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Eating Disorders. Anorexia Nervosa DSM-IV Definition 1) Refusal to maintain body weight within a normal range for height and age ( > 15% below ideal weight) 2) Fear of weight gain 3) Severe body image disturbances (self-worth and denial of serious illness)

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eating disorders
Eating Disorders
  • Anorexia Nervosa DSM-IV Definition
  • 1) Refusal to maintain body weight within a normal range for height and age ( > 15% below ideal weight)
  • 2) Fear of weight gain
  • 3) Severe body image disturbances (self-worth and denial of serious illness)
  • 4) Absence of menstrual cycle/ amenorrhoea (for > 3 cycles)
  • 2 subtypes = restricting + binge/purging
eating disorders1
Eating Disorders
  • Bulimia Nervosa DSM-IV Definition
  • 1) Episodes of binge eating (loss of control)
  • 2) Followed by compensatory behaviour of
    • Purging type (vomiting, laxatives, diuretics)
    • Non-purging (execise, fasting, diets)
  • 3) Occurring > 2x / week for 3/12
  • 4) Dissatisfaction with body shape / weight
epidemiology
Epidemiology
  • 1-2 million BN in USA
  • 1/2 million AN in USA
  • AN prevalence overall = 0.27%
  • AN prevalence in 15-19y = 0.48%
  • BN prevalence overall = 1.5%
  • BN is more common in the >18y
  • Women 10:1 Men
  • Many more have ED-NOS ( eating disorder not otherwise specified
pathogenesis
Pathogenesis
  • Social pressure
  • Female athelete triad (eating disorder, amenorrhoea, and osteoprosis)
  • Related to a combination of psychological, biological, family, genetic, environmental and social factors.
  • Decreased self esteem or self control then using dieting behaviour and weight loss as a way of providing stability/ control on life.
  • Genetics = Monozygotic twins and 1st degree relatives have higher rates of eating disorders, Xolism, affective disorders
pathogenesis1
Pathogenesis
  • Sexual abuse - no evidence
  • Family characteristics = high parental expectations, difficulty managing conflict, poor communication skills, enmeshment, estrangement, devaluation of maternal role and maritial tensions.
  • CNS / Hormonal
    • Nad = bradycardia and hypotension in starvation
    • Serotonin = high in AN, affects the appetite and satiety centres
screening
Screening
  • SCOFF Score >2
  • Sick
  • Control ( or rather loss of it )
  • One stone in < 3/12
  • Fat
  • Food dominates life
examination
Examination
  • Vital signs ( PR and BP)
  • Lanugo hair
  • Callous formation
  • Parotid gland hypertrophy
  • Erosion of dental enamel on anterior teeth
  • CVS ( bradycardia, arrhythmias, MVP )
  • GI
  • Neuro
investigations
Investigations
  • FBC (anaemia)
  • Ur + Cr (dehydration)
  • Electrolytes + K, Ca, Mg, PO4
  • B- HCG
  • TFTs
  • Prolactin (prolactinoma)
  • FSH
complications
Complications
  • Osteoporosis
  • Cardiac impairment
  • Psychiatric + Cognitive Changes
  • Infertility
  • GI Dysfunction ( slow motility, N, bloating)
  • Electrolytes ( K, metabolic alkalosis )
  • Endocrine
    • low LH and FSH
    • Sick euthyroid ( high rT3 )
    • low DHEA + IGF-1
    • high cortisol + GH
osteopenia osteoporosis
Osteopenia / Osteoporosis
  • Women accrue 40-60% of their bone mass during the adolescent years
  • Seen in 90% of those with AN
  • Long term risk of fracture increases x 3
  • Causes - oestogen deficiency
  • - inadequate Vitamin D and Ca
  • - Lean body mass and nutritional
  • Pathophysiology - increased bone resorption
  • - decreased bone formation
  • (differing from meopause)
osteopenia osteoporosis rx
Osteopenia / Osteoporosis Rx
  • Ix with DEXA then;
  • 1) Weight gain
  • 2) Elemental Ca 1200 - 1500 mg/ day
  • 3) Multivitamins providing 400 IU Vit D / day
  • 4) Oestrogen/ Progestin
    • no proven benefit as process is different to menopause
    • some benefit if < 70% ideal body weight
  • 5) IGF-1 (short term effects)
  • 6) DHEA
    • increases formation and decreases resorption in the short term
cardiac mx
Cardiac Mx
  • MVP occurs in 30 - 60% (3Xpopulation)
    • this is partly due to enhanced ability to detect MVP in patients with intravascular volume depletion
  • Prolonged QT interval seen in 33%
    • independent marker for arrhythmias and sudden death
  • Heart Failure in the first 2/52 of Re-feeding
    • Reduced cardiac contractility
    • Refeeding oedema
    • Mx by slow refeeding, repletion of PO4, avoid high Na
amenorrhoea
Amenorrhoea
  • Seen in 90% of AN
  • Low levels of LH + FSH = low Oestrogen
  • Mx = Increase weight
  • Menses restarts in 90% in < 6/12 after achieving 90% ideal body weight
multidisciplinary mx
Multidisciplinary Mx
  • a) Medical Provider
    • Vital signs
    • Fluoxetine (proven benefits in BN>AN)
    • Anxiolytics in AN prior to eating
    • Metoclopramide (delayed transit = bloating + constip)
  • b) Mental Health Provider
    • Individual and cognitive behavioral therapy
    • superior to medication, but synergistic with it
  • c) Nutritionalist
    • Specific and meal plan requirements
    • Weight goals
hospitalisation
Hospitalisation
  • Severe malnutrition (<75% IBW)
  • Dehydration
  • Electrolyte Disturbance
  • Cardiac Dysrythmias
  • Physiological AbNs (eg brady, hypotensive)
  • Arrested Growth and Development
  • Failure of Outpatient treatment
  • Complications (medical of psychiatrical)
  • Admission long enough to increase weight >90% IBW improves eventual outcome
management
Management
  • Nutritonal
    • IP Expected weight gain 0.9-1.4 kg/week
    • OP Expected weight gain 0.2-0.5 kg/week
    • Start intake at 30-40 kcal/day (1000-1600kcal/day)
    • Rapid early weight gain is related to fluid retention and to low metabolic rate
  • Refeed Syndrome
    • At risk are those > 10% beneath their ideal body weight
    • Hypophosphataemia
    • Decreased IC ATP = impaired enegy stores
    • Decreased rbc 2,3-DPG = tissue hypoxia
outcome
Outcome
  • AN
    • 50% good outcome
    • 25% intermediate ( with relapses)
    • 25% poor ( associated with later age of onset, duration, lower minimum weight, strong maturity fears )
    • 30 - 70% fully recovered at 20y follow up
    • 10% continue to meet criteria for AN at 12y
  • BN
    • 30% continue to meet criteria for BN at 10y
    • Low self esteem associated with a poor outcome
    • Dehydration
  • Mortality Rate in AN = 6.6%
    • 54% complications, 27% suicide, 19% others