DIG Exam 3 ILA Eating Disorders Hundley

____-__% of anorexia patients die of medical complications annually

2-10

The mortality rate for anorexia is __x higher than the mortality rate of all other causes of death of adolescent girls and young women

12

• Weight less than the minimum normal range for age and height

• Fear of gaining weight or becoming fat despite being underweight

• Disturbance in the way one’s body weight or shape is perceived

• Excessive influence of body weight or shape on self-evaluation

• Most common in adolescent/young adult females

Anorexia

• Recurrent episodes of binge eating

• Recurrent inappropriate compensatory behaviors aimed at preventing weight gain

• Self-evaluation unduly influenced by body shape and weight

Bulemia

Recurrent episodes of eating large amount of food in brief period with sense of loss of control and marked distress

Binge Eating disorder

• Presents in 0.5% adolescents and young adults

• Male:female 1:3 to 1:12

• Presents in 5% adolescents and young adults

• Male:female 1:3 to 1:18

• Presents in 1-4% adolescents and young adults

• Male:female 1:2 to 1:6

Anorexia

Bulimia

Binge eating disorder

Do you ever make yourself sick because you feel uncomfortably full?

Do you worry you have lost Control over how much you eat?

Have you recently lost more than one stone (14 lbs) in 3 month period?

Do you believe you are fat when others say you are too thin?

Would you say that Food dominates your life?

1 point per yes, 2 or more indicates probable disordered eating

Scoff questionnaire

Non-specific complaints

Lethargy

Dizziness

Dysthymia

Anxiety

Amenorrhea

Presentation of eating disorder

Physical Findings

Vital sign abnormalities

Exercise induced injury

Hair loss

Lanugo hair

Dental Erosions and caries

Parotid inflammation

Russell sign

Dehydration

Presentation of eating disorder

Marked calorie restriction

300-700 cal/day

Compensatory exercise

Restrictive clinical features

May have enormous calorie intake (>20,000 cal)

May have normal meal with excessive guilt

Binging clinical features

Chronic Emesis

• Electrolyte disturbances

• Dehydration

• Parotitis

• Esophogeal injury

• Ipecac – potentially irreversible cardiac dysfunction

Purging clinical features

Melanosis Coli

Chronic laxative abuse clinical feature

Dental erosion and caries

Lanugo hair

Parotid inflammation

Major Depression – 50-75%

Anxiety - 60%

OCD - 40%

EtOh or drugs – 27%

Significant psychiatric co-morbidities

Complete Physical

ECG

• Bradycardia

• QT prolongation

CBC

• Leukopenia

• Anemia

CMP

• Hypokalemia, Hyponatremia

• Hypophosphotemia and Magnesimia

• Liver enzyme abnormalities

• Hypoalbuminemia

Workup for suspected eating disorder

• Depression, anxiety, and social withdrawal, as well as the specific symptoms of disordered eating.

• Psychiatric symptoms: irritability, obsessionality, and preoccupation with food may be secondary to semi starvation and may remit with refeeding.

• Physical symptoms of semi starvation or malnutrition:

  • Lanugo, osteopenia or osteoporosis, dehydration, hypothermia, cardiovascular or renal irregularities, gastrointestinal and endocrine disturbances.

  • changes in neuropsychological functioning.

  • Laboratory results may be normal, especially in restricting AN, but patients still may be at risk for cardiac events resulting from malnutrition.

Anorexia nervosa signs and symptoms

• Binge-eating/purging type: During and off current episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Self-evaluation is unduly influenced by body shape and weight (DSM5)

• Restricting type: without the above behavior.

Types of anorexia nervosa

• Depression, anxiety, and social withdrawal, as well as the specific symptoms of disordered eating.

• due to purging behavior

  • dental enamel erosion secondary to vomiting

  • Finger callus (russell’s signs)

  • gastrointestinal symptoms (bloating, nausea, vomiting)

  • salivary gland hypertrophy

  • electrolyte disturbances (from the vomiting)

  • Misuse of stimulant laxatives: hypomagnesia or hypophosphatemia

  • Binge eating is associated with gastric distention and, in rare cases, gastric rupture

Bulimia nervosa signs and symptoms

• Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

• Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Types of bulimia nervosa

• Refusal to maintain body weight at or above a minimally normal weight for age and height (Energy restriction below requirements-DSM 5)

  • weight loss leading to maintenance of body weight less than 85% of that expected.

  • Failure to make expected weight gain during period of growth, leading to 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 post-menarchal females, amenorrhea, that is, the absence of at least three consecutive menstrual cycles

Diagnostic criteria for anorexia nervosa

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

  • Eating, in a discrete period of time (e.g.,within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

  • A sense of lack of control over eating during the episodes (e.g. ,a feeling that one cannot stop eating or control what or how much one is eating).

• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. Self-evaluation is unduly influenced by body shape and weight.

• The disturbance does not occur exclusively during episodes of anorexia nervosa

Diagnostic criteria for bulimia nervosa

A 17-year-old teenager is evaluated during an office visit. She is brought in by her mother who is concerned about her focus on diet and weight. The patient states that she believes that she is obese and feels as though she needs to diet to achieve a more appropriate body weight. She also reports exercising on a daily basis to help her lose weight. Dietary history suggests that most of the time she consumes very little food, but at least twice per week she will eat large amounts of high-calorie desserts over the course of 1 to 2 hours. She describes feeling guilty after doing so and will make herself vomit. Medical history is otherwise unremarkable, although she indicates that her menstrual periods are highly irregular.

On physical examination, vital signs are normal. BMI is 23. The parotid glands are enlarged, but the remainder of the examination is unremarkable.

Which of the following is the most likely diagnosis?

Bulimia nervosa

Subspecialty consultation

• Pediatrics/Adolescent Medicine

• Endocrine

• Gastroenterology

• Mental Health Providers

Location of therapy depends on severity

Nutritional Rehabilitation

• Important in Anorexia

Weight gain Goals

• 1-1.5 Kg/week inpatient

• 0.2-0.5 kg/week outpatient

Cognitive Behavioral Therapy

• Interrupt problem behaviors

• Decrease Concern about body shape and weight

• Remission of Binge and Purge 30-50%

• Especially successful in Bulimia and BED

Interpersonal Therapy

• Recognition of interpersonal problems that contribute to eating disorders

• Combines with CBT

Family Based Therapy in adolescents and children

Medications have stronger evidence for bulimia treatment

Treatment of eating disorders

1-1.5 Kg/week __patient

0.2-0.5 kg/week ____patient

in

out

weight gain goals

weight restoration to at least 90% of predicted weight.

restoration of all clinical consequences , hypotension, hair loss, osteopenia)

Goals of treatment

they typically exaggerate their food intake and minimize their symptoms.

Some resort to subterfuge to make their weights appear higher: water-loading before they are weighed.

Example: a 19 year old admitted for bradycardia and hypotension has a BMI of 13k/m2. the next day she has gained 3lbs on a 1000calories per day. What explains this weight gain?

How patients resist weight gain goal

reassure the patient that weight gain will not be permitted to get out of control

weight restoration is medically and psychologically imperative

Physicians job

current weight

the rapidity of recent weight loss

the severity of medical and psychological complications

determinants for intensity of initial treatment

<75% ideal body weight or weight loss despite treatment

• Feeding Refusal

• Body fat <10%

Vital Signs

• Bradycardia (<50 during day, <45 at night)

• SBP<90 Temp <35.5

Cardiac

• Arrhythmia

• Prolonged Qtc

• Syncope

• Orthostasis

Electrolyte Disturbance

• Kcl < 3

• Cl < 90

GI manifestations

• Hematemesis

• Intractable emesis

• Esophageal Laceration

Suicidal Ideation

Signs of Hepatic, Renal, or cardiovascular compromise

Admit to hospital

Nutritional restoration can almost always be successfully accomplished by oral feeding

Calories can then be gradually increased to achieve a weight gain of 1–2 kg (2–4 lb) per week, (typically requiring an intake of 3000–4000 kcal/d.)

Much less in adolescents : 300 calories daily above pre treatment caloric level.( which can be as low as 6-700 calories.)

Team: psychiatrists or psychologists experienced in the treatment of AN is usually necessary.

Oral treatment

Antidepressants

• Strong evidence of improvement in binge/purge in bulimia

  • Only Fluoxetine has indication

  • Bupropion not recommended due to increase risk of seizures in bulimia

Topiramate

• Medium quality evidence of benefit in Bulimia

• Caution advised secondary to side effect – weight loss

Medication treatment for weight loss specifically bulimia

Naltrexone and ondansetron – __ evidence of efficacy

No

Antidepressants no better than placebo in _____

anorexia

Antidepressants in setting of concurrent depression, no improvement in depression until weight is ______

restored

Small studies with improvement of weight in anorexia

Atypical antipsychotics

Grade A evidence

• Imipramine

• Topiramate

• SSRI (sertraline, citalopram)

Lisdexamfetamine

• Patients >18 years

• Must monitor for cardiac disease and inadequate intake

Treatment for Binge eating disorder

Life-threatening complication in about 6%

Most common in patients <70kg

Widespread organ dysfunction from failure to make ATP

• Longstanding undernutrition depletes phosphorus stores

• Insulin secretion shifts phosphorus intracellularly

• Hypophosphatemia results in 12-72 hours post re-feeding

Refeeding syndrome

Recommend 1200-1500 cal/day with increase of 500cal/day to goal of 3500 (female) or 4000 (male)cal/day

Refeeding

Peripheral edema

Cardiopulmonary function

GI symptoms including bloating

Refeeding syndrome

Monitor for these during refeeding

Decreased serum potassium

• Increase Energy (carbohydrate, Fat and Protein)

• increased insulin K+ to shift from extracellular fluid into K+-depleted cells

Decreased serum phosphorus (as the body resumes synthesis of ATP)

Edema related to fluid shifts or congestive heart failure.

Refeeding syndrome

1/3 do well

1/3 revert to disordered eating in times of stress

1/3 chronic relapsing course

Prognosis of eating disorder

Prolonged disease duration

Low Initial Weight

Pre-renal Azotemia

Premorbid obesity

Compulsive Exercise

OCD traits

Conflicting family relationships

Neurotic Personality

Poor prognostic indicators

5X more likely to have premature death

18x more likely to die of suicide

33% recovery in 5 years with standard therapy

50% recovery with FBT

Anorexia

highest mortality of any mental illness

Anorexia

33-66% full recovery by 5 years

Less common mortality – 2X more likely to have premature death

Bulimea

30-80% recovery

No difference in mortality than general population

Complications related to obesity

Binge eating disorder

CBT is the ________ of therapy for these syndromes

cornerstone

20% developed a chronic course of illness.

50% of patients with AN develop bulimic symptoms

better outcomes for adolescent patients, but time to recovery nevertheless may be protracted (5 to 6 years).

Anorexia nervosa outcome

on average, problematic eating behaviors persist for several years in treated patients

most individuals with BN achieve full recovery at some point, but rates of relapse are high (i.e., 35%)

one third of patients continue to exhibit some symptoms.

Bulimia nervosa outcome

comparison

Comparison