Karen-Rose WilsonAcademic Half Day- Thursday August 30 2012Preceptor: Dr. Jorge Pinzon

Approach to Eating Disorders

Outline of presentation

DemographicsDiagnosisDifferential diagnosisScreening for eating disordersInitial evaluationPhysical examination findingsMedical complicationsTreatmentPrognosis

Demographics

Incidence rates steadily increasing Prevalence of anorexia nervosa in adolescent girls = 0.5% Prevalence of bulimia nervosa in adolescent girls = 1-3%

Large number of children with eating disorders do not meet DSM-IV criteria- prevalence of ED-NOS= 0.8%-14%

Epidemiology has gradually changed increasing prevalence in: Males- 5-10% of all cases of eating disorders Minority populations In children 8-14 years old

Anorexia nervosa has highest fatality rate of any mental health disorder- mortality rate ~5% (Steinhausen, 2009)

Eating disorders

Anorexia nervosa (AN)Bulimia nervosa (BN)Eating disorder not otherwise specified (ED-

NOS)Appetite loss secondary to depressionFood avoidance emotional disorderSelective eating

Diagnosis

What are the DSV- IV criteria for anorexia nervosa?

Diagnosis- Anorexia Nervosa

Diagnosis- Anorexia Nervosa

Ideal body weight calculation:Square of height in metres x 50th percentile BMI for age and

sex

For example, the ideal weight of a 14 year old female who is 1.626 m in height is calculated as follows:

(1.626m)2 x 19.4kg/m2 = 1.626 x 1.626 x 19.4= 51.3 kg

Diagnosis- Anorexia Nervosa

What are the subtypes?

Diagnosis- Anorexia Nervosa

Subtypes:1.Restricting type: no regular bingeing or

purging (self-induced vomiting or use of laxatives and diuretics)

2.Binge eating/ purging type: regular bingeing or purging behaviour

Diagnosis

What are the DSM-IV criteria for bulimia nervosa (BN)?

Diagnosis- Bulimia Nervosa (BN)

Diagnosis- Bulimia Nervosa

What are the subtypes?

Diagnosis- Bulimia Nervosa

Subtypes:1.Purging type: the person has regularly

engaged in self-induced vomiting or misuse of laxatives, diuretics, or enemas

2.Nonpurging type: the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Diagnosis- ED NOS

Disorders of eating that do not meet criteria for either AN or BN; examples include: Patients that have not yet missed three menstrual cycles Not quite 15% below IBW All criteria for AN are met except that despite significant

weight loss, weight remains in normal range All criteria for BN are met except that binge-eating &

inappropriate compensatory behaviours occur less frequently than twice per week or <3 months duration

Children 8-12 years old who eating disorder behaviours are not driven by a specific fear of gaining weight

Outline of presentation

DemographicsDiagnosisDifferential diagnosisScreening for eating disordersPhysical examination findingsMedical complicationsInitial evaluationTreatmentRefeeding SyndromeOutcomes

Differential Diagnosis

Conditions that may cause weight loss with or without amenorrhea?

Differential Diagnosis

Screening for eating disorders

16 year old who initially was underweight has been dieting and lost 20 lbs in the last 3 months….

14 year old boy has been exercising 3 hours a day and eliminated all fat from his diet to “increase my muscle mass and decrease my fat”...

11 year old girl has grown 2 inches but has gained no weight since her last check-up 1 year ago…

15 year old girl is found to have empty boxes of laxatives hidden under her bed but denies they are hers…

Screening for eating disorders

Suspicious behaviour? Assumption of a vegetarian, vegan, low fat or

“healthier” diet Scrutiny of ingredient lists Initiation of precise calorie counting Weighing one’s self several times a day Mealtime behaviours- smaller portions, longer time to

eat, hiding food Difficulty eating in social settings Avoiding eating with family and friends Frequent trips to the bathroom after meals Dressing with extra layers of clothing to cover up

signs of emaciation

Screening for eating disorders

The SCOFF Questionnaire: Do you make yourself Sick because you feel uncomfortably full? Do you worry that you have lost Control over how much you eat? In any recent 3-month period, have you lost Over 6.5 Kg or 15 lbs? Do you believe yourself to be Fat when others say you are thin? Would you say that Food dominates your life?

One point for every “yes” answer; a score of ≥2 indicates a likelihood for AN or BN.

The BMJ Publishing group, Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319(7223):467-8.

Initial Evaluation

History- child/adolescent, collateral hxPhysical examinationInitial investigations

Initial Evaluation- history

Questions for children/adolescents with a possible eating disorder?

Initial Evaluation- History

Initial Evaluation- Review of systems/ Physical examination

Break for 5-10 minutes to brainstorm physical exam findings and medical complications of eating disorders

Initial Evaluation- Review of systems/ Physical examination

Multisystem disorder: Fluids & Electrolytes Metabolic Cardiovascular Pulmonary Gastrointestinal Renal Endocrine Hematologic Immunologic Neurologic Dermatologic

Physical findings & medical complications

System Anorexia Bulimia

General Cachexia, facial wastingHypothermiaEdema

Normal weight

Dermatologic

Dry, sallow skin; lanugoDull, thinning scalp hair, alopeciaCold extremities; acrocyanosis; poor perfusionCarotenemia (orange discoloration of skin, particularly palms, soles)Cheilosis

Periorbital petechiaRussel sign (calluses over PIP joints of hands)

Orofacial Halitosis Injury to palate and posterior pharynxDental caries, enamel erosionParotid gland enlargement, Submandibular adenopathy

Physical findings & medical complications

System Anorexia Bulimia

Cardiac Palpitations, chest pain, shortness of breath, exercise intoleranceSinus bradycardiaOrthostatic changes in pulse or blood pressureArrhythmiaProlonged QT intervalMurmur- 1/3 with mitral valve prolapsePericardial effusions

Arrythmia, orthostasisIrreversible cardiomyopathy and myositis (ipecac toxicity)

Pulmonary Pneumothorax or aspiration secondary to vomiting, pulmonary edema during refeeding

Pneumothorax or aspiration secondary to vomiting

Physical findings & medical complications

System

Anorexia Bulimia

GI Palpable stool secondary to constipationScaphoid abdomenDelayed gastric emptying and impaired GI tract motiltiyBloating: postprandial fullnessTransaminitisFatty degeneration of the liverSuperior Mesenteric artery syndrome

Abdominal fullness, gastric dilatation

Vomiting related:•Hypocholoremic metabolic alkalosis•Esophagitis•Gastroesophageal reflux•Mallory-Weiss tears•Esophageal or gastric rupture (rare)

Laxative related:•Hyperchloremic metabolic alkalosis•Hyperuricemia•Hypocalcemia•Fluid retention (may gain up to 10lbs in 24 hrs) with laxative withdrawal

Physical findings & medical complications

System Anorexia

Breasts & GU

Breast atrophy, atrophic vaginitis and atrophy of the female genitalia

Bone FracturesLow bone mineral density- osteopenia, osteoporosis

Endocrine & metabolic

Amenorrhea (1o or 2o) and menstrual irregularities- hypogonadotrophic hypogonadism with estrogen deficiencyDelayed puberty, reduced beard growth in malesArrested growthEuthyroid sick syndrome- T4/ TSH low-normal range, decrease conversion of reverse T3 to T3HypercortisolismWeakness- loss of muscle mass

Physical findings & medical complications

System Anorexia Bulimia

FEN Usually normalDehydrationHyponatremia/ hypernatremiaHypophosphatemiaEdema

HypochloremiaHypokalemiaMetabolic AlkalosisDehydrationHyponatremia

Neurological and mental status

Neurocognitive deficitDiminished muscle strengthPeripheral neuropathyMovement disorderSeizures- hyponatremia Suicidal ideation, comorbid psychiatric disorders

Suicidal ideation, comorbid psychiatric disorders

Initial work up

What initial investigations would you complete?

Initial work up

Plot height and weight on growth chart, assess trend

Calculate ideal body weight/ BMICBCElectrolytes, extended lytesLiver enzymes/ function testsUrea/ CreatinineThyroid function tests (TSH, T4)LH/ FSH/ estradiol/prolactinECGBone density studies- DEXA in those patients who

have amenorrhea ≥ 6-12 monthsVitamin studies generally not ordered

Treatment Continuum

Most patients will be treated as an outpatient collaborative outpatient care by a multidisciplinary team

Medical stabilization and nutritional rehabilitation are essential for correcting cognitive deficits to allow for effective mental health interventions

Oral refeeding preferred modality- but may need supplements/ NG feeding

Treatment -Nutritional rehabilitation

Refeeding syndrome: rapid refeeding of patients who are severely malnourished (hospitalized, more than 30-35% below IBW) can lead to: Shifts of phosphate from extracellular to intracellular

spaces in the setting of total body phosphorus depletion

Hypophosphatemia- can result in major complications such as cardiac failure, stupor, coma…

Cautious refeeding, monitoring electrolytes, low threshold for phosphorus supplementation

Unusual after first 2 weeks of treatment

Treatment Continuum

Collaborative outpatient careFamily-based (“Maudsley”) therapyDay-treatment programsHospital-based treatmentPharmacotherapy

Treatment Continuum

Family-based (“Maudsley”) therapy Work originally performed at Maudsley Hospital in

London 3 phases:

1. Parents supported by therapist take responsibility to make sure adolescent is eating adequately and limiting pathologic weight control behaviours

2. Substantial weight recovery has occurred, and the adolescent is helped to gradually resume responsibility for own eating

3. Weight restored, therapy shifts to address the more general issues of adolescent

Treatment Continuum

Day-treatment Programs Intermediate level of care for patients who require

more than outpatient care but less than 24 hour hospital care

Prevent need for hospitalization, “step down” from inpatient to outpatient

Typically involves 8-10hrs of care (including meals, therapy, groups, other activities) by a multidisciplinary staff 5 days/week

Treatment Continuum

Hospital-based Treatment

Criteria?

Treatment Continuum

Treatment Continuum

Pharmacotherapy- Anorexia Nervosa: No medication has been approved by FDA for treatment of AN. If prescribed typically targeted at comorbid symptoms of

anxiety and depression. SSRIs most often used but may not be effective in severely

malnourished patients. In recent case reports and open label trials- olanzapine shown

to improve weight gain & dysfunctional thinking in patients with AN. Further evaluation needed.

Hormonal supplementation although capable of restoring menstruation has not been shown to improve bone mineral density

American Academy of Pediatrics. Clinical Report- Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126 (6): 1240-1251

Treatment Continuum

Pharmacotherapy- Bulimia Nervosa: Fluoxetine approved by FDA Other SSRIs, SNRIs and TCAs have been shown to

decrease binge-eating and purging in BN Topiramate has been shown to significantly decrease

binge-eating

American Academy of Pediatrics. Clinical Report- Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126 (6): 1240-1251

Prognosis

Prognosis varies widely in the literatureIn AN: approximately 50% of patients do well

overtime, 30% do reasonable well and 20% do poorly

High rates of residual psychiatric disorders even after full recovery from AN

Mortality rates for AN- 5-10% due to medical complications or suicide

Thanks!

References:1. American Academy of Pediatrics. Clinical Report-

Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126 (6): 1240-1251

2. American Academy of Pediatrics. Committee on Adolescence. Identifying and treating eating disorders. Pediatrics. 2003;111: 204–211

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994

4. The BMJ Publishing group, Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319(7223):467-8.

5. Goldstein,M, Dechant, E & Beresin, E. Eating disorders. Pediatrics in Review. 2011; 32 (12) 508-520.

6. Fisher, M. Treatment of eating disorders in children, adolescents, and young adults. Pediatrics in Review. 2006; 27(1) 5-16.