Eating Disorders (Behavior)

Feeding & Eating disorders

group of conditions characterized by a persistent disturbance of eating or eating-related behavior that results in altered consumption or absorption of food & significantly impairs an individual’s physical health or psychosocial functioning

What is the spectrum of eating behavior

Optimized nutrition

Disorderd Eating

Eating Disorder

Optimized nutrition

Safe, supported, purposfil and individualized nurtirion practices

Disorderd Eating

eating & weight-related behaviors that are harmful, can be serious, and impact an individual’s daily living & overall well-being.

(T/F) Eating disorders are generally underdiagnosed

True

Who are more at risk for eating disorders

Cisgender women

Transgender

Non-binary

LGBTQ+

Emotional Signs of Disordered Eating

Extreme mood swings

Hoarding & hiding food

Eat food in specific order, excess chewing, rearrange food on plate

Frequent mirror checks

Excessive exercise

May avoid eating whole food groups (carbs, fats)

What are contributing factors to eating disorders

Low self-esteem

Poor body image

Anxiety

Depression

Peer Pressure

media pressure

Trauma

Exposure to those with disordered eating

Genetics

Female Athelete Triad Disorder / Relative Energy Deficiency in sport (RED-S_

1. Menstrual disorder

2. Abnormal eating habits  Eating Disorder

3. Low BMD

Risk factors for RED-S

Gymnastics

Dancing

Figure skating

Long distance runners

Early age sport specialization

Family dysfunction

Abuse

Parent/Coach Pressure

Prevention of RED-S

Stress management – Yoga, Meditation, Sleep

Proper nourishment – Balanced meals, Avoid food restrictions

Exercise – Low intensity, Rest days

Treatment of RED-S

Counseling

Consultation with Registered Dietician

Exercise modification

Types of Feeding / Eating Disorders

Pica

Rumination Disorder

Avoidant/Restrictive Food Intake Disorder

Anorexia Nervosa

Bulimia Nervosa

Binge Eating Disorder

Other Specified Feeding or Eating Disorder (OSFED)

Unspecified Feeding or Eating Disorder (UFED)

Criteria for Pica

A. Persistent eating of nonnutritive, non-food substances at least 1 month

B. inappropriate to the developmental level of the individual (> 2 years old)

C. not part of a culturally supported or socially normative practice

D. If this occurs in the context of another mental disorder or medical condition, it is sufficiently severe to warrant additional clinical attention

Duration needed to dx Pica

1 month

What mental disorders may present with pica as a sign

Autism spectrum disorder

Schizophrenia

Intellectual developmental disorder

What medicial disorders may present with pica as a sign

Pregnancy

Iron Deficiency

Zinc Deficiency

Anemia

When do patients with pica often present medically

bowel obstruction or perforation,

infection,

poisoning

electrolyte abnormality

What is the minimum age to dx Pica

2 years

Acuphagia

Pica of sharps

Amylophagia

Pica of laundary strach

Cautopyreiophagia

Pica of burnt matches

Coprophagia

Pica of feces

Foliophagia

Pica of leaves, grass, and wild nuts

Geomelophagia

Pica of raw potato

Geophagia

Pica of dirt and soil

Lignophagia

Pica of wood

Lithophagia

Pica of rocks

Pagophagia

Pica of ice

Plumbophagia

Pica of paint

Tobaccophagia

Pica of cigarette butts

Trichophagia

Pica of hair

s/s of Pica

Nausea

Stomach Pain

Vomiting

Constipation

Cravings

What is the best indicator for pica secondary to nurtiontial deficiency

Replete and the pica should resolve

If a patient has Plumbophagia, what lab should be run as part of clinical work-up

Lead

Treatment for Pica

Remove dangerous substances

Treat ACUTE medical issues related to Pica

Behavioral modification/psychosocial therapy

Address any maltreatment or neglect

Treat underlying nutritional deficiency

Treat dental issues

Criteria for Rumination Disorder

A. Repeated regurgitation of food over a period of at least 1 month . Regurgitated food may be re-chewed, re-swallowed or spit out

B. not attributable to an associated GI or other medical condition

C. does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge eating disorder, or avoidant/restrictive food intake disorder

D. If the symptoms occur in the context of another mental disorder (intellectual disability), they are sufficiently severe to warrant additional clinical attention

Duration Need to dx Rumination Disorder

1 months

Rumination Disorder

Previously swallowed food brought up into the mouth without apparent nausea, involuntary retching. They do NOT appear to be stressed, upset or disgusted.

When does the regurg of Rumination Disorder tend to occur

10 min after a meal

Persist for 1-2 hours

Characteristics of Rumination Disorder

Discomfort in abdomen relieved by regurgitation

Occurs at least several times per week, typically daily

May be described as habitual or out of their control

Malnutrition may be prevalent

Cessation occurs when regurgitated material turns Acidic

Rumination disorder is often misdagonised as

GERD

Vomiting

Patho of Rumination Disorder

Likely related to increased postprandial intra-abdominal pressure that causes undigested food to travel from stomach back into the esophagus

Upper & Lower Esophageal sphincter dysfunction also likely plays a role

What conditions are associated with rumination disorder

chronic constipation,

anxiety,

depression,

PTSD,

OCD,

ADHD

, intellectual disabilities

Treatment of rumination disorder

Recognize signs & situations when rumination is likely to occur

Learn diaphragmatic breathing techniques to use after eating to PREVENT regurgitation of food

Reverse habits (Replace rumination habit with deep breathing techniques

Treatment for Refractory Rumination Disorder

Other behavioral therapy (Biofeedback)

still no resolution → TCA’s & Baclofen 10 mg TID x7 days

Why does breathing execrises help with Rumination Disorder

decrease intra-abdominal pressure

How are breathing execrises done with Rumination Disorder

Slow breath 6-8 resp/min

Immediately after meal for 10-15 min until sensation resolves

What condition was previously called “Feeding Disorder of Infancy or Early Childhood”

AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (ARFID)

Criteria for ARFID

A. An eating or feeding disturbance (lack of interest in eating or food; avoidance based on sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with 1 of the following:

• Significant weight loss

• Significant nutritional deficiency

• Dependence on enteral feeding or oral nutritional supplements

• Marked interference with psychosocial functioning

B. not better explained by lack of available food or by an associated culturally sanctioned practice

C. does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced

D. not attributable to a concurrent medical condition or not better explained by another mental disorder.

Features of ARFID

Lack of interest in eating/food,

sensory sensitivity  “selective eating”,

fear of aversive consequences (choke or vomit)

Can be related to negative experience associated with food

NOT due to fear of becoming obese or distress regarding weight

involve all types of food, or only certain foods

starts in early childhood & continue into adulthood

cause high levels of stress during meals

What conditions are associated with ARFID

Autism,

anxiety disorders,

intellectual disability,

ADHD,

obsessive-compulsive disorders

Treatment for ARFID

Multidisciplinary team: Psychiatrist + Psychotherapist + Dietician

Newer → Family-based therapy, CBT & parent-based behavioral approach (

Fix nutritional deficiencies

Criteria for Anorexia Nervosa

A. Restriction of energy intake relative to requirements, leading to a significant low body weight in context of age, sex, developmental trajectory, and physical health.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight

C. 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 persistent lack of recognition of the seriousness of the currently low body weight

Duration needed to dx ARFID

None

Duration of Anorexia Nervosa for dx

3 months

Subtypes of Anorexia Nervosa

Restricting type

Binge eating/purging type

Restricting type Anorexia Nervosa

NO recurrent episodes of binge eating or purging behavior.

Weight loss accomplished with dieting, fasting, or excessive exercise

Binge eating/purging type Anorexia Nervosa

recurrent episodes of binge eating or purging behavior

What is important to note about subtypes of anorexia nervosa

Crossover can be seen as the subtypes only describe the current symptoms not the past

How is severity of anorexia nervosa gauged

BMI

Mild Anorexia Nervosa

BMI 17-18.49

Moderate Anorexia Nervosa

BMI 16-16.99

Severe Anorexia Nervosa

BMI 15-15.99

Extreme Anorexia Nervosa

BMI <15

Who is the highest risk for anorexia nervousa

Women 15-19 y/o

How does anorexia nervosa effect generaly mortality

6x more likely to die prematurely compared to general population

Risk Factors for Anorexia Nervosa

Family history of anorexia nervosa

Stressful life events

Childhood trauma or abuse

Perfectionist personality

Sports/activities that encourage thinness - Modeling

Cultural or social pressure to be thin

Main Features of Anorexia Nervosa

Energy restriction

Intense fear of becoming fat

Disturbance in self-perceived weight/shape

Additional Features of Anorexia Nervosa

Preoccupied with food

Restricts food types/fears of certain foods

Overuse of artificial sweeteners and low calorie foods/condiments

Overestimate caloric intake

Avoiding social situations/eating in public

Food rituals- cut food into small bites, frequently rearrange food on plate

Exercise rituals/excessive activity/restlessness

Lack insight regarding condition

How are vitals effected by anorexia nervosa

Hypothermia

Bradycardia

Hypotension

What cardiac complications occur from anorexia nervosa

Decreased cardiac output

Decrease in exercise capacity

Mitral valve prolapse

QT interval prolongation

Arrhythmias

Hyperlipidemia

What GI complications occur from anorexia nervosa

Gastroparesis

Constipation

Mild transaminitis

What electrolyte complications occur from anorexia nervosa

HypoK

HypoMg

HypoPhos

What heme complications occur from anorexia nervosa

Cytopenias

What derm complications occur from anorexia nervosa

Dry skin

Lanugo

Acrocyanosis

Livedo reticularis

Hair loss

What endocrine complications occur from anorexia nervosa

Mild hypercortisolemia → Anxiety, depression, stress

T3 low + TSH and T4 normal or low – Slow metabolism

Growth restriction

Functional hypothalamic amenorrhea (decreased GRH)

Reduced bone density

What MSK issues are anorexia nervosa patients at higher risk for

Stress Fractures

Where can anorexia nervosa be treated

Inpatient hospital or residential program

Partial hospitalization program (6-8 hours per day)

Intensive outpatient (2-3 hours per day)

Outpatient

Indications to Hospitalize for Anorexia Nervosa

Weight < 70% of ideal body weight or extreme severity (BMI < 15)

Poor response to outpatient treatment

Unstable vital signs

Cardiac dysrhythmia

Severe dehydration

Acute medical complication of malnutrition

Goals of Treatment for Anorexia Nervosa

Treat acute medical complications, dehydration, electrolyte imbalances

Improve nutritional status/weight gain

Psychotherapy

What medication can be considered as an add-on for anorexia nervosa

olanzapine (Zyprexa)

Why is olanzapine (Zyprexa) an add-on for anorexia nervosa

Modest increase in weight

Due to cardiac risk, what psych meds should be avoided in patients with anorexia nervosa

TCA

Due to seizure risk, what psych meds should be avoided in patients with anorexia nervosa

Bupropion (Wellbutrin)

Due to malnourishment, what psych meds should be used with caution in patients with anorexia nervosa

Antipsychotics & antidepressants

What medications are contraindicated with anorexia nervosa

TCA

Bupropion (Wellbutrin)

How do we mod diet for anorexia nervosa

500 calories above what patient requires, 6 feedings per day

Limit bathroom privileges for 2 hours after meals or closely monitor while in bathroom to limit purging

Ideal Weight Gain for Anorexia Nervosa

1-2 lbs. per week

Refeeding syndrome

fluid & electrolyte shifts during aggressive nutritional rehabilitation

Patho of Refeeding Syndroem

Patients with already depleted Phos/Mg/K

Refeeding occurs Glc intake increased  Insulin released

Cells take up already low supplies of Phos/Mg/K

Not enough nutrients to assist with glycogen/protein/fat synthesis and increased basal metabolic rate

Presentation of Refeeding Syndrome

aggressive nutritional rehabilitation trigger

peripheral edema,

cardiac complications,

rhabdomyolysis,

seizures,

hemolysis

Prevention of Refeeding Syndrome

replace electrolytes before starting to refeed,

increase caloric intake slowly,

monitor labs and clinical condition during refeeding

Which subtype of anorexia nervosa is less likely to recover

Restricting type

Criteria for Bulimia Nervosa

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

1. Eating, in a discrete period of time (i.e. within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances

2. A sense of lacking control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating)

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

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months

D. Self-evaluation is unduly influenced by body shape and weight

E. The disturbance does not occur exclusively during episodes of anorexia nervosa

Duration for dx of Bulimia

once a week for 3 months

How is the severity gauged for biulimia

# of inappropriate compensatory behaviors per week

Mild Bulimia Nervosa

1-3 episodes per week

Moderate Bulimia Nervosa

4-7 episodes per week

Severe Bulimia Nervosa

8-13 episodes per week