Transcript Medical Aspects of Eating Disorders

Medical Aspects of Eating
Disorders
Richard Kreipe, M.D.
Professor of Pediatrics, Division of Adolescent Medicine,
Golisano Children’s Hospital
Medical Director, Eating Disorders
Recovery Center of Western New York
February 29, 2008
The role of the physicians on the
eating disorder treatment team is
to
1. Identify the disorder.
2. Rule out other causes.
3. Monitor for consequences.
4. Treat the disorder
.
Identification of patients with
eating disorders
Determination of normal
weight for height in adults
Predicted body weight method (PBW):
• Predict body weight based on height.
• Divide actual weight by predicted weight
Example: PBW for 5'6" woman is 130 lb. If
actual weight is 110 lb., then patient is 85%
of predicted weight.
Determination of normal weight
for height in children and
adolescents
Growth chart
• Height
• Weight
• Body mass index for age
Growth chart: height and weight for age
Height
Weight
Age in years
Growth chart: body mass index for age
body mass index
= weight/height2
Age in years
Symptoms of patients with
anorexia nervosa
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Dizziness, weakness, fainting, fatigue
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Cold intolerance
•
Hair loss
•
Bloating, abdominal pain, heartburn, constipation,
diarrhea
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Lack of menstrual periods
•
Bone pain from stress fractures in athletes
Physical examination:
anorexia nervosa
Appearance of malnutrition:
• Thin, loss of subcutaneous tissue,
muscle wasting
• Skin pale, poor circulation, dry
• Hair dry, brittle, thinning
• Lanugo: fine body hair as in newborns
Physical examination:
anorexia nervosa
(continued)
• Low blood pressure
• Slow heart rate
• Orthostatic “positional” changes in heart
rate and blood pressure
• Low body temperature
Symptoms of patients with
bulimia nervosa
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Feeling faint or fainting
Depression and anxiety
Bloody vomiting (unusual)
Throat or upper abdominal pain
Fatigue, weakness, difficulty concentrating
Facial swelling around jaw
Physical exam:
bulimia nervosa
Signs of vomiting:
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Enlargement of salivary glands
Throat irritation
Subconjunctival hemorrhages
Upper abdominal tenderness
Dental erosions
Diagnosis
• Complete history and physical exam
• Screening lab work: blood count,
chemistry panel, thyroid-stimulating
hormone, urinalysis
• Targeted lab work: done based on
findings
Differential diagnosis of eating
disorders
Differentiation of eating disorders
from other diseases
Gastrointestinal disease
•
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Crohn’s disease, ulcerative colitis
Celiac disease
Endocrine disease
•
Diabetes mellitus
•
Hyperthyroidism
Differentiation of eating disorders
from other diseases (continued)
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Pulmonary diseases
Malignancy
Chronic infection
Central nervous system tumors
Differentiation of eating disorders
from other diseases (continued)
Psychiatric disorders
• Depression
• Obsessive compulsive disorder
• General anxiety disorder
• Panic disorder
Monitoring for
consequences of
eating disorders
Metabolic consequences of
eating disorders
•
Lowered basal metabolic rate—suppressed
metabolism
•
Increased catabolism—breakdown of tissue—
muscle, brain, bone

70% of weight loss is lean tissue, 30% is fat
•
Decreased anabolism—building of tissue
•
Electrolyte abnormalities

•
Potassium, sodium, phosphorous
Hypercholesterolemia early and
hypocholesterolemia late
Endocrine system consequences
of eating disorders
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Lack of menstrual periods, estrogen
deficiency
Irregular menstrual periods
Lowered testosterone levels
Elevated cortisol levels
Thyroid adaptation
Bone consequences of eating
disorders: osteoporosis
• Lack of normal bone density gains in
adolescence and early adulthood
• Midlife osteoporosis if peak bone density
is low
• Stress fractures
• Suppressed bone formation related to hormonal
changes that affect calcium uptake into bone.
Normal bone density growth
Osteoporosis
Gastrointestinal system
consequences of eating disorders
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Reduced intestinal
movement and delayed
stomach emptying
Gastroesophageal reflux
Gastric tears
Dental erosions
Elevated liver enzymes
Cardiovascular consequences of
eating disorders
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Decreased heart size
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Abnormal heart rhythms
Hematologic consequences of
eating disorders
Bone marrow depression
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Anemia: low red blood cell count
Leukopenia: low white blood cell count
Thrombocytopenia: low platelet count
Behavioral and psychological
consequences of eating disorders
• Ancel Keys’ study of the effects of starvation on
healthy young men showed that many
psychological and behavioral symptoms of
eating disorders were the result of the biology of
starvation.
• Weight and caloric intake must be returned to
normal in treatment process while psychological
issues are also addressed.
• Binge eating is in part a physiologically based
reaction to starvation.
Treatment of patients
with
eating disorders
Improve nutritional status
• A subnormal weight cannot be
healthfully maintained.
• Malnutrition cannot be corrected without
adequate intake of carbohydrates,
proteins, fats, and total calories.
Improve nutritional status
(continued)
• Malnutrition can be seen in patients who
are normal or overweight and have
restrictive eating, bulimia, or binge
eating disorder.
Coordinating with the treatment
team
Physician and medical staff have ongoing
consultation with:
• Dietitian
• Social worker/case manager (if separate from
psychotherapist or other team member)
• Psychotherapist
• Psychiatrist
Regular—weekly or biweekly—appointments
until weight gain is well established or
symptoms have decreased.
Management:
education
Educate on:
• Effect of malnutrition on the body: metabolic,
gastrointestinal, psychological.
• Normal body weight/acceptance of current body
weight.
• Risks of purging behaviors.
• Long-term risks of being underweight.
• Use of “blind” weights, if applicable.
Pharmacologic treatment
Psychotropic medications
• SSRI medications decrease purging behaviors,
address co-morbid conditions such as depression
or anxiety.
• SSRI medications are not effective for promoting
weight gain in anorexia nervosa.
• SSRI, tricyclics, and anticonvulsant medications
being tried with binge eating disorder.
Reference: Devlin, M. J. (2005) “Binge Eating Disorder 2005,” 15th Annual
Conference, Renfrew Center Foundation, Nov. 12.
Pharmacologic treatment
(continued)
No evidence of effectiveness:
• Appetite stimulants for weight gain
• Estrogen replacement
Treatment plan
• Establish a relationship.
• Address the patient’s and family’s concerns, even
if different from our own.
• Set nutritional intake to support nutritionist’s
recommendations.
• Monitor weight and medical status.
• Set treatment plan for
expected rate of gain.
weight or medical criteria for which hospitalization
may be required.
Treatment: Adults
• Adults age 18 and over must agree to
treatment.
• Health care for patients 18 and over is
confidential.
Signed release required for medical
provider to discuss specifics with family.
Confidentiality does not include a situation
that is life-threatening.
Management:
Anorexia Nervosa
(continued)
Osteoporosis:
• Weight gain.
• Calcium 1,500 mg with Vitamin D 400 IU per day
or four servings of calcium-rich food per day.
• Dexa scan if no menstrual period for six months to
one year or prolonged malnutrition.
• Estrogen replacement does not treat osteoporosis
in young women.
• Drugs like Fosamax used to increase bone density
are not currently used in women before or during
childbearing years because the safety profile is
not known.
Treatment: Anorexia Nervosa
Refeeding syndrome—fluid and electrolyte
abnormalities that occur when a patient who is
malnourished suddenly eats large amounts:
• Occurs in patients less than 75% PBW.
• Usually occurs in first few days of a high-calorie diet.
• Prevent by starting with low caloric intake and increase
slowly.
• Check electrolytes, especially phosphorous, frequently.
Management:
Bulimia Nervosa
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Monitor for electrolyte abnormalities.
Help patients stop laxative abuse.
Discuss dental care.
Discourage dieting in conjunction with
treatment team members:
Eat three meals a day plus two snacks.
Increase protein in diet.
Indications for hospitalization in
patients with eating disorders
• Less than 75% of predicted body
weight.
• Inability to eat.
• Changes in blood pressure, pulse, and
temperature indicative of seriously
compromised circulation and organ
perfusion.
• Cardiac arrhythmias.
Indications for hospitalization in
patients with eating disorders
(continued)
• Serious serum electrolyte abnormalities:
potassium, phosphorous, sodium
• Esophageal tears
• Intractable vomiting
• Failure to improve despite intensive
out-patient treatment
• Psychiatric instability: Danger to self or
others, e.g., suicide risk
“The road to success is always
under construction.”
References
• Garner, D. M., and Garfinkel, P. E. (1997) Handbook of
Treatment for Eating Disorders, 2nd ed. New York: Guilford
Press.
• Kreipe, R. E., and Yussman, S. M. (2003) “The Role of the
Primary Care Practitioner in the Treatment of Eating Disorders.”
Adolescent Medicine 14(1).
• Levine, R. L. (2002) “Endocrine Aspects of Eating Disorders in
Adolescents.” Adolescent Medicine 13(1).
• Mitchell, J. E. et al. (2001) “Combining Pharmacotherapy and
Psychotherapy in Treatment of Patients with Eating Disorders.”
Psychiatric Clinics of North America 24(2).