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Eating Disorders in Adolescents. Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College. Anorexia Nervosa (DSM-IV). Body weight less than 85% of expected Intense fear of gaining weight even though underweight Disturbance in body image

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Eating Disorders in Adolescents

Keren Kazis, M.D.

Adolescent Medicine

Department of Pediatrics

New York Medical College


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Anorexia Nervosa (DSM-IV)

  • Body weight less than 85% of expected

  • Intense fear of gaining weight even though underweight

  • Disturbance in body image

  • In post-menarchal females absence of at least three consecutive menstrual cycles

  • Two types are defined:

    • Restricting type

    • Binge-eating or purging type


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Bulimia Nervosa (DSM-IV)

  • Recurrent episodes of binge eating

  • A sense of lack of control over eating during these episodes

  • A regular cycle of self-induced vomiting, laxatives, diuretics, exercise or dieting

  • Two binge-eating episodes per week for at least three months

  • Two types identified:

    • Purging type

    • Non-purging type


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Epidemiology

  • Anorexia Nervosa

    • Incidence1/100,000worldwide, in white females in western countries 1/200

    • Incidence in adolescent females 0.5-1%

    • Female predominance of 9-10:1

    • Becoming more diverse

    • Mean age 13.75 (range 10-25 yrs)


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Epidemiology

  • Bulimia Nervosa

    • Prevalence 1-3% in young females

    • Prevalence of 3-10% in college aged females

    • 90-95% female

    • Onset is usually during late adolescence, age range of 13-58 years


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Family Risk Factors

  • Achievement oriented

  • Intrusive, enmeshed, overprotective, rigid

  • Unable to resolve conflicts

  • Frugal with support or encouragement

  • Maternal preoccupation with diet, weight and appearance

  • Positive family history of Eating Disorder


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Individual Risk Factors

  • Perfectionist- “good little girls”

  • Feeling of low self-esteem

  • Obsessional style

  • Early puberty

  • Overweight

  • History of sexual abuse

  • Athletes


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Eating Behaviors

  • 40-60% girls in high school have dieted

  • 18% reported fasting >24 hrs to control weight

  • 30-40% of Jr. high school girls were concerned with wt.

  • 42% of college women diet, 10% purge, 7% use diet pills

  • 80% of girls in LI HS reported they would be happier at a lower weight


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Comorbidity

  • Major depression and dysthymia in 50-75% AN/BN

  • Bipolar 4-13% of AN/BN

  • OCD in 25% of AN

  • Substance abuse 30% of BN, 15% of AN

  • Personality disorders 42-75% of AN/BN

  • Sexual abuse 20-50% of BN

  • Anxiety disorders high in AN/BN


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History –Eating Disorder Symptoms

  • Pinpoint exact time

  • Reinforcement of behavior

  • Food faddism, rituals and para-eating behaviors

  • Family characteristics

  • School behavior

  • Peer contacts

  • Lack of concern

  • Food as a battleground


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History

  • Parental concern or patient concern?

  • Weight loss- highest wt, lowest wt, patients personal goal wt.

  • Menstrual history

  • Exercise

  • Binging, purging, laxatives, diet pills or diuretics

  • Body image

  • Family conflicts over food

  • 24 hour food recall


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History

  • HEADS assessment

    • Home

    • Education

    • Activity

    • Drugs/Depression

    • Suicide/Sexual Activity

  • ROS- dizziness, syncope, cold intolerance, constipation and abd pain, dry skin and hair, fatigue


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Physical Exam- Vital Signs

  • Bradycardia

  • Hypothermia

  • Orthostatic hypotension- HR inc. 20, BP dec. 20

  • Weight and height


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Physical Exam

  • General-cachectic, depressed, dehydrated

  • HEENT- dental enamel erosion, parotid hypertrophy

  • Breasts- atrophic

  • Abdomen- scaphoid, palpable stool

  • Extremities- acrocyanosis, Russell’s sign, peripheral edema

  • Skin- lanugo hair, yellow skin discoloration, bruising


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Laboratory Evaluation

  • CBC- leukopenia, anemia, thrombocytopenia

  • ESR- low

  • UA- specific gravity, ketones

  • Chemistries- hypokalemia, hyponatremia, BUN high, low Ca, Mg, Phos, LFT’s and chol high, carotene elevated

  • TFT’s- TSH nl, T4 low or nl, T3 low

  • Hormones- estradiol low in females, testosterone low in males, prolactin nl, LH and FSH low or low nl


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Complications

  • Cardiac

    • EKG- bradycardia, low voltage, t wave changes, prolonged QTc

    • Echocardiography- decreased cardiac size, reduced myocardial contractibility, increased prevalence of MVP, Ipecac CM, pericardial effusion


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Complications

  • Gastrointestinal

    • Delayed gastric emptying- abdominal bloating/pain

    • Hypomotility- constipation

    • Fatty infiltration of the liver

    • Superior mesenteric artery syndrome

    • Esophagitis

    • Mallory-Weiss tear


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Complications

  • Neurologic

    • Poor attention and concentration

    • Poor problem solving skills

    • Cerebral atrophy

    • Cerebral ventricular enlargement

    • Atrophy correlates with degree of malnutrition and is reversible with weight gain


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Complications

  • Osteoporosis

    • Related to amenorrhea and hypoestrogenism

    • Can lead to increased fracture risk

    • DEXA (Dual Energy X-ray Absorptometry) if amenorrheic >6months

    • Exercise not protective

    • Adequate Ca intake necessary

    • NOT completely reversible even with weight gain and resumption of menses


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Treatment

  • Multidisciplinary approach

    • Physician

    • Psychiatrist

    • Therapist- individual, group, family

    • Nutritionist

    • Family involvement a must!!!!


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Out-Patient Management

  • Multidisciplinary approach

  • Weekly visits- UA, Wt in gown, Food records

  • No exercise until Wt gain

  • Behavioral contract can be used

  • Medications-SSRI’s

  • Weight gain- expect about 1-2lbs per week until goal weight-90% of IBW-resumption of menses

  • Parents and family need to avoid food conflicts

  • Bulimia- focus on binging not purging


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Indications for Admission

  • Weight <75% of IBW

  • Dehydration or Electrolyte disturbances

  • EKG abnormalities

  • HR<40, SBP<70, T<35C, Orthostatic

  • Failure of outpatient management

  • Acute food refusal

  • Uncontrollable binging and purging

  • Medical/ Psychiatric emergencies


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In-Patient Management

  • Multidisciplinary approach

  • Daily weights after voiding and in hospital gown

  • Behavioral Modification Protocol: Privileges- phone, TV, visitors

  • Start at 1400 Kcal and increase calories slowly, 200Kcal/day

  • Follow electrolytes carefully for the first week

  • If food refusal use supplements or NGT

  • Day treatment program as a transition


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The Refeeding Syndrome

  • Starved state- catabolic breakdown of fat and muscle- Inc. nutrients in blood

  • Refeeding- Carbohydrates inc Insulin leading to anabolic protein synthesis and inc uptake of glucose, phosphorous, and water into cells

  • Combo of TBD of phosphorous during catabolic phase and intracellular influx during anabolic phase leads to severe extracellular phosphorous depletion


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Refeeding

  • Severe phosphorous depletion leads to decrease in ATP production

  • Leads to muscle problems- cardiac, hepatic, neuromuscular, respiratory

  • Most lethal- altered myocardial function/arrhythmia


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Recommendations to Avoid the Refeeding Syndrome

  • Be aware of the syndrome

  • Recognize the patient at risk

  • Cardiac monitoring during refeeding

  • Increase caloric delivery slowly

  • Administer multivitamins routinely and neutrophos if phosphorous drops <3.0

  • Carefully monitor electrolytes daily for the first week and then biweekly


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Prognosis

  • 50% good outcome, 25% intermediate outcome, 25% poor outcome

  • Mortality less than 4%

  • Of those that recover- 1/3 recover over 3yrs, 1/3 by 6yrs, 1/3 by 12yrs

  • Adolescents better prognosis than adults


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Prognosis

  • Poor prognosis

    • Early Onset

    • Longer duration of illness

    • Lower weight

    • Failed previous treatment

    • Personality disorder/ depression

    • Difficult family relationships

    • Social Isolation