© copyright annals of internal medicine, 2012 ann int med. 156 (7): itc4-1. terms of use the in...

© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (7): ITC4-1.

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in the clinic

Eating Disorders


Who is at risk for an eating disorder?

Females

Particularly adolescent, young adult

Participants in activities that emphasize low weight

Dancing, modeling, certain sports

Patients with family history of eating disorders


How should a patient be screened for an eating disorder?

Screen all patients in high-risk groups…

Ask about eating practices and weight concerns

Beware patients often deny or underreport symptoms

Use SCOFF Questionnaire

BMI <18.5 kg/m2: ? anorexia nervosa

High BMI + weight fluctuations: ? binge eating

In children and adolescents, use percentiles to follow status (normal BMI ranges vary)


Can eating disorders be prevented?

Screening can identify early symptoms

Early identification = better outcomes

Even in individuals not yet meeting full criteria:

Aim to reverse early signs

Emphasize normal weight and eating


CLINICAL BOTTOM LINE: Screening and Prevention…

Systematically screen: as part of general health assessment

High risk groups

Adolescents and young adult females

Individuals with family history

Athletes, models, dancers

Early recognition and treatment improve outcomes


What are the major categories of eating disorders?

Anorexia nervosa

Weight < minimum normal range for age and height

Bulimia nervosa

Binge eating + inappropriate compensatory behaviors

(self-induced vomiting, laxative misuse, diuretics, enemas)

Binge eating disorder (BED)

Eating lots of food during brief period

Sense of loss of control and marked distress


What signs or symptoms should alert the clinician to a possible eating disorder?

Anorexia nervosa Weight loss

Hypometabolism (bradycardia, hypotension, hypothermia)

If underweight: amenorrhea, stress fractures, hair loss, fine lanugo hair

Bulimia nervosa Dental erosion or excess cavities

Prominent or inflamed parotid glands

Calluses or abrasions on hand

Dehydration, electrolyte imbalances

BED Overweight or obese and distressed over binging


What features should be evaluated in the physical exam of a patient with a possible eating disorder?

Height and weight

Heart rate, blood pressure, and temperature

Heart sounds

Flow murmurs consistent with mitral valve insufficiency sometimes seen in anorexia

Skin

Dry, scaly; lanugo; poor turgor; thinning hair; brittle nails

Head and neck

Note appearance of salivary glands and general dentition


What other problems should be considered in the evaluation of a patient with a possible eating disorder? Other causes for weight loss

Chronic infections

Intestinal disorders with malabsorption

Endocrinopathies

Cancer

Psychiatric illness

Other causes of vomiting or diarrhea

Eating disorders differentiated by…

an extreme fear of becoming fat

and a relentless pursuit of thinness


Are there other conditions that are associated with eating disorders?

Depression

Common with all types of eating disorders

High suicide rate in anorexia nervosa

Anxiety disorders (OCD specifically)

Associated with anorexia nervosa

Substance abuse disorders

More common among individuals who binge or purge


How is anorexia nervosa diagnosed?

No objective “test” confirms presence (and affected individuals may obfuscate symptoms)

Refusal to maintain body weight at or above minimally normal weight

Intense fear of gaining weight or becoming fat

Disturbance in perception of body weight or shape

Undue influence to body weight and shape

Denial of seriousness of current low body weight

Amenorrhea (absence ≥3 consecutive menstrual cycles)


How is bulimia nervosa diagnosed?

Recurrent episodes of binge eating

Recurrent compensatory behavior to prevent weight gain

Self-induced vomiting; misuse of laxatives

Diuretics, enemas, fasting

Excessive exercise

Undue influence to body weight and shape

Disturbance not only during episodes of anorexia nervosa


How is BED diagnosed?

Regular episodes of binge eating

At least weekly for 3 months

Associated with distress and sense of lack of control

Not accompanied by compensatory behaviors aimed at weight loss


What tests are used in evaluating a patient with an eating disorder?

Electrocardiography Arrhythmias ? electrolyte disturbances

Complete laboratory assessment

Hypokalemia ? purging

Hyponatremia or hyperchloremia ? excessive water intake

Hypophosphatemia, hypomagnesemia; hypoalbuminemia, elevated liver enzymes; leucopenia, anemia if underweight

Radiography or endoscopy If clinical presentation unusual ? bulimia nervosa


When should a consultation be sought to aid in the diagnosis of an eating disorder?

When eating disorder suspected but not confirmed

When comorbid conditions or atypical features present

Consult:

Adolescent medicine specialist, pediatrician

Endocrinologist

Psychologist / psychiatrist with expertise in this area


CLINICAL BOTTOM LINE: Diagnosis…

Anorexia nervosa Weight loss, hypometabolism, amenorrhea, stress fractures,

hair loss, lanugo hair, arrhythmias Underweight but fearful of gaining

Bulimia nervosa Dehydration, electrolyte imbalances, dental erosion,

prominent parotid glands, abrasions on hand Binge eating + inappropriate compensatory behaviors

BED Likely overweight or obese and distressed over binging

Affected individuals commonly obfuscate symptoms Associated conditions: depression, anxiety, substance abuse


When do patients with eating disorders require hospitalization?

Medical or psychiatric instability manifests

Less-invasive attempts at refeeding fail

Need to interrupt use of laxatives, diuretics, enemas or diet pills


What is the therapy for an eating disorder?

Cognitive-behavioral therapy

Challenges distorted thoughts contributing to aberrant habits

Decreases undue concern about body shape and weight

Replaces dysfunctional dieting with normal eating habits

Interpersonal therapy

Targets interpersonal problems contributing to disorder

Family-based treatment

Aids nutritional rehabilitation & recovery

Empowers parents to refeed their underweight child


Are there useful principles to guide treatment of patients with this illness?

Nutritional rehabilitation: central to anorexia nervosa treatment

Weight restoration is essential

Emphasize normalizing weight and eating behaviors

Behavioral management reinforces healthy behaviors


Is there a role for pharmacologic interventions?

Antidepressants

If CBT alone not enough or significant depression present

Decreases binge-purge behaviors, regardless of depression

Fluoxetine: FDA-indicated for bulimia nervosa

Tricyclics, MAOIs, SSRIs: better than placebo

Topiramate

Antiseizure mood-stabilizer

May aid treatment of bulimia nervosa

Use caution due to risk for weight loss


When should consultation be sought to assist in treatment of an eating disorder?

When the disorder is identified

Mental health provider with expertise in eating disorders

For bulimia nervosa or BED: CBT

For children or adolescents anorexia nervosa: FBT

For anorexia nervosa: Nutritional rehabilitation

Multidisciplinary clinical treatment team, including an experienced nutritionist


What is the prognosis for a patient with an eating disorder?

The course of eating disorders varies

Mortality rates are elevated for all with eating disorders

Highest rate with anorexia nervosa (≈5%)

Early intervention may improve clinical outcomes

BED: tend to have long Hx of intermittent binge eating


What is the appropriate follow-up for patients with an eating disorder?

Regularly monitor weight and other vital signs

Regularly check for medical complications

Provide ongoing treatment & support to prevent relapse


What should patients be taught about their eating disorder?

Risk for medical complications from eating disorders

Association between eating disorders and mood, anxiety, and substance use disorders

Information on the basics of healthy eating and exercise


CLINICAL BOTTOM LINE: Treatment… Anorexia nervosa

Focus on nutritional rehabilitation and weight restoration

Recommend FBT for younger patients

Hospitalization may be needed if no response as outpatient

Bulimia nervosa and BED Focus on CBT, IPT, or self-help based on CBT principles

Consider adding antidepressants to treatment plan

Monitor weight and symptoms regularly

Relapse may occur after short-term resolution

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