EATING DISORDERS

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EATING DISORDERS

• Resmy Palliyil Gopi

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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

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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.

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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.

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Anorexia nervosa

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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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.

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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

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ASSOCIATED PSYCHIATRIC CONDITIONS

• affective disorders
• anxiety disorders
• obsessive-compulsive disorder
• personality disorders
• substance abuse

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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

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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?

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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?

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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?

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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)

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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

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PHYSICAL EXAM bulimia

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

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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

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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)

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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

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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.

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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

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Medical Complications From Caloric Restriction

• Hematologic leukopenia anemia iron deficiency
  thrombocytopenia.
• Endocrine euthyroid sick syndrome amenorrhea
  osteopenia.
• Neurologic cortical atrophy seizures.

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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

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REFEEDING SYNDROME

• Severe hypophosphatemia
• Cardiovascular collapse
• Rhabdomyolysis
• Seizures
• Delirium

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TREATMENT AND OUTCOME
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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.

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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

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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

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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

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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

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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

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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.

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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

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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

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Question 4
A. Achalasia B. BN C. Crohns disease D. Duodenal
ulcer E. Gall stones
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Question 5
A. AN B. Hyperthyroidism C. Crohns disease D.
Depression E. Tuberculosis
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Thank you!