Firdous Inderyas Ross University Pediatrics Core

Eating disorders are syndromes characterized by severe

disturbances in eating behavior and by distress or excessive concern about body shape or weight. These disorders may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Though primarily thought of as affecting females (an estimated 510 million being affected in the U.S.), eating disorders affect males as well (an estimated 1 million U.S. males being affected) Although eating disorders are increasing all over the world among both men and women, there is evidence to suggest that it is women in the Western world who are at the highest risk of developing them and the degree of westernization increases the risk.

Cultural Facts
Our culture is obsessed with weight loss
Our cultures obsession to achieve lower weight conveys

an unavoidable message to maturing adolescents. According to Youth Risk Behavior Survey 35% of adolescent females thought they were overweight. 60% were attempting to lose weight.

Epidemiology
Trends in the epidemiology of eating disorders are difficult to

assess: a. Changes in diagnostic criteria overtime b. Detection by self report may not be reliable because it is a disease of secrecy and denial. Most studies report increased prevalence over the past 50 years. Lifetime prevalence of anorexia in women is 0.3- 1.0%. National Comorbidity Replication Survey indicate a lifetime prevalence of 0.3% in men. The estimated lifetime prevalence of bulimia nervosa is 1-3%. ED-NOS occurs in approximately 3 to 5 percent of women between the ages of 15 and 30 in Western countries.

Classification

According to Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR1) major eating disorders can be classified as: a. Anorexia nervosa -Restricting Type -Binge-eating/purging b. Bulimia nervosa c. Eating disorder not otherwise specified

Many patients demonstrate a mixture of both anorexia and bulimia. Up to 50% of patients with anorexia nervosa develop bulimic symptoms, and a smaller percentage of patients who are initially bulimic develop anorexic symptoms

Anorexia Nervosa
Diagnostic Criteria
DSM-IV-TR criteria for anorexia nervosa include:
o Refusal to maintain body weight at or above a minimally

normal weight for age and height. o Weight loss leading to maintenance of body weight <85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected. o BMI (ratio of weight in kg divided by height in m2) 17.5
o Intense fear of gaining weight or becoming fat despite

being underweight.
o Distorted perception of body weight and shape.
o Amenorrhea (at least three consecutive cycles) in

postmenarchal girls and women.

Anorexia pictures

Psychological and behavioral features

Relentless pursuit of thinness Obsessional preoccupation with food (eg, collecting recipes or hoarding food) Fear of certain foods Restricted repertoire of foods Preference for low calorie foods (low energy density) Overestimating number of calories consumed Overusing condiments and/or artificially sweetened products Food-related rituals (eg, cutting food into small pieces or refusing to mix different types or colors of food on the plate) Concerns about eating in public Social withdrawal Exercise-related rituals (eg, walking or running a set distance each day; swimming a specified number of laps in a pool) Restlessness or hyperactivity Limited insight into or denial of core clinical features Resistance to treatment and weight gain Inhibited expression of emotions Feelings of ineffectiveness Inflexible thinking Perfectionism Need to control ones environment Behavioral rigidity (eg, purchasing food only in certain stores or from certain salespeople, inability to accommodate to changes in schedule or environment).

Subtypes of Anorexia Nervosa

Restrictive Subtype:

The restricting subtype is characterized by dieting or excessive exercise, and the absence of regular binge-eating or purging during the current episode of anorexia nervosa. is characterized by episodes of binge-eating or purging at least once per week.

The binge-eating/purging subtype:

Pathogenesis
There is no consensus regarding the causes of eating disorders.
A combination of genetic, biological, psychological, family, environmental,

and social factors probably contribute to developing an eating disorder. A role for genetics in the pathogenesis of eating disorders is supported by studies that found that young women whose first degree relatives have eating disorders were at a six- to ten-fold increased risk for developing an eating disorder . Monozygotic twins have a higher rate of concordance for eating disorders compared with dizygotic twins. Linkage analysis studies have found a susceptibility locus for bulimia nervosa on chromosome 10p and for anorexia nervosa on chromosome 1p. Family distress of any kind can be a significant factor in the development of an eating disorder.

Pathogenesis
Prior Psychiatric history or family history of psychiatric disorders may

predispose a patient to eating disorders. Adult women with eating disorders appear to have had higher rates of obsessive-compulsive personality traits in childhood. Role of the central nervous system: Neurotransmitters may have a role in the pathogenesis of anorexia nervosa. Serotonin plays a role in the brain's appetite and satiety centers and may account for some neuropsychiatric changes and loss of appetite. Studies have demonstrated that Stimulation of serotonin (5-HT4) receptors in the brain reward center of mice reduced their eating drive; these receptors also mediate the anorectic effect of the "club drug" ecstasy in mice, suggesting a possible path for the addictive aspect of anorexia nervosa.

Screening tools
A number of instruments have been developed to identify

patients with eating disorders. Two shorter instruments include:

SCOFF Questionnaire Eating disorder screen for primary care ( ESP)

SCOFF Questionnaire
Do you make yourself Sick because you feel

uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (14 pounds or 6.35 kg) in a three month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life?

The Eating disorder Screen for Primary care (ESP)

Are you satisfied with your eating patterns? (No is

abnormal) Do you ever eat in secret? (Yes is abnormal) Does your weight 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)

Medical Evaluation
The evaluation should include a history, physical examination, and laboratory testing. All patients should be evaluated for complications. Complications are secondary to caloric restriction and weight loss in anorexia nervosa and persistent purging.

Complication of Anorexia Nervosa

The medical complications of anorexia nervosa (AN) are a

direct result of weight loss and malnutrition and include:

a. Cardiovascular:
1- Structural changes include decreased cardiac mass, reduced cardiac
chamber volumes, and mitral valve prolapse 2- Functional changes include bradycardia, hypotension, QT dispersion, and diminished heart rate variability, and the long QT syndrome.

b-Gynecological and Reproductive:

1-Secretion of gonadotropin releasing hormone is reduced, which ultimately prevents ovulation and causes a functional hypothalamic amenorrhea.

Complication of Anorexia Nervosa

Endocrine:
Patients with anorexia nervosa (AN) have abnormal levels of several hormones,
including low levels of gonadotropin releasing hormone (GnRH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), insulin-like growth factor 1 (IGF-1), free testosterone, triiodothyronine (T3), thyroxine (T4), leptin, and antidiuretic hormone (ADH).In addition, there are increased levels of growth hormone and cortisol.

Osteoporosis:
At least 30 percent of female patients with AN have osteoporosis, which
increases their risk of fractures.

Gastrointestinal:
Anorexia nervosa (AN) consistently causes gastroparesis (delayed emptying of

the stomach) and constipation , and there may be mild elevation of liver function tests . Acute pancreatitis in patients with AN has been described in case reports . In addition, the superior mesenteric artery syndrome is a rare complication

Complication of Anorexia Nervosa

RENAL AND ELECTROLYTES:
Patients with AN may demonstrate a reduced glomerular filtration rate

and problems concentrating their urine, which leads to diuresis and dehydration . Patients with restricting AN typically present with low creatinine due to reduced muscle mass.

PULMONARY:
AN can lead to weakness and wasting of respiratory muscles, dyspnea,

reduced aerobic capacity, and decreased pulmonary capacity . Respiratory muscle weakness and diaphragmatic functioning may be slow to recover after refeeding. An overview of dyspnea and other causes and diagnosis of bilateral and unilateral diaphragmatic paralysis

HEMATOLOGIC:
Cytopenias and bone marrow changes are observed in AN, and are all

reversible with nutritional rehabilitation

Changes in CNS
MRI studies have shown brain changes in patients with

anorexia nervosa, including decreased volumes in the gray and white matter with increased CSF volume. Another report found that the grey matter volumes did not entirely normalize and cerebrospinal fluid volume remained significantly increased compared with controls after weight recovery. In comparison, white matter did not significantly differ from controls after weight recovery. The significance of these findings is unclear.

Complication of Anorexia Nervosa

DERMATOLOGIC:

Xerosis (dry, scaly skin) Lanugo-like body hair (fine, downy, dark hair) Telogen effluvium (hair loss) Carotenoderma (yellowing) Acne Hyperpigmentation Seborrheic dermatitis (erythema and greasy scales) Acrocyanosis (cold, blue, and occasionally sweaty hands or feet) Perniosis (painful or pruritic erythema) Petechiae Livedo reticularis (reddish-cyanotic circular patches) Paronychia (inflamed lateral and posterior nail folds) Pruritus Striae distensae (erythematous or hypopigmented linear patches) Slower wound healing

Specific Complications in Adolescents

Growth retardation
Pubertal delay or arrest Reduction of peak bone mass

Treatment of Anorexia Nervosa

Treatment of Anorexia Nervosa involves: Nutritional rehabilitation Medical Monitoring Psychological treatment

Cognitive behavioral therapy Family therapy Specialist supportive clinical management

The most accepted treatment for eating disorders involves an

interdisciplinary team approach, involving a medical provider, dietitian (with experience in treating eating disorders), and a mental health professional.

Nutritional Therapy:
The American Psychiatric Association (APC) recommends that an individualized nutritional rehabilitation program should be established for each patient with Anorexia Nervosa.
Expected rates of controlled weight gain are 2-3 pounds / week for inpatient and 0.5 -1 pound for outpatients. Intakes levels usually begin at 30-40 kcal/kg and advanced progressively.

Psychotherapy
Cognitive-behavioral therapy: CBT emphasizes the

relationship of thoughts and feelings to behavior and helps patients learn to recognize the thoughts and feelings that lead to disordered eating. The evidence for the efficacy of CBT for anorexia nervosa is more limited. Family therapy has been shown to be beneficial for adolescents with anorexia nervosa.

Pharmacotherapy
Pharmacotherapy is not an initial or primary treatment for anorexia nervosa. Adjunctive pharmacotherapy is indicated for acutely ill patients who do not

gain weight despite initial treatment with nutritional rehabilitation and psychotherapy. Commonly used Pharmacologic agents include:
Olanzapine

Weight restoration may be accelerated with adjunctive olanzapine. A dose of 2.5 to 10 mg /day may help restore weight Antidepresants: Adjunctive antidepressants do not help restore weight in patients with anorexia nervosa

Eating disorder psychopathology about body image and food generally

does not respond to first or second generation antipsychotics, or to antidepressants. Although improvement has been described in openlabel studies and case reports, randomized trials have found no clear benefit

Pharmacotherapy
Comorbid psychopathology Depressive disorders and

anxiety disorders, including obsessive-compulsive disorder, are common in anorexia nervosa. Randomized trials show that adjunctive pharmacotherapy, eg antidepressants, do not relieve comorbid depression or anxiety

Criteria for Hospitalization

The Society for Adolescent Medicine (SAM) has published guidelines for hospitalization of adolescents with eating disorders; one or more of the following justify hospitalization Severe malnutrition (weight less than 75 percent of average body weight for age, sex, and height) Dehydration Electrolyte disturbances (hypokalemia, hyponatremia, hypophosphatemia) Cardiac dysrhythmia Physiologic instability severe bradycardia (heart rate <50 beats per minute during the day or <45 at night) hypotension (blood pressure <80/50 mmHg) hypothermia (<96F) orthostatic changes in pulse (>20 beats per minute) or blood pressure (>10 mmHg) Arrested growth and development Failure of outpatient treatment Acute food refusal Uncontrollable binging and purging Acute medical complication of malnutrition (eg, syncope, seizures, cardiac failure, pancreatitis) Acute psychiatric emergencies (eg, suicidal ideation, acute psychosis) Comorbid diagnosis that interferes with the treatment of eating disorders (eg, severe depression, obsessive compulsive disorder, concurrent substance abuse, severe family dysfunctio

Bulimia Nervosa
DSM-IV-TR Criteria
A DSM-IV-TR diagnosis of bulimia nervosa requires all of the

following criteria:
Recurrent episodes of binge eating, defined as eating an unusually large

amount of food in a discrete period of time (eg, two hours). Patients feel they cannot control their eating during the episode. Recurrent inappropriate compensatory behavior to prevent weight gain Binge eating and inappropriate compensatory behaviors occur at least two times per week for three months The patients self-evaluation is unduly influenced by body shape and weight The disturbance does not occur exclusively during an episode of anorexia nervosa

Bulimia Nervosa
Common physical signs include: Hypotension Tachycardia Dry skin Menstrual irregularities Eroded dental enamel Hypertrophy of parotid glands ( puffy cheeks)

Anorexia vs. Bulimia

Anorexia Nervosa
Patients are underweight (

Bulimia Nervosa
Patients are of normal wt. or

less than 85% of normal wt.) Disturbed body image. Use extensive measures to avoid weight gain. Binge eating. Patients are typically not distressed by their illness. Resist treatment

overweight Same
Same Patients are distressed about

symptoms and are easier to treat.

COMORBID PSYCHOPATHOLOGY
Patients with bulimia nervosa are often suicidal, and usually have a lifetime

history of other psychiatric disorders. There is general agreement that patients with bulimia nervosa usually suffer from comorbid axis I pathology, including :
Anxiety disorders

Mood disorders
Substance use disorders

Comorbid personality disorders and traits are usually present in bulimia

nervosa.
Borderline (21 percent of patients with bulimia nervosa)

Avoidant (19 percent)

Dependent (10 percent) Paranoid (10 percent) Histrionic (9 percent) Obsessive-compulsive (9 percent)

Treatment of Bulimia Nervosa

Treatment of Bulimia Nervosa involves: Nutritional rehabilitation Medical Monitoring Psychotherapy Pharmacotherapy Pharmacotherapy: Randomized trials have demonstrated that a number of drugs are efficacious for treating BN. Fluoxitine (SSRI) is the first line treatment. (60mg/day). To enhance adherence inform the patient of side effects.

Eating disorder not otherwise specified

Eating disorder not otherwise specified includes disorders of eating that do not meet the criteria for any specific eating disorder. For female patients, all of the criteria for anorexia nervosa are met except that the patient has regular menses. All of the criteria for anorexia nervosa are met except that, despite significant weight loss, the patient's current weight is in the normal range. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur less than twice a week or for less than 3 months. The patient has normal body weight and regularly uses inappropriate compensatory behavior after eating small amounts of food (e.g., self-induced vomiting after consuming two cookies). Repeatedly chewing and spitting out, but not swallowing, large amounts of food. Binge-eating disorder is recurrent episodes of binge eating in the absence if regular inappropriate compensatory behavior characteristic of bulimia nervosa.

Resources
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