Eating Disorders - Dayton Children`s Hospital

Eating Disorders: What the
Primary Care Provider Needs to
Know
Sonny B. Amisola, MD
Adolescent Medicine
Pediatrics
Outline
I. Definition
II. Screening
III.Types (DSM 5, et al)
IV.History and Physical Exam
V. Work-up
VI.Treatment
Definition
Feeding and eating disorder are characterized by
a persistent disturbance of eating or eatingrelated behaviors that results in the altered
consumption or absorption of food and that
significantly alters physical health and
psychosocial functioning.
Types: DSM V
A. Anorexia Nervosa (AN)
B. Bulimia Nervosa (BN)
C. Binge-Eating Disorder (BED)
D. ARFID (Avoidant/Restrictive Food Intake D/O)
E. Rumination Disorder
F. Pica
EDNOS – was removed
Types-Other Specified Feeding or Eating
Disorder, DSM 5
• Atypical Anorexia Nervosa
• Bulimia Nervosa (of low frequency and/or limited
duration)
• Binge-Eating Disorder (of low frequency and/or
limited duration)
• Purging Disorder
• Night Eating Syndrome
Types: Great Ormond Street Hospital Criteria
•Food Avoidance Emotional Disorder
•Selective Eating Disorder
•Functional Dysphagia
•Pervasive Food Refusal
Screening
Screening
Screening
Questions 47-50 deal with body image
and dieting:
•
Do you worry about your weight?
•
Are you on a special diet or do you
avoid certain types of food?
•
Are you trying to gain or lose
weight? Has anyone recommended
that you do?
•
Have you every had an eating
disorder?
Screening
Questions 52-54 deal with menstrual
issues
• Have you ever has a menstrual period?
• How old were you when you first had
your first menstrual period?
• How many periods have you had in the
last 12 months.
Screening
HEEADSSS Assessment:
Bright Futures has screening questions
for disordered eating and body image.
>Eating regular meals including adequate
fruits and veggies
> Calcium source
> Drinks non-carbonated liquids
> Has concerns about body or appearance
SCOFF Questionnaire
• Validated in adults
• One point for every
positive response
• A score of 2 indicates
likelihood of BN or AN
• 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 >1 stone(14
pounds) in a 3 month period?
• Do you believe yourself to be
FAT when others say you are too
thin?
• Would you say that food DOMINATES
your life?
Case A
• 17/F, decided to have a healthier lifestyle on year PTC.
• She started to run and diet to lose weight. While running, she
sustained a knee injury and was put on NSAIDS. She developed
epigastric pain that worsened with eating.
• She decreased her intake and her weight steadily decreased.
• She was getting praises from her friends and family about how
healthy she looked and so she continued to restrict her intake till the
point of severe malnutrition. She continues to be afraid of gaining
weight.
• She has been to several in-patient and partial hospitalization
programs in the state.
Types – Anorexia Nervosa
DSM IV-TR Classification
• Refusal to maintain body weight at or above a minimum normal weight for age
and height or failure to make expected gain during period of growth, leading to
body weight less than 85% of that expected
• Intense fear of gaining weight or becoming fat , even though underweight
• Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body shape and weight on self-evaluation, or denial of the
seriousness of the current low body weight
• In post-menarcheal females, amenorrhea for 3 months
> 2 sub-types: Restrictive and Binge/Purge
Types – Anorexia Nervosa
DSM V Classification
• Restriction of energy intake relative to requirements, leading to a significantly low
body weight in the context of age, sex, developmental trajectory and physical
health. Significantly low weight is defined as a weight that is less than minimally
normal or for children and adolescents, less than that minimally expected.
• Intense fear of gaining weight or becoming fat , even though underweight
• Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body shape and weight on self-evaluation, or denial of the
seriousness of the current low body weight
• > 2 sub-types: Restrictive and Binge/Purge
Types-Anorexia Nervosa
• Specify:
• Partial Remission: After full criteria were previously
met, Criterion A has not been met for a sustained
period of time, but Criterion B and /or C is still met.
• Full Remission: After full criteria has been met,
none of the criteria have been met for a sustained
period of time
Types-Anorexia Nervosa
•Severity:
Mild: BMI >= 17 kg/m2
Moderate: BMI 16-16.99 kg/m2
Severe: BMI 15-15.99kg/m2
Extreme: BMI <15 kg/m2
Case B:
• 16/F whose mom found out that patient was vomiting to lose weight
last week.
• Patient stated that she had always felt overweight.
• She started vomiting to lose weight 2-3 months PTC. She threw up
after she felt that she had eaten too much (regular serving of dinner)
• She then learned that she could get rid of her food by vomiting.
• She started using a toothbrush to make herself sick, but eventually
she could make herself regurgitate her food without using any tools.
Bulimia Nervosa
Types-Bulimia Nervosa
• DSM-5 Diagnostic Criteria
o Recurrent episodes of binge eating
Eating, in a discrete period of time, an amount that is definitely larger than most
individuals would eat in a similar period of time
A sense of lack of control over eating during this period
o Recurrent inappropriate compensatory behavior in order to prevent weight
gain, such as self-induced vomiting, laxative and diuretic misuse or other
medication, exercise or fasting
o Binge-eating and inappropriate compensatory behavior occurring at least
once week for 3 months
o Self-Evaluation is unduly influenced by body shape and size
o Episodes do not occur during episodes of AN
Types-Bulimia Nervosa
• Specify
• Partial Remission
• Full Remission
• Severity
•
•
•
•
Mild: 1-3 inappropriate compensatory behaviors per week
Moderate: 4-7 inappropriate compensatory behaviors per
Severe: 8-13 inappropriate compensatory behaviors per week
Extreme: >14 inappropriate compensatory behaviors per week
Binge-Eating Disorder
Types – Binge Eating Disorder
A. Recurrent episodes of binge-eating
B. Binge-eating episodes are associated with three or more of the
following:
1.
2.
3.
4.
5.
Eating much more rapidly than normal
Eating until uncomfortably full
Eating large amount of food when not feeling physically hungry
Eating alone because of feeling embarrassed by how much one is eating
Feeling disgusted with oneself, depressed or very guilty afterward
Types- Binge-Eating Disorder
C. Marked distress regarding binge eating is present
D. Binge-eating happens at least once a week for three months
E. Binge-eating is not associated with the recurrent use of
inappropriate compensatory behavior as in BN and does not occur
exclusively during the course of BN or AN.
Medical Complications
Malnutrition/Hypometabolism
Dehydration, Electrolyte disturbances
Sick euthyroid
Hypothermia, hair thinning, lanugo
Anemia, leukopenia, thrombocytopenia
Impaired Gastric Emptying Time, constipation,
post-prandial fullness, abnormal LFT’s
Cognitive and Mood Defects, Suicidality
Obsessive-Compulsive Disorders
Amenorrhea
Osteopenia/Low Bone Mineral Density
Rhythm disorders
Purging Behavior
Hypochloremic metabolic alkalosis
Esophagitis
Gastro esophageal Reflux
Dental erosions
Mallory-Weiss tears
Esophageal or Gastric Rupture
Aspiration Pneumonia
Laxative and Diuretic Abuse
Hyperchloremic Metabolic
Acidosis
Hyperuricmia
Hypocalcemia
Fluid Retention
Major Complications
•Sudden Death
•Growth Retardation, short stature
•Low Bone Mineral Density
•Structural Brain Changes
History and Physical
History and Physical Exam
• History:
•
•
•
•
•
Rate of weight loss/change
Nutritional Status
Methods of weight control
Reason
Goal Weight
• Assess Weight Control Methods
•
•
•
•
•
Compensatory Behaviors
Dietary Intake
Menstrual History
Growth and Development
Temperament and Personality Traits
History and Physical Exam
• Body Image
• HEEADDSS
• Family Concerns/Feelings
History
Symptoms of hypometabolism:
Hair growth (lanugo)
Feeling cold
Fatigue
Preoccupation with food
Physical Examination
• Vital Sign:
• Heart Rate
• Bradycardia
• Irregular Rhytm
• Respiratory Rate
• Blood Pressure
• Orthostatic Blood Pressure
and Heart Rate
• Temperature
• Hypothermia
• Growth Chart
Physical Examination
General
• Habitus (cachectic, normal
physique, obese)
• Affect
• Dysmorphic
• Tattoos and piercings
• Clothing
Physical Examination
Skin
• Lanugo,
• Yellow/orange discoloration,
• Acrocyanosis
• Russell sign
• Acanthosis nigricans,
• Hirsutism
• Cold extremities
Physical Examination
HEENT:
CVS:
• Bitemporal wasting
• Parotid enlargement
• Enamel erosion
• Rate
• Rhythm
• Murmur
• Pulses
• Capillary Refill
Physical Examination
Abdomen:
• soft, masses
• Bowel Sounds
• Organomegaly
• Shape: scaphoid, /flat
• Striae
External Genitalia:
• Sexual Maturity Rating:
• Breast
• Pubic hair
Physical Examination
Extremities/Back
•Muscle Bulk
•Strength
•Bony Prominence
•Excoriation or
Abrasions on bony
prominences
Laboratory Work-up
• CBC
• Comprehensive Metabolic Panel
• Sed Rate
• FSH/LH
• Estradiol/Testosterone
• Urinalysis
• FT4 /TSH
• Free T3
• Celiac Panel
EKG
Dexa – amenorrheic for 6 months
Resting Energy
Expenditure/Metcart
Brain Imaging
Role
•Identify patients
•Initiate treatment
•Coordinate care, monitor progress,
decide treatment setting,
•Refer to a specialist
Treatment Setting/Levels of Care
• Out-patient/Intensive out-patient
• Registered Dietitian
• Therapist
• Day Hospital / Partial Hospitalization
• In-patient treatment
• Medical stabilization
• Psychiatric
Criteria for Hospital Admission
• Severe Malnutrition (less than 75% of Average Body Weight for age, sex and
height)
• Dehydration (hypokalemia, hyponatremia, hypophosphatemia)
• Cardiac dysrhythmias
• Physiological instability
• Severe bradycardia (heart rate < 50 beats/minute daytime; <45 beats/minute
at night)
• Hypotension (< 80/50 mm Hg)
• Hypothermia (body temperature < 96° F)
• Orthostatic changes in pulse (> 20 beats per minute) or blood pressure (>10
mm Hg)
Criteria for Hospital Admission
• Arrested growth and development
• Failure of outpatient treatment
• Acute food refusal
• Uncontrollable binging and purging
• Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac
failure, pancreatitis, etc.)
• Acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis)
• Comorbid diagnosis that interferes with the treatment of the eating disorder
(e.g., severe depression, obsessive compulsive disorder, severe family dysfunction
Treatment
• Family-Based Therapy
• Cognitive Behavior therapy
• Interpersonal Therapy
• Medication:
• Fluoxetine – for bulimia
• Atypical antipsychotics – questionable results
• OCP – does not help improve bone density
References
• Casiero, Deena and Frishman, William H. Cardiovascular Complications of Eating Disorders.
Cardiology in Review 2006.
• Treasure, Janet, et.al.Eating Disorders. The Lancet, Early Online Edition. 19November2009.
• Neinstein, et.al. Adolescent Health Care – A Practical Guide, 5th Ed.
• Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
• Rosen, et al. Clinical Report Identification and Management of Eating Disorders in Children and
Adolescents.
• Fisher, et al (eds.)Textbook of Adolescent Health Care. American Academy of Pediatrics. 2011
• AED Report 2012. Eating Disorders, 2nd edition. Academy of Eating Disorders. 2012
• Eating disorders in adolescents: position paper of the Society for Adolescent Medicine.Golden NH1,
Katzman DK, Kreipe RE, Stevens SL, Sawyer SM, Rees J, Nicholls D, Rome ES; Society For Adolescent
Medicine. J Adolesc Health. 2003 Dec;33(6):496-503