Feeding and Eating Disorders

Eating and Feeding Disorder (Definition)

-Persistent disturbance of eating or behaviors related to eating that results in altered consumption/absorption of food and impairs physical health or psychosocial functioning

PICA Criteria (3)

A. Persistent eating of non-nutritious, non-food substances x 1 month

B. Inappropriate to developmental level of the individual

C. Not culturally supported or socially normative practice

Substances ppl eat in PICA

1. Paper so

2. Soap

3. Cloth

4. Hair

5. String

6. Wool

7. Gum

8.Ice

9. Soil

10. Chalk

T/F iron deficiency anemia is seen in PICA

TRUE

What disorders are associated with PICA (4)

1. Autism spectrum

2. Intellectual disability

3. Schizophrenia

4. OCD (trichotillomania, skin picking)

Treatment for PICA (2)

Distraction and reward for putting down food

Rumination disorder criteria

A. Repeated regurgitation (within 10 min of eating) of food (voluntary or involuntary) for at least 1 month

B. Not due to medical condition (GERD or Pyloric stenosis)

C. Regurgitant is brought back up without nausea, involuntary retching or disgust (should occur several times per week, usually daily)

Rumination disorder is most common in?

- Infants and intellectual disability

Characteristics of infants with Rumination disorder (3)

-Infants (MC 3-12 months)

1. Display characteristic position of straining, arching their back with the head held back

2. Making sucking movements with their tongue

3. Weight loss – may remit spontaneously

Characteristics of elderly with Rumination disorder (6)

1. Halitosis

2. Esophageal damage

3. Aspiration/ choking

4. Tooth decay

5. Chapped lips

6. Possible aspiration pneumonia

Treatment for Rumination Disorder (4)

1. Diaphragmatic breathing

(↓postprandial gastric pressure – contracts diaphragm and expands abdomen)

2. Increase LES pressure Refractory – baclofen (↑LES tone)

3. In children adverse conditioning

4. Exclude mechanical obstruction gastroesophageal fundoplication (if concurrent GERD)

Avoidant/Restrictive Food Intake Disorder Criteria (2)

1. Eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional or energy needs(i.e. apparent lack of interest in eating or food; avoidance based on sensory character; concern about aversive consequence)

Associated with 1 or more of the following:

1. Significant weight loss

2. Significant nutritional deficiency

3. Dependence on enteral feeding or oral nutritional supplements

4. Marked interference with psychosocial functioning

B. Not due to lack of food, cultural practice, other eating disorder, medical condition or mental disorder

Avoidant/Restrictive Food Intake Disorder onset and characteristics (8)

- Usually begins in infancy or early childhood

Characteristics:

1. avoidance based on sensory characteristics begins 1st decade

2. “grazers, eats like a bird”

3. Rigid/picky

4. Low appetite and early satiety,

5. Indifferent to food

6. Growth delay

7. Malnutrition

8. Developmental/learning disability

*r/o child abuse or neglect

Treatment for avoidant/restrictive food intake disorder (5)

1. Exposure

2. Therapeutic means

3. Family based tx

4. SSRI

5 Appetite stimulators

What is the most common eating disorder

-Binge eating then bulimia

Most common cause of eating disorders

-MCC substantial weight loss in young adolescent females in western countries

- Unrelenting pursuit of thinness manifests struggle to maintain as sense of personal autonomy and self control

What do r/o before dx of an eating disorder (5)

1. Cancer

2. Thyroid issue

3. IBS

4. Type I Diabetes

5. HIV

Risk factors for anorexia nervosa (AN) and bulimia nervosa (BN) (9)

1. Family Hx of obesity, substance abuse, eating disorder and/or depression

2. Culture or family members that stress thinness and equate it with attractiveness and success

3. Career or sports participation where thinness is stressed

4. Onset may be stress-related

5. History of dieting

6. Sense of personal helplessness or fear of losing control

7. Low self-esteem and body dissatisfaction

8. Perfectionist personality, achievement pressure, compulsive, impulsive, obsessive, high stress, tight schedules

8. Trauma or major stressful life event such as physical or sexual abuse (more associated with BN)

9. Serotonin dysregulation commonly implicated

T/F eating disorders are seen more in black and latino

FALSEEEEEEE

Conditions associated with Anorexia and Bulimia (9)

1. Major depression or dysthymia

2. Anxiety disorder, social phobia, OCD, PTSD

3. Non-suicidal self-injury (cutting, picking, burning skin)

4. Substance abuse disorder

5. Body dysmorphia

6. OCPD (more with anorexia) ,

7. Impulsive personality disorder (more bulimia)

8. Kleptomania

9. History of sexual abuse (BN)

Questionnaires used to help dx eating disorders

1. SCOFF (score of 2 indicates likely dx)

2. Eating disorder screen for primary care (ESP)

3. Eating attitude test (26 item scale, where score at or above 20 indicates likely dx)

Median onset age of anorexia and bulimia

18 yrs old

Bulimia prevalence

-1% prevalence in US

- More common in men

-Male pts often sports related and gay men

Anorexia prevalence

- 0.6% prevalence in US

- More common in women

Crossover between anorexia and bulimia

- 15% crossover from bulimia to anorexia

- 34% crossover from anorexia to bulimia

- if you have both you get a dx of anorexia

Anorexia Nervosa (AN) Criteria (3)

A. Restriction of energy intake relative to requirements, “significantly low body weight” in the context of age, sex, developmental trajectory and physical health

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

C. Disturbance in way one’s body weight/shape is experienced, undue influence of weight on self-evaluation, or persistent lack of recognition of seriousness of current low body weight

Anorexia nervosa specifiers (2)

1. Restricting Type: During the last 3 months, has not regularly engaged in recurrent episodes of binge-eating or purging behavior; weight loss accomplished primarily through dieting, fasting or excessive exercise (hyperactive even when emaciated)

2. Binge-eating/Purging Type: During the last 3 months, has regularly engaged in recurrent episodes of binge-eating or purging behavior

(i.e. self-induced vomiting, laxatives, enemas or diuretics – insulin/thyroid meds); may purge after small amount of food

Severity of Anorexia Nervosa

1. Mild: BMI > 17

2. Moderate: BMI 16-16.99

3. Severe: BMI 15-15.99

4. Extreme: BMI <15

*normal BMI is 18.5-24.9

Anorexia nervosa DSM4 VS. DSM5

- In the DSM-4 amenorrhea (no menses) was required for diagnosis

Clinical manifestations of Anorexia Nervosa (16)

1. Hypothalamus shuts down,

2. Adipose tissue needed to convert estrogen to active form leading to amenorrhea/oligomenorrhea,

3. Growth arrest if pre- menarche, breast atrophy,

4. Decreased libido (hypothalamic hypogonadism)

5. Hypotension (SBP <70), bradycardia (HR 30-40), hypothermia

6. Syncope

7. Cold intolerance, fine, downy lanugo hair (hair seen on premature babies)

8. Acrocyanosis

9. Peripheral edema (due to decreased onconic pressure due to protein deficiency)

10. Delayed gastric emptying

11. Abdominal pain, N/V, dehydration,

12. Arrhythmias

13. Cerebral atrophy, peripheral neuropathy

14. Decreases pain sensitivity (due to increase release of endogenous opioids)

15. NO organomegaly (liver, spleen) or Lymphadenopathy (to r/o cancer/infection

16. Anemia, leukemia

*proportional to degree of malnutrition (especially protein deficiency)

Female athlete triad

1. Eating disorder

2. Hypothalamic amenorrhea

3. Osteoporosis (due to low estrogen)

Thoughts and feelings associated with Anorexia

1. Fear and/or restriction of certain foods and preference for low-calorie food for weight loss

2. Low self-esteem

3. Cognitive impairment

4. Sleep disturbances

5. Sexual disinterest/↓ libido,

6. Developmental immaturity

7. Constricted affect

❖ They have Limited insight into or deny clinical features, resist weight gain and treatment

OCD traits in anorexia (5)

1. Elaborate food prep/eating rituals

2. Exercise rituals

3. Inflexible thinking

4. Perfectionism

5. Need to control environment

Question to ask pt with anorexia (8)

1. Last menstrual period

2. East habits (restriction vs. purging)

3. Exercise habits

4. Highest weight, current weight, Goal weight

5. Purging method used

6. Sexual hx

7. Comorbid psychiatric disorders

8 Suicidal ideation

Labs needed for anorexia (6)

- Thorough medical exam:

1. Chemistry panel

2. CBC

3. UA

4. HCG

5. Measure percent body fat and bone density (DEXA)

6. EKG – QT prolongation due to starvation

What labs will be decreased in anorexia (5)

1. Glucose

2. TSH, T3, T4 (bc of hypothalamus shut down)

3. FSH and LH

4. Estrogen

5. Phosphate

What labs will be increased in anorexia (4)

1. Cortisol (increase bc of stress)

2. ADH ( to keep water in)

3. BUN (bc of hemoconcentration)

4. Aldosterone (saving Na+ to save water)

Treatments for anorexia (first line)

- Initial correction of fluid-electrolyte imbalances and any life-threatening conditions

-first-line: Nutritional rehabilitation, therapeutic meal, CBT

Focus of CBT in anorexia

-Focus on overall health, rather than weight gain and challenge fear of uncontrolled weight gain

Medication used in anorexia

- Olanzapine (Zyprexa) more widely studied for treatment of AN than any other antipsychotic -- evidence suggests it is reasonable to try for PTs who do not gain weight despite first line treatment

-Avoid drugs that prolong QT interval: antipsychotics, antidepressants

T/F: You should give estrogen to pts with anorexia

FALSE

- Estrogen is not helpful bc it does not enhance bone mineral density in underweight pts

Conditions where you hospitalize anorexia pts

1. Weight < 75% of normal for height and age

2. Marked orthostatic hypotension

3. Moderate electrolyte abnormalities

4. Bradycardia < 40; tachycardia > 100, dysrhythmia

5. Unable to sustain core body temp of 98.6

6. Altered mental status or suicidal ideation

7. Failure of outpatient therapy

8. *Tube feeding --> last Resort

Precaution in anorexia

-starved patients more sensitive to medication, dangerous or lethal side effects - compromised cardiac, liver, kidney function

Complications in anorexia (5)

1. Wernicke’s encephalopathy = acute psychosis, ophthalmoplegia, ataxia

2. Hypophosphatemia = short runs of ventricular tachycardia - predisposition to arrhythmia

3. Electrolyte disturbances: cardiac arrhythmia convulsions, peripheral neuropathy, syncope

4. Cardiac or liver failure

5. Too rapid initial weight gain can cause fluid retention and congestive heart failure

Causes of death in anorexia (2)

1. Medical complication associated with starvation (60%)

2. Suicide (1 in 5 deaths)

*restrictive specifier is worse

* highest mortality rate of any mental disorder

Prognosis of anorexia

- 50% good outcomes (including weight gain),

- 25% intermediate outcomes

- 25% poor outcomes

Favorable: insight, successful interpersonal relationships, good psychosocial adjustment, early age at onset, less extreme weight

loss, less denial of illnesso

Poor: low socioeconomic status, longer duration of illness, repeated hospitalization, failed treatment, comorbid conditions

Refeeding syndrome (Definition)

-Potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding

Referring syndrome criteria

A. Either the patient has one or more of the following:

1. BMI <16

2. Unintentional weight loss >15% in the past 3 to 6 months

3. Little or no nutritional intake for >10 days

4. Low levels of potassium, phosphate, or magnesium before feeding

Or

B. The patient has two or more of the following:

1. BMI <18.5

2. Unintentional weight loss >10% in the past 3 to 6 months

4. Little or no nutritional intake for >5 days

5. History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics

Bulimia Nersova Criteria (5)

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

1. Eating, in a discrete period of time (within any 2-hour period), amount of food that is definitely larger than

most people would eat during similar time and under similar circumstances

2. Sense of lack of control over eating during episode (feel can’t stop eating or control what/how much eating)

B. Recurrent inappropriate compensatory behavior to prevent weight gain

(self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise)

C. Binge eating & inappropriate compensatory behaviors both occur about 1x/week x 3 months

(DSM4- 2x/week x 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

Severity of Bulimia Nervosa (4)

1. Mild (1-3 episodes compensation/week)

2. Moderate (4-7/week)

3. Severe (8-13/week),

4. Extreme (14/week)

Clinical Manifestations of Bulimia (10)

1. Aware of disordered eating habits, distinguish eating binges from simple overeating;

2. MC antecedent of binge is negative affect; depressive/anxious moods or dietary restraint leading to binge

3. Frequent fluctuations in weight, usually normal weight or overweight (BMI >18.5 and >30)

4. Binges usually occur in secret; last few minutes to 1-2 hours

6. Eat "junk foods" they ordinarily deny themselves but frequently eat whatever is available

7. Excessive desire for privacy in the bathroom or bedroom after meals, may take unexpected walks or drives

8. Alternate between purging and non-purging behavior

9. Self-induced vomiting very common but is not essential for Dx

(Maintain weight by fasting, laxative, diet pills, exercise, diuretics, etc)

10. May misuse medication

Vomiting in bulimia

- may use emetics (ipecac) or induce vomiting (Russell’s sign)

-Russell's sign: Abrasion on 1st and 2nd knuckle of index and middle finger of dominant hand

- Vomiting causes increase intracranial pressure leading to subconjunctival hemorrhage, petechiae, epistaxis

Boerhaave syndrome

-spontaneous esophageal rupture due to forceful vomiting

Mallory-Weiss syndrome

-tear of esophagus from vomiting

T/F: Sexual activity is normal in bulimia pts

TRUE

T/F Severe dehydration and electrolyte imbalance is most common in anorexia pts

FALSE

- MC in bulimia pts (50%)

T/F Laxative or diuretic use causes metabolic acidosis

TRUE

T/F chronic vomiting causes metabolic alkalosis

TRUE

Treatment of bulimia nervosa

- First line: national rehabilitation and psychotherapy

-Most treated outpatient

Conditions to hospitalize a bulimia pt (6)

1. Suicidal

2. Lab or ECG evidence of marked electrolyte imbalance

3. Marked dehydration

4. Severe depression

5. Substanceabuse,

6. If there has had no response to outpatient therapy

Combination treatment in bulimia

- Pharmacotherapy plus psychotherapy appears to be more efficacious than either treatment alone for treating episodes of bingeing and purging

- Recommend: First line SSRI → different SSRI → TCA → MAOI (3rd line: topiramate)

*caution with MAOI- HTN crisis and binge on high tyramine foods

*Avoid Bupropion (Wellbutrin) bc of seizures

How long do you continue pharmacotherapy

- For at least 6-12 months after response or remission

(30% relapse rate)

Prognosis of bulimia

- Recurrent binge-purge behaviors persisted for 10 years of follow-up in 30% of patients

- Substance abuse and long duration of disorder were associated with poorer outcome -- suicide attempts occurred in 17 % and 1% committed

Binge eating disorder criteria (5)

- Most common eating disorder

A. Recurrent episodes of binge eating characterized by both:

1. Eating, in a discrete period of time (within any 2-hour period), amount of food that is definitely larger than

most people would eat during similar time and under similar circumstances

3. Sense of lack of control over eating during episode

B. Binge eating episodes associated with 3 or more of the following:

1. Eating much more rapidly than normal

2. Eating until feeling uncomfortably full

3. Eating large amounts of food when not feeling hungry

4. Eating alone because embarrassed about how much you’re eating

5. Feeling disgusted, depressed or guilty afterwards

C. Marked distress regarding eating is present

D. Binge eating occurs about 1x/week x 3 months

E. Not associated with compensatory behaviors & not due to anorexia or bulimia

Prevalence of binge eating disorder

-Affects 2.6% US adults in lifetime

- More common in females from racial/ethnic minorities and ppl who always diet

Age of onset and associated disorder of binge eating disorder

- Mean onset 23 (BMI > 30)

-Associated disorders: depression and anxiety

Severity of binger eating disorder (4)

1. Mild (1-3 episodes/week)

2. Moderate (4-7/week)

3. Severe (8-13/week)

4. Extreme (14/week)

Treatment for binge eating disorder (3)

1. cognitive-behavioral therapy (meds are less effective vs. CBT)

2. Antidepressants (SSRI)

3. Bariatric surgery

Prevention and pt education for eating disorders (4)

1. Children and adolescents frequently screened for symptoms of eating disorders and weight dissatisfaction at PCP appointments

2. Body dissatisfaction, eating habits, moodiness, risk-taking behavior should be addressed openly (not “normal for adolescence”)

3. Warned against use of diet pills and amphetamines, all-natural energy pills, diet teas, energy drinks

(contain herbal forms of caffeine and ephedrine and have been associated with hypertension, MI and CVA)

4. Exercise, participation in school activities, and healthy family relationships are important.

Night eating disorder

- 1% prevalence

- Recurrent episodes of “night-eating” -- eating large quantities of food at night after awakening from sleep or by excessive food consumption (35% intake) after the evening meal x 2 months

Sleep related eating disorder (SRED)

- Variant of sleepwalking (episodes in first 1/3 of sleep)

-Most common in women

- Recurrent episodes of involuntary eating associated with diminished levels of consciousness and awareness during arousal from sleep

SRED must be accompanied by what? (5)

1 or more of the following:

1. Consumption of inedible or toxic substances

2. Insomnia

3. Sleep-related injury/danger in search for or while cooking food

4. Morning anorexia,

5. Adverse health consequences from recurrent binge eating (i.e. weight gain and metabolic disorders)

Orthorexia Nervosa

- focuses on perfect or pure diet

- Obsession with eating nutritious/healthy - Refuses and feel guilty about eating unhealthy foods

- Eliminates all sugars and fats from their diets

- No longer enjoy food

- Isolate from eating with family/friends

Under what protocols is orthorexia nervosa best treated?

OCD protocols

Prader-Willi Syndrome

- Congenital disorder (chromosomal 15 microdeletion) characterized by OBESITY: bc of defect in the hypothalamus

- Patient never feels full – actually need to eat less than those of equal age and height because of less muscle mass

- Tend to burn less calories

- Associated with OCD behaviors

Neonatal hypotonia

- Hallmark of prader-willi syndrome

- Short stature, behavior problems, mental retardation and hypogonadism

Tx for prader-willi syndrome

- No cure

- Eat extremely low-calorie diets and very little access to food

Complications of prader-willi syndrome (2)

1. Complication related to obesity

2. Gastric dilation, necrosis or rupture

Cause of Kluver-Bucy syndrome

- Bilateral amygdala & hippocampus destruction

Most common cause is HSV encephalitis – temporal lobe

Characteristics of Kluver-Bucky Syndrome (5)

1. Hyperphagia: extreme weight gain without strictly monitored diet; compulsively place inedible objects in their mouths

2. “hyperorality”: compulsion to put thing in the mouth

3. Emotional Blunting: flat affect, may not respond appropriately to stimuli; placidity – no longer show fear/anger when appropriate

4. Inappropriate Sexual Behavior: fail to publicly observe social sexual morays; hypersexuality: suggestive behavior and talk,masturbation, sex with inanimate objects

5. Agnosia (visual*, tactile and auditory): inability to recognize objects...

Medical hints for hormonal cause of childhood obesity (4)

1. Short stature or a ↓ rate of linear growth (GH deficiency, hypothyroidism, cortisol excess,

pseudohypoparathyroidism)

2. Dry skin, constipation, intolerance to cold, and fatigability (Hashimoto/hypothyroidism)

3. Accumulation of fat in neck & trunk but not in the arms or legs (Cushing's or cortisol excess)

4. Inappropriate sexual development at an early age (treatment with certain drugs or medications)