Eating Disorders

anorexia nervosa

thin pts who restrict food intake and/or binge eat, followed by compensatory behaviors of vomiting, using laxatives, or excessive exercise

bulimia nervosa

normal to overweight pts who binge eat, followed by compensatory behaviors of vomiting or fasting

binge-eating disorder (BED)

overweight or obese pts with recurrent episodes of eating a large amount of food, without compensatory behavior following

SCOFF, EAT

What are the names of the two questionnaires we discussed in class today that are used to assess for eating disorders?

fear, image, restriction, low, adolescents, >, family, substance, middle/upper

Anorexia

• Intense _____ of obesity, a distorted body ________ and __________ of food intake leading to significantly ___ body weight

• Risk Factors

  • ___________ and teenagers, female _ male

  • co-morbid mood disorders, anxiety, substance abuse, personality disorders

  • Poor _______ dynamic

  • FHx ___________ abuse or eating disorders

  • _______/_______ socioeconomic class

Type 1 (restrictive)

Which type of anorexia is this?

• restrict food intake without purging, often also excessively exercise

Type 2 (binge-eating and purging)

Which type of anorexia is this?

• Eat large amount, then induce vomiting and/or misuse laxative or enemas

malnutrition, weakness, adapting, estrogen, mitral, increased, increased

Anorexia Pathophysiology

• _____________ → multiple organ system dysfunction and overall ________

  • Difficulty __________ to new situations and focusing on the big picture, along with challenges in social and emotional understanding, which may be linked to how _________ affects learning and memory

  • Decrease in heart muscle mass, chamber size, and cardiac output → high risk of arrhythmias and murmurs (_______ valve prolapse)

  • Endocrine abnormalities → hypogonadism, hypothyroidism, _________ cortisol levels

  • Prolonged starvation → _________ healing time / risk of infection

loss, layers, calories, rituals, public, exercises, fear, limited

Anorexia Presentation

• Dramatic weight ____

• Dressed in ________

• Preoccupied with weight and tracking __________

• Food-related _________

• Cooks meals for others without eating themselves

• Avoids eating in _______

• __________ to burn calories consumed

• Intense _____ of gaining weight

• sleep disturbances

• amenorrhea

• Spends a lot of time studying diets and calories

• __________ insight into their situation

18.49, hypotension, Lanugo, Russel, erosion, Parotid, QT

Anorexia Physical Exam

• Lower than ideal body weight with BMI < __.__

• __________

• Bradycardia

• Hypothermia

• (+) __________ hair → fine hair all over body

• If induced vomiting (type 2)

  • ________ sign → callus on knuckles from striking upper teeth

  • Dental enamel __________

  • __________ gland enlargement from constant stimulation of salivary gland, symmetric and painless compared to infectious cause

• EKG → prolonged __ intervals

length, dehydration, starvation, alkalosis, albumin, elevated

Anorexia Diagnostics → Labs

• Labs can be normal or abnormal depending on _______ of behavior, abnormal d/t prolonged ___________ and/or ____________

• CMP → hypokalemia, hyponatremia, hypoglycemia, hypochloremia → metabolic _________

• Also low _________

• CBC → anemia, leukopenia, thrombocytopenia

• LFTs → __________

• Phosphorus and Vit D → low 

pregnancy, thyroid, elevated, low, high, DEXA

Anorexia Screening Tests for Complications

• Check urine _____________ in all female patients

• Screen for _______ disorder, hypogonadism, hypercortisolism

  • TSH → if abnormal, typically __________ TSH with normal free hormones, can be hypothyroid

  • FSH, LH, sex hormones (estrogen and testosterone) → can be ___

  • Cortisol levels → can be _____

• Check _____ scan if underweight for > 6 months d/t likely hypercortisolism

restriction, low, fear, disturbance, lack

Anorexia → DSM 5 Criteria

1. _________ of energy intake relative to requirements - eating much less than the body needs, leading to significantly ___ body weight

2. Intense _____ gaining weight or becoming fat - even when underweight

3. ___________ in body image  - seeing oneself as larger than they are or having an inaccurate sense of body shape/size

4. ____ of recognition of the seriousness of low body weight  - denial or minimization of the health risks 

17-18.49, 16-16.99, 15-15.99, 15

Anorexia Classes of Severity

• Mild → BMI __-__.__

• Moderate → BMI __-__.__

• Severe → BMI __-__.__

• Extreme → BMI < __

1-2, health, weight, CBT, SSRI, olanzapine

Anorexia Outpatient Treatment

• Nutrition Therapy → healthy diet and exercise plan with goal to gain _-_ lbs/week, focus on ______ and not _______

• Psychotherapy → ___ ± family therapy

• Pharmacotherapy → add if other mental health disorders present

  • ____ are 1st line

  • Atypical antipsychotics (___________) can help with anxiety and cause weight gain

14, 75, unstable, dehydration, symptomatic, dysrhythmias

Anorexia → when to admit

• BMI < __, less than __% of expected body weight

• __________ vital signs → bradycardia, hypotensive, hypothermia

• Marked ____________

• _________ hypoglycemia

• Electrolyte and/or acid/base disturbances

• Cardiac ___________

refeeding, hypophosphatemia, vitamin, dysrhythmias, edema, death, carbs, uptake, plasma

Anorexia Treatment Complication

• ________ syndrome → risk of introducing food too quickly in severely malnourished patient

• Fluid and electrolyte shifts may cause

  • ____________ → hallmark

  • hypokalemia, hypomagnesemia, hyponatremia, hypocalcemia

  • ________ deficiencies

  • CHF

  • Life threatening ____________

  • Muscle weakness

  • Peripheral _______

  • Rhabdo

  • Seizures

  • Hemolysis

  • _______

• Eating _____ in malnourished pt → insulin release → cells increase _______ of phosphate, potassium, and magnesium → decreased levels of these three in _______ → tissue hypoxia, myocardial dysfunction, respiratory failure

control, compensatory, excessive, unhealthy, overweight

Bulimia

• Eating an excessive amount rapidly with feelings of loss of ________, followed by feelings of guilt and remorse leading to a _________ behavior

• _________ → more than most people would eat in the same amount of time

• Loss of control → food is usually _________, high in calories

• Pts are typically of normal weight or ____________

• Behavior bothers them, but feels they cannot stop

teens, 20, >, obesity, perfection, impulse, trauma

Bulimia Risk Factors

• ______/young adults, around __ y/o

• Female _ male

• Hx of _________ and dieting, fad diets

• Environments demanding __________, high achievement, physical fitness

• Body dissatisfaction

• Poor ________ control

• Substance abuse, FHx of substance abuse or eating disorders

• Hx childhood ________

Type 1 (purging type)

Which type of bulimia is this?

• Most common

• Self-induced vomiting or misuse of laxatives, diuretics, or enemas after binge eating episodes

Type 2 (non-purging type)

Which type of bulimia is this?

• Other compensatory behaviors, such as fasting, strict dieting, excessive exercise after binge eating episodes

• More difficult to detect, less physical evidence on exam

serotonin, pancreatic, satiety, low, satiety, impulse, guilt

Bulimia Pathophysiology

• What is supposed to happen

  • ________ balance → __________ polypeptide regulates pancreatic secretions with eating, these secretions slow gastric emptying, promoting feeling of ________ (feel full after eating)

• With bulimia

  • ___ serotonin → Impaired __________ → binge episodes b/c pt does not feel full, ________ control issues → Feelings of ______ and remorse → anxiety, depression, obsessive preoccupation with weight and body shape

restriction, binge, compensatory, fluctuations, diet, irregularities, prolapse, dental

Bulimia Presentation

• Behavior sequence → caloric ________ or attempt, ______ eating, self-induced vomiting or other ___________ behavior

• Normal to above normal body weight, frequent weight _________

• Frequent failed _____ attempts

• Fatigue

• Menstrual ___________

• Abd pain, bloating, diarrhea, rectal _________

• _______ issues

• Mental health disorders

Russel, erosion, parotid, gastritis, fissures, normal

Bulimia Physical Exam

• If induced vomiting

  • _______ sign → callus on knuckles from striking upper teeth

  • Dental enamel _______

  • _______ gland enlargement

  • __________ or esophagitis

• If enema use

  • Abd pain, gastritis

  • anal ___________, rectal prolapse

• Same labs as anorexia, but typically _______ b/c less extreme, not at level of starvation

EGD, pancreatitis, arrhythmias, purging

Bulimia Screening for Complications

• ___ → r/o Mallory Weiss tear, Boerhaave’s syndrome

• Labs → lipase/amylase to r/o __________, would be elevated

• EKG → could show __________ (torsades, PVCs), depressed ST segment, prolonged QT, especially with _________ type and electrolyte disturbances

once, recurrent, control, compensatory

Bulimia DSM-5 Criteria

• Episodes occur at least ______ a week for 3+ months

• __________ binge eating defined by eating larger portion of food than most people would eat in one sitting AND lack of ________ over that eating

• Recurrent _________ behaviors to prevent weight gain from binge eating episode, such as self-induced vomiting/laxative/enema/diuretic use, fasting or excessive exercise

1-3, 4-7, 8-13, 14`

Bulimia Classes of Severity

• Mild → _-_ episodes/week

• Moderate → _-_ episodes/week (pts MC fall here)

• Severe → _-__ episodes/week

• Extreme → __+ episodes/week

body dysmorphic disorder

difference of this from bulimia is that this patient will observe 1+ flaws that do not exist, or others view as very minor → repetitive behaviors, such as excessive grooming, skin picking, mirror checking

Closely related to OC

outpatient, CBT, fluoxetine, buproprion

Bulimia Treatment

• Typically ___________ treatment unless (+) EGD/EKG, severe pancreatitis or severe electrolyte abnormalities

• Nutrition therapy → healthy diet and exercise plan

• Psychotherapy → ___ can help with impulse control and change distorted thinking patterns

• Pharmacotherapy

  • SSRI __________ is 1st line and only FDA approved med with bulimia, pairs well in these pts with CBT

  • AVOID ___________ because it lowers seizure threshold and causes appetite suppression

control, not, constant, obese, avoid, obesity

Binge Eating Disorder

• Recurrent episodes of consuming a lot of food d/t loss of ________, not followed by ____________ behavior → _________ overeating

• Overweight or _______ pts

• Tend to _______ questions about diet, lifestyle choices, exercise

• High risk of __________ complications

obesity, >, family, trauma

Binge Eating Disorder Risk Factors

• _________ - main risk factor

• Female _ male

• __________ Hx

• Childhood or previous ________

• HTN

• MDD, bipolar, anxiety, PTSD, OCD, personality disorder, SUDs

BDNF, reward, control, impulses, genetic, serotonin

Binge Eating Disorder Pathophysiology

• Decreased brain-derived neurotrophic factor (____) → disruption in the brain circuits that balance drive (reward-seeking) with impulse control, leading to difficulty resisting urges

• AKA the _______ and self-_______ system has problems that are making it harder to manage __________

• ________ issuses

• Low levels of ___________

gain, dry, metabolic, MSK, depression, obesity

Binge Eating Disorder Presentation

• Obesity, weight _____

• ___ skin, GI issues, sleep disturbances

• __________ syndrome

• ___ issues, chronic pain

• Mild to moderate ____________-

• No specific physical exam findings other than obesity and signs of metabolic syndrome

• Screen for __________ complications

once, larger, lack, compensatory, rapidly, full, hungry, embarrassed, guilty

Binge Eating Disorder DSM-5

• Recurrent binge-eating episodes at least _____ a week for 3 months or more, which is characterized by BOTH of the following

  • Eating, in a discrete period of time, an amount of food that is definitely _______ than what would most people would eat in a similar period under similar circumstances

  • A sense of _____ of control over eating during episode

• NOT associated with the recurrent use of inappropriate ____________ behaviors

• Binge-eating episodes are associated with 3+ of the following

  • eating much more ________ than normal

  • Eating until feeling uncomfortably ____

  • Eating large amounts of food when not physically _______

  • Eating alone b/c of being ____________ by how much one is eating

  • Feeling disgusted with oneself, depressed, or very _______ afterward

CBT, portion, interpersonal, SSRI, vyvanse, topiramate

Binge Eating Disorder Treatment

• ___ is the most studied and best support treatment

  • Focuses on how thoughts, beliefs, and behaviors contribute

• Encourage healthy lifestyle choices - weight loss, exercise, ________ control

• _____________ psychotherapy

  • Focuses on how interpersonal relationships and life events contribute

  • Also effective, but takes longer to achieve results

• Medications

  • Short term → _____ can temporarily eliminate binge eating symptoms

  • Lisdexamfetamine (_________) is the only FDA approved drug for BED

  • _____________ (topamax) can help suppress appetite

  • Can use weight loss drugs

nutritional, body image, sensory, children

Avoidant/Restrictive Food Intake Disorder (ARFID)

• Persistent failure to meet __________/energy needs → weight loss, nutritional deficiency, or dependence on supplements

• Not due to _____ _______ concerns

• Often due to ________ sensitivities, fear of choking/vomiting, or low appetite

• Most common in ___________, but can persist into adulthood

rumination disorder

What is this describing?

• Repeated regurgitation of food (rechewing, re-swallowing, or spitting out) for > 1 month

• Not d/t a medical condition and not exclusively during anorexia, bulimia, BED, or ARFID

Pica

What is this describing?

• Persistent eating of non-nutritive, non-food substances (eg: dirt, paper, hair, ice, soap, chalk, metal, pebbles, starch, etc) for > 1 month

• Inappropriate to developmental level and not culturally sanctioned

• Associated with: pregnancy, iron/zinc deficiency, intellectual disability

purging disorder

What is this describing?

• purging without binge eating to influence weight and shape

night eating syndrome

What is this describing?

• recurrent eating after waking or excessive eating after the evening meal