROME
  • Severe hypophosphatemia
  • Cardiovascular collapse
  • Rhabdomyolysis
  • Seizures
  • Delirium

33
TREATMENT AND OUTCOME
34
ANOREXIA
  • Multifaceted and interdisciplinary
  • Interdisciplinary care team
  • Medical provider
  • Dietician regain to goal of 90-92 of IBW
  • Mental health professional
  • Cognitive behavioral therapy
  • Best proven approach to the treatment
  • Focuses on reconstructing thinking errors.

35
MEDICATIONS
  • Overall, disappointing results
  • Effective only for treating comorbid conditions
    of depression and OCD
  • Anxiolytics may be helpful before meals to
    suppress the anxiety associated with eating

36
Criteria for hospital admission AN
  • lt 75 ideal body weight, or ongoing weight loss
    despite intensive management
  • Refusal to eat
  • Body fat lt10
  • Heart rate lt50 beats per minute daytime 45 beats
    per min nighttime
  • Systolic pressure lt90
  • Orthostatic changes in pulse (gt20 beats per min)
    or blood pressure (gt10 mm Hg)
  • Temperature lt 96F
  • Arrhythmia

37
BULIMIA
  • Cognitive behavioral therapy is effective
  • Pharmacotherapyhigh success rate
  • Fluoxetinestudies reveal up to a 67 reduction
    in binge eating and a 56 reduction in vomiting
  • TCAs
  • Topiramatereduced binge eating by 94 and
    average wt. loss of 6.2 kg
  • Ondansetron, 24 mg/day

38
Criteria for hospital admission BN
  • Syncope
  • Serum potassium concentration lt 3.2 mmol/L
  • Serum chloride concentration lt 88 mmol/L
  • Esophageal tears
  • Cardiac arrhythmias including prolonged QTc
  • Hypothermia
  • Suicide risk
  • Intractable vomiting
  • Hematemesis
  • Failure to respond to outpatient treatment

39
OUTCOME
  • 75-85 of individuals hospitalized for AN recover
    fully
  • 25 poor outcome
  • Associated with later age of onset
  • Longer duration of illness
  • Lower minimal weight
  • Vomiting
  • Concomitant personality disorder
  • Disturbed parent child relation
  • In BN, 60 have good outcome, 30 have
    intermediate outcome

40
Question 1
  • You are evaluating a 17-year-old girl who has
    anorexia nervosa for possible hospital admission.
    She denies a recent history of vomiting, syncope,
    and hematemesis. Of the following physical
    findings, the most appropriate indication for
    hospitalization includes
  • A. Hyperthermia.
  • B. Lower extremity edema.
  • C. Orthostatic changes.
  • D. Resting tachycardia.
  • E. Tachypnea.

41
Question 2
  • An afebrile 15yr old girl presents with
    bilateral swelling of the parotid glands She has
    lost 30lb(18kg) in the last 6 months. Her current
    weight is at the 75th percentile for age. She has
    had an endoscopy for recurrent epigastric pain.
    She admits to inducing vomiting after meals. Of
    the following the clinical feature most specific
    to her diagnosis.
  • A. A body mass index that is less than 15
  • B. A distorted perception of body size
  • C. Amenorrhea for more than 3 months
  • D. Binge eating at least twice a week for 3
    months
  • E. Hypokalemic hypochloremic metabolic alkalosis

42
Question 3
  • The parents of a 14-yr-girl are concerned about
    her weight loss. Her weight today is 20 lb less
    than a documented wt obtained 1 yr ago at her
    camp PE. She complains of frequent nausea,
    decreased appetite, and early satiety, even after
    eating very small portions. She has no vomiting
    or diarrhea, but frequent constipation. She
    complains of increased fatigue but is still able
    to participate in diving 5 days/wk. She is doing
    well in school academically. She attained
    menarche at 12 and had monthly periods for about
    18 months, but she has had no menses for the past
    7 months. She has been a vegetarian for the past
    18 months and feels she is at a good weight
    currently. On PE, her BMI is 17.0. Her UPT test
    result is negative. Of the following, the MOST
    likely diagnosis is
  • anorexia nervosa
  • Depression
  • hypothalamic tumor
  • Hypothyroidism
  • inflammatory bowel disease

43
Question 4
A. Achalasia B. BN C. Crohns disease D. Duodenal
ulcer E. Gall stones
44
Question 5
A. AN B. Hyperthyroidism C. Crohns disease D.
Depression E. Tuberculosis
45
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