EATING DISORDERS Resmy Palliyil Gopi
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
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 one’s 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.
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.
Anorexia nervosa • Outstanding feature of AN is persistent and severe restriction of energy intake, delusion of being fat and obsession to be thinner.
Dry skin Cold extremities, acrocyanosis hypothermia Sinus bradycardia Pitting edema Weakness, fatigue Cardiac murmurs Fainting Orthostatic hypotension Lanugo hair Scalp hair loss Early satiety Constipation Short stature Osteopenia Breast atrophy Atrophic vaginitis Primary or secondary amenorrhea Delayed puberty SIGNS AND SYMPTOMS
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
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.
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 SIGNS AND SYMPTOMS
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
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
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 < twice a week or for < 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
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: 12–16yrs • 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
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%
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.
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
ASSOCIATED PSYCHIATRIC CONDITIONS • affective disorders • anxiety disorders • obsessive-compulsive disorder • personality disorders • substance abuse
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
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 specifics—amounts, 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?
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?
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?
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)
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
PHYSICAL EXAM: bulimia • All previous elements plus: • Parotid gland hypertrophy • Erosion of the teeth enamel • Skin lesions on the fingers (Russel’s sign)
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
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)
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
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.
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
Medical Complications From Caloric Restriction • Hematologic: leukopenia; anemia; iron deficiency; thrombocytopenia. • Endocrine: euthyroid sick syndrome; amenorrhea; osteopenia. • Neurologic: cortical atrophy; seizures.
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
REFEEDING SYNDROME • Severe hypophosphatemia • Cardiovascular collapse • Rhabdomyolysis • Seizures • Delirium
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.
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
Criteria for hospital admission: AN • < 75% ideal body weight, or ongoing weight loss despite intensive management • Refusal to eat • Body fat <10% • Heart rate <50 beats per minute daytime; 45 beats per min nighttime • Systolic pressure <90 • Orthostatic changes in pulse (>20 beats per min) or blood pressure (>10 mm Hg) • Temperature < 96°F • Arrhythmia
BULIMIA • Cognitive behavioral therapy is effective • Pharmacotherapy—high success rate • Fluoxetine—studies reveal up to a 67% reduction in binge eating and a 56% reduction in vomiting • TCAs • Topiramate—reduced binge eating by 94% and average wt. loss of 6.2 kg • Ondansetron, 24 mg/day
Criteria for hospital admission: BN • Syncope • Serum potassium concentration < 3.2 mmol/L • Serum chloride concentration < 88 mmol/L • Esophageal tears • Cardiac arrhythmias including prolonged QTc • Hypothermia • Suicide risk • Intractable vomiting • Hematemesis • Failure to respond to outpatient treatment
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
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.
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
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
Question 4 A. Achalasia B. BN C. Crohn’s disease D. Duodenal ulcer E. Gall stones
Question 5 A. AN B. Hyperthyroidism C. Crohn’s disease D. Depression E. Tuberculosis