Eating Disorders

Question 1

Case 1: 18 yo female presents with 5 mo h/o wt loss

• she began reducing the fat in her diet - lost 22 lbs and now weighs 95 lbs
• she hardly eats has a BM 4-5 days, runs 4 miles q day and does 100 sit ups, LMP was 6 mo, not sexually active
• She constantly feels cool and is dizzy upon standing, hair is dry, feels bloated after meals, she still thinks she is too large and she doesn’t think she has a problem
• DSM 5 criteria?

Answer 1

• classic example of anorexia nervosa
• DSM-5 criteria:
  restriction of energy intake relative to requirements, leading to sig. low body wt in context of age, sex, developmental trajectory and physical health
• fear of wt gain
• severe body image disturbance in which body image is predominant measure of self worth with denial of the seriousness of the illness

Question 2

Subtypes of anorexia nervosa?

Answer 2

• restricting: restriction of intake to reduce wt
• binge eating/purging: may binge and/or purge to control wt
  considered anorexic if she/he is 15% below ideal body wt

Question 3

Signs and sxs of anorexia nervosa?

Answer 3

• dry skin
• cold intolerance
• blue hands and feet
• constipation
• bloating
• delayed puberty
• primary or secondary amenorrhea
• fainting
• orthostatic hypotension
• lanugo hair: fine hair - body’s response to malnourishment, keeping warm
• scalp hair loss
• early satiety
• weakness, fatigue
• short stature
• osteopenia
• breast atrophy
• atrophic vaginitis
• pitting edema
• cardiac murmurs
• sinus brady
• hypothermia

Question 4

Case 2: 20 yo female - presents for eval of hematemesis - admits to self-induced vomiting for past 3 yrs, 62” tall, 140 lbs - gorges and vomits 3-5x week, uncontrollable eating binges, feels guilty, smokes 1 pack of cigs a day, gets drunk weekly - binge drinks, irregular menses, hasn’t lost wt. Characteristic of? DSM-V criteria?

Answer 4

• bulimia
  A. recurrent of binge eating. An episode of binge eating is characterized by both of the following:
  1. eating in a discrete period of time, an amt of food that is definitely larger than what most individuals would eat
  2. a sense of lack control over eating during the episode
  B. recurrent inappropriate compensatory behaviors in order to prevent wt gain, such as self-induced vomiting, misuse of laxatives, diuretics, other meds, fasting, or excessive exerciese
  C. binge eating and inappropriate compensatory behaviors both occur, on average at least 1x a week for 3 months
  D. self eval is unduly influenced by body shape and wt
  E. the disturbance doesn’t occur exclusively during periods of anorexia nervosa

Question 5

Signs and sxs of bulimia?

Answer 5

• mouth sores
• pharyngeal trauma
• dental caries
• heartburn, chest pain
• esophageal rupture
• impulsivity: stealing, ETOH abuse, drugs/tobacco
• muscle cramps
• weakness
• bloody diarrhea
• bleeding or easy bruising
• irregular periods
• fainting
• swollen parotid glands (from overuse)
• hypotension
• russell’s sign: callouses on knuckles

Question 6

Binge eating disorder?

Answer 6

• eating, in a discrete period of time, an amt of food that is larger than most people would eat in similar period
• occurs 2 days/week for 6 month duration
• assoc with lack of control and with distress over the binge eating

Question 7

Binge eating disorder criteria?

Answer 7

must have at least 3 of 5:

• eating much more rapidly than normal
• eating until uncomfortably full
• eating large amts of food when not feeling physically hungry
• eating alone b/c of embarrassment
• feeling disgusted, depressed or very guilty about overeating

Question 8

Eating disorder, NOS - DSM-5 criteria?

Answer 8

1. all criteria for anorexia nervosa except has regular menses
2. all criteria for anorexia except wt still in normal range
3. all criteria for bulimia except binges less than 2x a week for less than 3 months
4. pts with normal body wt who regularly engage in inappropriate compensatory behavior after eating small amts of food (self induced vomiting after eating 2 cookies)
5. a pt who repeatedly chews and spits out large amts of food without swallowing

Question 9

Epidemiology of eating disorders?

Answer 9

• anorexia: incidence rates have increased in past 25 years, affects 1% of adolescent females, rates for men only 10% of those for women, seen in pts as young as 6
• bulimia: occurs in 1-5% of high school girls, and as high as 19% in college women
• eating disordre NOS: occurs in 3-5% of women b/t ages 15-30 in western countries, as minority culture groups assimilate into american society - rates increase
• binge eating disorder: occurs more commonly in women, depening on pop surveryed, can vary from 3%-30%

Question 10

Assoc psych conditions with Eating disorders?

Answer 10

• anxiety disorders
• OCD
• personality disorders
• substance abuse

Question 11

Pathogenesis of eating disorders?

Answer 11

• no consensus on precise cause

- combo of psychological, biological, family, genetic, enviro and social factors

Question 12

Screening tools - SCOFF questionnaire?

Answer 12

• do you make yourself Sick b/c you feel uncomfortably full?
• do you worry you have lost Control over how much you eat?
• have you recently lost more than 14 lbs (One stone) in a 3 month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?

Question 13

Screening tool - eating disorder screen for primary care (ESP)?

Answer 13

• are you satisfied with your eating patterns? (no is abnormal)
• do you ever eat in secret? (yes is abnormal)
• does your wt affect the way you feel about yourself? (yes is abnormal)
• have any members of your family suffered with an eating disorder? (yes is abnormal)
• do you currently suffer with or have you ever suffered in the past with an eating disorder? (yes is abnormal)

Question 14

Impt hx ?s to hit?

Answer 14

• max ht and wt
• exercise habits: intensity, hrs/week
• stress level
• habits and behaviors: smoking, ETOH, drugs, sexual activity
• eating attitudes and behaviors
• ROS

Question 15

PE findings in anorexia?

Answer 15

• vital signs to include orthostatics
• skin and extremity eval: dryness, bruising, lanugo
• cardiac exam: bradycardia, arrhythmia, MVP (heart muscle shrinks but valves don’t)
• abdominal exam
• neuro exam: eval for other causes of wt loss or vomiting (brain tumor)

Question 16

PE findings in bulimia?

Answer 16

• all previous elements seen in anorexia plus:
  parotid gland hypertrophy
  erosion of the teeth enamel

Question 17

Lab assessment in Eating disorders?

Answer 17

• CBC: anemia
• lytes, BUN/Cr
• Mg, PO4, Calcium, k+
• albumin, serum protein
• B-HCG
• UA: specific gravity
• thyroid fxn tests
• serum prolactin
• FSH
• bone density

Question 18

DDx of eating disorder?

Answer 18

• new onset diabetes
• adrenal insufficiency
• primary depression with anorexia
• IBD
• abdominal masses
• CNS lesions

Question 19

Complications of eating disorder?

Answer 19

- fluid and lytes imbalance:
hypokalemia
hyponatremia
hypochloremic alkalosis
elevated BUN
inability to concentrate urine
decreased GFR
ketonuria

Question 20

Complications - osteopenia? Tx?

Answer 20

• one of the most severe complications
• difficult to reverse
• tx:
  wt gain
  1200-1500 mg/day of elemental Ca2+
  multivitamin w/ 400 IU vit D
  consider estrogen/progesterone replacement

Question 21

Complications - amenorrhea? Tx?

Answer 21

• secondary amenorrhea affects more than 90% of pts with anorexia
• caused by low levels of FSH and LH
• menses resumes w/in 6 months of achieving 90% IBW

Question 22

Complications - cardiac changes? When is risk of heart failure the greatest?

Answer 22

• MVP: occurs in 32-60% of pts with anorexia
• long QT: one study found as many as 33% of pts:
  independent marker for arrhythmia
  immediate attention if pt is bradycardic and underwt as well
• risk of heart failure is greatest in first 2 weeks of refeeding: reduced cardiac contractility and refeeding edema, slow referring, repletion of K+, avoidance of Na+ intake

Question 23

non pharm Tx of anorexia?

Answer 23

• CBT: emphasizes the relationship of thoughts and feelings to behavior
• limited efficacy
• interdisciplinary care team: medical provider, dietician with experience in eating disorders, mental health professional

Question 24

med use for anorexia?

Answer 24

• overall, disappointing results
• effective only for tx co-morbid conditions of depression and OCD
• anxiolytics may be helpful b/f meals to suppress the anxiety assoc with eating
• case reports in the literature supporting use of olanzapine (zyprexa) - atypical antipsychotic

Question 25

When should pt with anorexia be hospitalized?

Answer 25

- severe malnutrition (less than 75% IBW) - dehydration - lyte disturbances - cardiac dysrhymia - arrested growth and development - physiologic instability - failure of outpt tx - acute psychiatric emergencies - comorbid conditions that interfere with tx of the ED

Question 26

Nutrition goals in anorexia tx?

Answer 26

- goal: regain to goal of 90-92% of IBW - inpt tx varies by facility: oral liquid nutrition - NG tube feedings - gradula caloric increase with "regular" food - parenteral nutrition (IV feeding) rarely indicated

Question 27

Outcome for pts with anorexia?

Answer 27

- 50% good outcome: return of menses and wt gain - 25% intermediate outcome: some wt regained - 25% poor outcome: assoc with later age onset longer duration of illness lower min. wt overally mortality rate: 6.6%

Question 28

Bulimia - tx?

Answer 28

- CBT: effective pharm: high success rate - fluoxetine (prozac) SSRI studies reveal up to a 67% reduction in binge eating and 56% reduction in vomiting - TCAs - topiramate (topamax - antiepileptic) reduced binge eating by 94% and average wt loss of 6.2 kg - ondansetron (zofran) 24 mg/day for nausea ***better outcome with tx than anorexia

Question 29

Tx of binge eating disorder?

Answer 29

- CBT | - pharmacotherapy

Question 30

What is the female athlete triad? Who is at risk?

Answer 30

- eating disorders - stress fractures - amenorrhea - at risk: appearance related sports high performance sports

Question 31

What to look for if suspecting female athlete triad?

Answer 31

- wt - HR of 40-50 - hypotension - parotid swelling - poor dentition - overuse injuries, especially stress fractures

Question 32

Tx of the female athlete triad?

Answer 32

tx: multidisciplinary effort - estrogen replacement: 3 yrs post menarche and older than 16 or if hx of stress fracture - decrease energy expenditure - nutritional consultation - Ca and Vitamin D - psychological counseling - avoid NSAIDs