Eating Disorders

1
Eating Disorders

• Anorexia Nervosa DSM-IV Definition
• 1) Refusal to maintain body weight within a
  normal range for height and age
  ( gt 15 below ideal weight)
• 2) Fear of weight gain
• 3) Severe body image disturbances
  (self-worth and denial of serious illness)
• 4) Absence of menstrual cycle/ amenorrhoea (for
  gt 3 cycles)
• 2 subtypes restricting binge/purging

2
Eating Disorders

• Bulimia Nervosa DSM-IV Definition
• 1) Episodes of binge eating (loss of control)
• 2) Followed by compensatory behaviour of
• Purging type (vomiting, laxatives, diuretics)
• Non-purging (execise, fasting, diets)
  
• 3) Occurring gt 2x / week for 3/12
• 4) Dissatisfaction with body shape / weight

3
Epidemiology

• 1-2 million BN in USA
• 1/2 million AN in USA
• AN prevalence overall 0.27
• AN prevalence in 15-19y 0.48
• BN prevalence overall 1.5
• BN is more common in the gt18y
• Women 101 Men
• Many more have ED-NOS ( eating disorder not
  otherwise specified

4
Pathogenesis

• Social pressure
• Female athelete triad (eating disorder,
  amenorrhoea, and osteoprosis)
• Related to a combination of psychological,
  biological, family, genetic, environmental and
  social factors.
• Decreased self esteem or self control then using
  dieting behaviour and weight loss as a way of
  providing stability/ control on life.
• Genetics Monozygotic twins and 1st degree
  relatives have higher rates of eating disorders,
  Xolism, affective disorders

5
Pathogenesis

• Sexual abuse - no evidence
• Family characteristics high parental
  expectations, difficulty managing conflict, poor
  communication skills, enmeshment, estrangement,
  devaluation of maternal role and maritial
  tensions.
• CNS / Hormonal
• Nad bradycardia and hypotension in starvation
• Serotonin high in AN, affects the appetite and
  satiety centres

6
Screening

• SCOFF Score gt2
• Sick
• Control ( or rather loss of it )
• One stone in lt 3/12
• Fat
• Food dominates life

7
Examination

• Vital signs ( PR and BP)
• Lanugo hair
• Callous formation
• Parotid gland hypertrophy
• Erosion of dental enamel on anterior teeth
• CVS ( bradycardia, arrhythmias, MVP )
• GI
• Neuro

8
Investigations

• FBC (anaemia)
• Ur Cr (dehydration)
• Electrolytes K, Ca, Mg, PO4
• B- HCG
• TFTs
• Prolactin (prolactinoma)
• FSH

9
Complications

• Osteoporosis
• Cardiac impairment
• Psychiatric Cognitive Changes
• Infertility
• GI Dysfunction ( slow motility, N, bloating)
• Electrolytes ( K, metabolic alkalosis )
• Endocrine
• low LH and FSH
• Sick euthyroid ( high rT3 )
• low DHEA IGF-1
• high cortisol GH

10
Osteopenia / Osteoporosis

• Women accrue 40-60 of their bone mass during the
  adolescent years
• Seen in 90 of those with AN
• Long term risk of fracture increases x 3
• Causes - oestogen deficiency
• - inadequate Vitamin D and Ca
• - Lean body mass and nutritional
• Pathophysiology - increased bone resorption
  
• - decreased bone
  formation
• (differing from
  meopause)

11
Osteopenia / Osteoporosis Rx

• Ix with DEXA then
• 1) Weight gain
• 2) Elemental Ca 1200 - 1500 mg/ day
• 3) Multivitamins providing 400 IU Vit D / day
• 4) Oestrogen/ Progestin
• no proven benefit as process is different to
  menopause
• some benefit if lt 70 ideal body weight
• 5) IGF-1 (short term effects)
• 6) DHEA
• increases formation and decreases resorption in
  the short term

12
Cardiac Mx

• MVP occurs in 30 - 60 (3Xpopulation)
• this is partly due to enhanced ability to detect
  MVP in patients with intravascular volume
  depletion
• Prolonged QT interval seen in 33
• independent marker for arrhythmias and sudden
  death
• Heart Failure in the first 2/52 of Re-feeding
• Reduced cardiac contractility
• Refeeding oedema
• Mx by slow refeeding, repletion of PO4, avoid
  high Na

13
Amenorrhoea

• Seen in 90 of AN
• Low levels of LH FSH low Oestrogen
• Mx Increase weight
• Menses restarts in 90 in lt 6/12 after achieving
  90 ideal body weight

14
Multidisciplinary Mx

• a) Medical Provider
• Vital signs
• Fluoxetine (proven benefits in BNgtAN)
• Anxiolytics in AN prior to eating
• Metoclopramide (delayed transit bloating
  constip)
• b) Mental Health Provider
• Individual and cognitive behavioral therapy
• superior to medication, but synergistic with it
• c) Nutritionalist
• Specific and meal plan requirements
• Weight goals

15
Hospitalisation

• Severe malnutrition (lt75 IBW)
• Dehydration
• Electrolyte Disturbance
• Cardiac Dysrythmias
• Physiological AbNs (eg brady, hypotensive)
• Arrested Growth and Development
• Failure of Outpatient treatment
• Complications (medical of psychiatrical)
• Admission long enough to increase weight gt90 IBW
  improves eventual outcome

16
Management

• Nutritonal
• IP Expected weight gain 0.9-1.4 kg/week
• OP Expected weight gain 0.2-0.5 kg/week
• Start intake at 30-40 kcal/day (1000-1600kcal/day)
  
• Rapid early weight gain is related to fluid
  retention and to low metabolic rate
• Refeed Syndrome
• At risk are those gt 10 beneath their ideal body
  weight
• Hypophosphataemia
• Decreased IC ATP impaired enegy stores
• Decreased rbc 2,3-DPG tissue hypoxia

17
Outcome

• AN
• 50 good outcome
• 25 intermediate ( with relapses)
• 25 poor ( associated with later age of onset,
  duration, lower minimum weight, strong maturity
  fears )
• 30 - 70 fully recovered at 20y follow up
• 10 continue to meet criteria for AN at 12y
• BN
• 30 continue to meet criteria for BN at 10y
• Low self esteem associated with a poor outcome
• Dehydration
• Mortality Rate in AN 6.6
• 54 complications, 27 suicide, 19 others