- 16 yo female with weight loss as chief complaint
- Hx of bullying, teased for weight, has had significant weight loss in the past 3 mo (lost 60 lb)
- No suicidal ideation or substance use
- Not involved in many extra-curricular activities
- Often skipping breakfast and dinner with only a small lunch (~salad)
- Weight: 100.6 lbs, height: 61.5 in (5'1")
- Growth curve (picture)
What is Mae's diagnosis?
A. Anorexia Nervosa
B. Bulimia Nervosa
A. Anorexia Nerovsa (binge-purge subtype)
What percentage of people (high school) are trying NOT to lose weight?
- 52% total
- 37% girls
- 67% boys
What percentage of people (high school) did not eat for 24 hours to try to lose weight?
- 13% total
- 19% girls
- 7% boys
What percentage of people (high school) took diet pills, powders, liquids in past 30 days without doctor's recommendation?
- 5% total
- 6.6% girls
- 3.5% boys
What percentage of people (high school) took laxatives to lose weight or to keep from gaining weight in the past 30 days?
- 4.4% total
- 6.6% girls
- 2.2% boys
Prevalence of eating disorders?
Average age for anorexia?
How many cases are male?
Growing number of people affected by eating disorders:
- 2-5% have bulimia nervosa
- 0.5-2% have anorexia nervosa (avg age 13.5)
- 5% other specified eating disorder
Up to 10% of cases are male
Individual risk factors for an eating disorder?
- Adolescent female
- Low self esteem
- Conflicts about personal identity and autonomy
- Negative attitude towards body at puberty
Cultural risk factors for an eating disorder?
- Thin ideal for beauty and happiness
- Acculturation to Western value
Family risk factors for an eating disorder?
- Achievement oriented
- Limited emotional support, nurturance or encouragement
- Maternal preoccupation with appearance, diet, weight or physical fitness
- Family history of eating disorders of mood disorder
Sports risk factors for an eating disorder?
- Weight loss for performance
- "Under-fueling" due to schedule and excessive practices
How does DSM 5 address eating disorders?
- Included as mental disorders
- Broadens AN and BN
- Adds other feeding disorders into the category (pica-eating ice/dirt, rumination, avoidant feeling...)
- Eliminating eating disorder NOS as a category but leaves an unspecified category
What is Anorexia Nervosa?
- Restriction leading to clinically significant low weight
- Intense fear of gaining weight OR behavior that interferes with gaining weight
- Disturbance in how body weight or shape is experienced or persistent lack of recognition of seriousness of low body weight
What are two-subtypes of Anorexia Nervosa?
- Restricting type: does not binge or purge, typically use dieting, fasting, or excessive exercise
- Binge-eating/purging type: recurrent bingeing and purging over the last 3 mo, purging includes self-induced vomiting, misuse of laxatives/diuretics/enemas...
How is severity given to cases of Anorexia Nervosa?
Severity is based on BMI
- Mild: BMI > 17
- Moderate: BMI 16-16.99
- Severe: BMI 15-15.99
- Extreme: BMI < 15
What is Bulimia Nervosa? Characteristics?
- Recurrent binge eating, includes both eating in a discrete period of time an amount more than most individuals, and having a sense of lack of control over this
- Recurrent inappropriate compensatory behaviors to prevent weight gain (self-induced vomiting, misuse of laxatives, diuretics or other meds, fasting, excessive exercise)
- Once a week for 3 mo (average)
- Self-evaluation unduly influenced by body shape and weight
- Disturbance not only during episodes of anorexia nervosa
How is severity given to Bulimia Nervosa?
Severity based on frequency of purging
- Mild: 1-3 episodes/wk
- Moderate: 4-7 episodes/wk
- Severe: 8-13 episodes/wk
- Extreme: 14+ episodes/wk
How is BN different from the bingeing/purging subtype of AN?
AN involves chronic low weight
How to calculate % ideal body weight (%IBW)
Determine using NHANES table, BMI, HAMWI method
% IBW = current body weight/ideal body weight x 100 OR
% IBW = current BMI/ideal BMI x 100
What are the different categories for degree of malnutrition?
Determined by %IBW (ideal body weight)
- Normal: 90-110%
- Mild: 80-89.9%
- Moderate: 70-79.9%
- Severe: < 70%
Common chief complaints for individuals with eating disorders?
- Well child check
- Weight loss
- GI complaints
What should you look for in vital signs?
- Low weight (look at growth charts!)
- Possibly stunted height
What are some questions you can use for screening? Results?
SCOFF screening questions:
- Do you make yourself SICK because you feel uncomfortably full?
- Do you worry that you've lost CONTROL over how much you eat?
- Have you recently lost more than ONE stone (14 lb) in a 3-mo period?
- Do you believe yourself to be FAT when others say you are too thin?
- Would you say that FOOD dominates your life?
Yes = 1 pt
Score > 2 suggests eating disorder
What are some non-SCOFF (additional) screening questions?
Perception of weight:
- "Do you fell you are too thin, too heavy, or just right?"
- "Do you have a fear of gaining weight?"
Efforts to control weight (diet, exercise, vomiting, laxatives...)
Physical findings with eating disorders?
- Fluid and Electrolytes
Physical findings: Neurologic?
- Cortical atrophy
- Cognitive impairment
Physical findings: Psychiatric?
- Obsessive-compulsive symptoms
Physical findings: Fluid and electrolytes?
Fluid and Electrolytes
- Electrolyte abnormalities (decreased Ca, Na, PO4, K, Mg)
Physical findings: Cardiovascular?
- Hypotension (especially orthostasis)
- Prolonged QTc
Physical findings: Dermatological?
- Lanugo (fine hair)
- Russell's sign (knuckles that may be impacted by teeth during vomiting)
Physical findings: HEENT?
- Enamel erosion
- Parotid hypertrophy
DDx for eating disorder?
- Feeding disorder
- Inflammatory bowel disease
- Primary endocrine disorder
- Diabetes mellitus
- Addison's disease
- Depression or other psychiatric disease
- Malignancy including CNS tumor
- Other GI illness (achalasia, cystic fibrosis)
Laboratory evaluations to look at?
- CBC, CMP including Ca, Mg, Phos-
- Thyroid stimulating hormone (may have decreased levels of T3/T4 secondary to malnutrition?)
- Urine POC dipstick, pregnancy test if sexually active
- ESR, CRP, (amylase, lipase)
- Baseline EKG when HR < 50 or moderate malnutrition
- FSH, LH, Prolactin, estradiol (amenorrhea)
Indications for hospitalization?
- Sever malnutrition (under 75% ideal body weight)
- Physiologic instability (severe bradycardia < 50, hypotension, hypothermia, severe orthostatic changes)
- Dehydration or electrolyte imbalance
- Cardiac arrhythmias
- Suicidal or acute mental status changes
- Others: intractable vomiting, hematemesis, esophageal tears
T/F: People with eating disorders have a higher lifetime suicidality?
General approach to treatment for eating disorder?
- < 30% seek care related to weight or eating
- Medical care provided by clinicians trained in eating disorders
- Interdisciplinary team is ideal (nutritional support, psychological component for individual and family, psychiatric evaluation as needed for diagnosis and medication)
- Tried SSRis (prob to increase appetite) and anti-psychotics, but not great results
Recommendations to PCP?
- PCP visits weekly until care is established with specialists
- Food supplements helpful when introduce as "prescribed medication"
- Treatment- empathic and not punitive
Natural history of eating disorder?
- 72% achieve partial or full recovery
- 28% persistent illness
- 22%-35% relapse
- Decrease in fertility
- Alterations in cognitive and social functioning
High mortality rates
- 5.9% AN
- 1.9% BN
What is Binge Eating Disorder?
- Eating in a discrete period of time within any 2 hours period, an amount of food that is definitely larger than what most people would eat in a similar period under similar circumstances
- Sense of lack of control over eating during the episode , a feeling that one cannot stop eating or control what or how much is eaten, and marked distress associated with the binge-eating episodes;
--- The episodes occur on average at least once a week for at least 3 months, are not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa, and do not occur exclusively during the course of bulimia nervosa or anorexia nervosa
--- Three or more of the following factors are also present:
+ Eating much more rapidly than normal
+ Eating until feeling uncomfortably full
+ Eating large amts of food when not feeling physically hungry
+ Eating alone b/c of feeling embarrassed by how much is being eaten
+ Feeling disgusted with oneself, depressed, or very guilty afterward
What is the most common eating disorder?
Binge Eating disorder
What is the prevalence of binge eating disorder?
- 1 in 35 adults
- 3.5% female
- 2% male
Up to __ of people with binge eating disorder are obese
Up to 2/3 of people with binge eating disorder are obese
Treatment for Binge Eating Disorder?
- Cognitive behavioral therapy (CBT)
- Mindfulness training
- One FDA approved drug in adults; Lisdexamfetamine dimesylate (Vyvanse)
- Eating disorders affect many adolescents and adults (chronic illness with high morbidity and mortality rate)
- Physicians should recognize the early signs
- Multidisciplinary care with experienced providers improves outcomes
- Urgent medical and/or psychiatric hospitalization may be needed