Eating disorders include anorexia nervosa,
bulimia
nervosa, and binge-eating disorders.
Epidemilogy
Female to male ratio of 10:1
Occurs in 3% of females with bimodal
peak ages of 14.5
years and 18 years. There has been an increase in the incidence in
young
children and adults greater than 40.
The highest incidence is in
industrialized countries
and the higher socio-economic groups.
50% will fully recover and 20% never
improve
The mortality rate in patients with
eating disorders
is 12x that in the general population.
The mean lifetime duration of disease
is 5.9 years for anorexia, 5.8 years for bulimia, and 14.4 years for
binge-eating
Etiology
Combination of genetics,
sociocultural,
and neurochemical
factors.
Preexisting psychiatric traits
include
dependency, isolation,
and developmental immaturity.
Risk Factors
a.Childhood preoccupation with thin body image
b. History of dieting
c. Activities that emphasize lean body types
(ballet, running, wrestiling, skating, and gymnastics
i. Female
Athlete Triad: eating disordeer, amenorrhea, osteoporosis
d. Significant family distres
e. History of Sexual abuse
Common Clinical Manifestations
Cardiac arrythmias, CHF,
hypotension,
and bradycardia
Electrolyte disturbances secondary
to
vomiting, use
of laxatives, and diuretics, and excessive water intake.
Hair loss, lanugo hair development,
dry
skin, abrasions
on the hands secondary to inducing vomiting.
Decrease bone density with resultant
increase number
of fractures.
Behavioral Changes
Decrease eating in public
Reluctant to be weighed
Acts withdrawn
Missing school and work
Increased exercise
Substance abuse
Diagnostic and Statistical Manual
(DSM-IV
of
Mental Disorders
Definition of :
Anorexia nervosa
< 85% ideal body weight or BMI
of
< 17.5
Intense fear of weight gain
Perception of body unrealistic.
"Feels
fat"
Denial of hunger
Amenorrhea
High academic success and
over-achievers.
Intense amount of exercise
2 subtypes:restricting and binge
eating/purge
Bulimia
2x/week for 3 months
Eat very rapidly and unable to
control
eating and stop
Purging (vomiting, use of ipecac,
diuretics, laxatives,
enemas, caffeine, and other uppers)
Increase exercise to counteract
binges
Binge Eating
(proposed by DSM-V)
Recurrent episodes of binge eating episodes
characterized by an unusually large amount of food and sense of loss of
control
Binge-eating episodes are associaed with 3 or more of
the following
Eating more rapidly than normal
Eating until feeling uncomfortably full
Eating when not physically hungry
Eating alone because of embarrassment over amount
eating
Feelings of disgust, depression, or guilt after
overeating
Presence of marked distress ove binge eating'
Occurrence of binge eating, on average, > 1x/wk
for 3 months
Not associated with inappropriate compensatory
behavior (purging)
Assessment
Monitor growth and weight changes.
May
have frequent
fluctuation of weight. Has there been an arrest of pubertal development.
Menstrual history, exercise
history
Are there an increase number of
fractures?
Electrolyte levels and CBC
Complete physical examination.
Signs unique in bulemia: paroatid
gland hypertrophy, teeth enamel erosion, skin lesion on fingers(
Russell's sign)
Psychiatric assessment for suicide,
depression, and
obsessive compulsive traits
Differential Diagnosis
Hyperthyroidism
Chronic disease- diabetes mellitus
and
inflammatory
bowel disease
Malignancy
Treatment
Discuss problem with the patient and
their family
Encourage improving nutritional
status
but may need
to use enteral or parenteral means
Should refer to medical and
psychiatric
specialist in
eating disorders
Pharmocotherapy often used but
should
obtain an ECG
prior to instituting therapy because of the risk of arrythmias with
some
drugs.
Often require inpatient management.
Monitor for refeeding syndrome,
especially if severely underweight (<75% ideal body weight)
Malnourishment depletes
intracellular phosphate stores. Glycolysis which occurs with
refeeding can further deplet stores leading to severe hypophosphatemia
Manifestations include heart
failure, rhabdomyolysis, seizures, delirium
Hypokalemia and hypomagnesemia can
also occur
Reference
Becker, Anne E., Grinspoon, Steven,
Klibanski, Anne,
and Herzog, David.Eating
Disorders. New England Journal of Medicine. April 8, 1999.
Kreipe RE and Dukarm CP. Eating
Disorders
in Adolescents
and Older Children. Pediatrics in Review. 1999; 20:410-421.
Mehler PS Diagnosis
and Care of Patients with Anorexia Nervosa in Primary Care Settings
Ann Intern Med 134 (11): 1048-1059 Jun 2001
Ornstein, RM
et al. Hypophosphatemia During Nutritional Rehabilitation in
Anorexia Nervosa: Implications for Refeeding and Monitoring. J.
Adolescent Health 32(1):83-88 Jan 2003
Chen LP et
al. Sexual Abuse and Lifetime Diagnosis of Psychiatric Disorders:
Systematic Review and Meta-Analysis Mayo Clinic Proc 85(5) May 2010