Eating disorders - F50 Flashcards
What are some investigations and findings in anorexia nervosa?
Physical findings:
Thin, muscle wasting, pallor
Lanugo hair (fine downy hair growth in response to the loss of body fat)
Failure to develop secondary sexual characteristics
Amenorrhoea
Bradycardia
Hypotension
Cold-intolerance
Yellow tinge on the skin (hypercarotenaemia)
Enlarged salivary glands
Bloods: Hypokalaemia Hypercholesterolaemia Low FSH, LH, oestrogens and testosterone Raised cortisol and growth hormone Impaired glucose tolerance Low T3
Everything is low but G’s and C’s are raised: growth hormone, glucose (hypo is a bad sign), salivary glands, cortisol, cholesterol, carotinaemia
What is the SCOFF screening tool for ED?
S – Do you make yourself SICK because you feel uncomfortably full?
C – Do you worry you have lost CONTROL over how much you eat
O – Have you recently lost more than ONE STONE (6kgs) in a three month period
F – Do you believe yourself to be FAT when other say you are thin?
F – Would you say FOOD dominates your life?
What signs are important to look for on examination in ED?
Weight, height and BMI
Check teeth for acid damage
Consider abdominal examination +/- PR as indicated from history
Check reflexes and examine thyroid gland. Consider full examination for signs of hyperthyroidism
What is the epidemiology of eating disorders?
Affects 1% of the population Most commonly affects girls (10:1) Bimodal age of onset Age 13-14 Age 17-18 Incidence is rising in boys Typically affects intelligent, diligent and highly motivated individuals Patients usually have poor insight
How does anorexia present?
Overestimation of actual weight and body size – the discrepancy between actual and perceived weight increases as weight reduces
Often the patient will deny any weight loss, and disagree that she is too thin
Phobia of normal body size and weight
Very low body weight – There is a ‘critical weight’ (usually around 48Kg) below which amenorrhoea will occur. If the patient is not completely through puberty, they may regress to a pre-pubertal state
The control of weight may give the patients a sense of power – puberty can be a difficult time of maturity, when many patients feel they are ‘losing control’ of their local environment. Anorexia gives control over weight which may be comforting
Obsession and pre-occupation with food and cooking – many patients take up cooking as a hobby, although never eat any of their own food
Methods of reducing weight: Restricting calorie intake Over-exercise Use of laxatives Vomiting Use of diuretics
What are some clinical signs of anorexia?
Low metabolic rate Cold peripheries Bradycardia Alopecia Osteopenia Vitamin deficiencies & electrolyte disturbances Amenorrhoea Lanugo hair – fine downy hair that may appear on the body Skin changes Falsely low T3 level – giving appearance of hypothyroidism Low plasma proteins Ankle oedema Urine - ↓LH and ↓FSH
How do you manage anorexia?
Parents should be involved right from the start - parental counselling to help get across the seriousness of the situation
Patients should be managed with outpatient hospital appointments involving a psychiatrist and a paediatrician, as well as other relevant staff (e.g. psychologist, support workers etc)
Weight gain is the most important part of treatment
Use of a contract:
The patient is encouraged to enter into an agreement of weight gain / maintenance, and simple targets are set. The weight gained and not the eating habits are recorded, and usually the target is around 500g per week. If the target is not met, then hospital care will be required
Only a small percentage of patients will continue to lose weight after admission. In these cases, tube feeding may be used
On admission, the patient is usually fed 2000 calories per day. This is not usually in big meals, as these can cause difficulties
Once a normal weight has been achieved, a more psychotherapeutic level of care is adopted.
Signs that indicate a good prognosis include:
Good relationship with the parents
Ability to discuss previous suppressed emotional difficulties – usually around pressures of adolescence, growing up and relationships.
Drug therapy (e.g. SSRI’s) are not effective
What is the epidemiology of bulimia nervosa?
More common than anorexia
More common in girls
Prevalence is increasing
Typically affects older teenagers than anorexia
How does bulimia present?
Typically patients may be slightly reduced or normal weight, although sometimes they may be overweight
Otherwise very similar pattern to anorexia
What is refeeding syndrome?
This is a scenario that occurs when eating after a long period of fasting
It is not only seen in anorexia, but is also sometimes a problem after a long hospital admission
Typically occurs 3-4 days after eating begins
The result of a change in metabolism, from metabolising fats to metabolising carbohydrates - spike in insulin released (from chroncially low levels when starving)
Protein is a particular aetiological factor (e.g. in meat, milk and cheese)
There are severe electrolyte disturbances, typically thymine and phosphate deficiencies, and there may also be hypoglycaemia, and low potassium and glucose
Lack of phosphate can lead to muscle weakness, which can result in diaphragmatic insufficiency
These deficiencies occur because there is a massive cellular uptake of electrolytes and thus serum levels fall.
How does refeeding syndrome present?
Confusion, coma
Convulsions
Death
How do you manage refeeding syndrome?
Typically thiamine and vitamin B complex supplements are given when feeding resumes in anorexia
Biochemistry should be closely monitored, and any abnormalities in potassium, magnesium and phosphate should be corrected
What is required for Dx of anorexia?
DSM5:
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health
- 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
ICD10:
- A disorder characterized by deliberate weight loss, induced and sustained by the patient
- Dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves
- There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function
- The symptoms include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics.
Lecture: <85% of body weight Fear of weight gain Disproportionate idea of body Amenorrhoea or decreased libido
