Eating Disorders

Eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorders.

  1. Epidemilogy
    1. Female to male ratio of 10:1
    2. 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.
    3. The highest incidence is in industrialized countries and the higher socio-economic groups. 
    4. 50% will fully recover and 20% never improve
    5. The mortality rate in patients with eating disorders is 12x that in the general population.
  2. Etiology
    1. Combination of genetics, sociocultural, and neurochemical factors. 
    2. Preexisting psychiatric traits include dependency, isolation, and developmental immaturity.
  3. Common Clinical Manifestations
    1. Cardiac arrythmias, CHF, hypotension, and bradycardia
    2. Sleep disturbances
    3. Hypothermia
    4. Irregular menses, amenorrhea, infertility, oligomenorrhea
    5. Constipation and rectal prolapse
    6. Bone marrow suppression with pancytopenia.
    7. Poor growth
    8. Electrolyte disturbances secondary to vomiting, use of laxatives, and diuretics, and excessive water intake. 
    9. Hair loss, lanugo hair development, dry skin, abrasions on the hands secondary to inducing vomiting. 
    10. Decrease bone density with resultant increase number of fractures.
  4. Behavioral Changes
    1. Decrease eating in public
    2. Reluctant to be weighed
    3. Acts withdrawn
    4. Missing school and work
    5. Increased exercise
    6. Substance abuse
  5. Diagnostic and Statistical Manual of Mental Disorders Definition of :
    1. Anorexia nervosa
      1. < 85% ideal body weight or BMI of < 17.5
      2. Intense fear of weight gain
      3. Perception of body unrealistic. "Feels fat"
      4. Denial of hunger
      5. Amenorrhea
      6. High academic success and over-achievers. 
      7. Intense amount of exercise
    2. Bulimia
      1. 2x/week for 3 months 
      2. Eat very rapidly and unable to control eating and stop
      3. Purging (vomiting, use of ipecac, diuretics, laxatives, enemas, caffeine, and other uppers)
      4. Increase exercise to counteract binges
  6. Assessment
    1. Monitor growth and weight changes. May have frequent fluctuation of weight. Has there been an arrest of pubertal development.
    2. Menstrual history, exercise history 
    3. Are there an increase number of fractures?
    4. Electrolyte levels and CBC
    5. Complete physical examination.
    6. Psychiatric assessment for suicide, depression, and obsessive compulsive traits
  7. Differential Diagnosis
    1. Hyperthyroidism
    2. Chronic disease- diabetes mellitus and inflammatory bowel disease
    3. Malignancy
  8. Treatment
    1. Discuss problem with the patient and their family
    2. Encourage improving nutritional status but may need to use enteral or parenteral means
    3. Should refer to medical and psychiatric specialist in eating disorders
    4. Pharmocotherapy often used but should obtain an ECG prior to instituting therapy because of the risk of arrythmias with some drugs. 
    5. Often require inpatient management.
Reference
  1. Becker, Anne E., Grinspoon, Steven, Klibanski, Anne, and Herzog, David.Eating Disorders. New England Journal of Medicine. April 8, 1999.
  2. Kreipe RE and Dukarm CP. Eating Disorders in Adolescents and Older Children. Pediatrics in Review. 1999; 20:410-421.
  3. Rome E. et al. Children and Adolescents with Eating Disorders: The State of the Art. Pediatrics Vol 111 e-98 January 2003
  4. Mehler P.S. Bulimia Nervosa. NEJM Vol 349 No. 9 Page 875
  5. Rome E , Ammerman S. Medical Complications of Eating Disorders: An Update. Journal of Adolescent Health 2003;33:418-426
  6. Golden N et al. Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine. Journal of Adolescent Health. 2003;33:496-503
  7. Yager J, Andersen E. Anorexia Nervosa. NEJM 353;14 pg 1481 October 6, 2005
  8. Lawrence L Perrin E. Benjamin J.  The challenges of managing eating disorders in your office. Contemporary Pediatircs January 2006
  9. Nichols et al. Prevalence of the Female Athlete Triad Syndrome Among High School Athletes. Arch Pediatr Adolesc Med Vol 160 Feb 2006
  10. Fisher M Treatment of Eating Disordeers in Adolescents and Young Children. Pediatrics in Review January 2006
  11. American Academy of Pediatrics. Identifying and Treating Eating Disorders Jan 2003