Transcript The World of EDU - UNC School of Medicine

Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Eating Disorder NOS
Nichole Grier MD
UNC Dept. of Psychiatry
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What is “normal” eating?
How do you know if you are “fat” or “too
thin”?
When is it a “mental illness”?
Does anyone talk about it?
How common is it?
Whose fault is it?
Who recovers?
How?
What is Healthy Eating?
•Mindful: Know the difference between physical
and emotional cues and needs. Eat when you are
hungry; stop when you are full. Meet your body’s
needs.
•Enjoyable: Eat pleasurable foods without guilt or
anxiety.
•Flexible: Be able to eat needed amount in
available time. No calorie counting. Eat a variety of
foods. Don’t avoid any food group. Try new things
without knowing all ingredients.
Defining “Healthy” Weight
 Pediatrics
 Standard: 50th Percentile BMI-for-age, CDC
growth charts for US
 Utilize height and weight history to plot growth on
BMI-for-age chart to establish individualized goal
 Adults
 Standard: Medium frame, 1983 Metropolitan
Height/Weight Tables, or BMI
 Set minimum goal for BMI 19.5
 Individualize based on premorbid weight,
resumption of menses, physical health indicators
What about fat . . .
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The American College of Sports Medicine
(ACSM) recommends that males age 16 and
under with < 7% body fat and males over 16
years of age with < 5% body fat not be allowed
to compete unless they have medical clearance.
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The ACSM recommends 12%-14% body fat as
the minimum safe percent body fat for high
school girls.
some historical context . . .
“Anorexia Nervosa” was first described
as a distinct diagnostic entity in 1873
 “Bulimia Nervosa” became a diagnostic
category in 1979
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Keyes study
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Healthy males
Voluntary starvation then refeeding
Development of apathy, ritualistic behaviors,
preoccupation with food
Physical symptoms cold intolerance, edema,
slowed heart rate, diminished sexual interest
Increased caloric needs with refeeding
Onset binge urges
DSM-IV criteria:
Anorexia Nervosa
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Refusal to maintain body weight at or above that
expected for age & height (<85%)
 Intense fear of gaining weight or becoming fat
 Disturbance in the way one’s body size is
experienced, OR undue influence of body size on
self evaluation, OR denial of seriousness of low
weight.
 Amenorrhea in postmenarcheal females (absence
of 3 or more consecutive menstrual cycles)
Anorexia Nervosa: Subtypes
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Restricting Type: during current episode
of AN, no regular binge eating or purging
behavior
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Binge-Eating/Purging Type: during
current episode of AN, regular binge
eating or purging
Anorexia nervosa is not a
disorder of appetite.
May report decreased appetite
Others FEAR appetite
DSM-IV criteria:
Bulimia Nervosa
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Recurrent episodes of binge eating
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objectively a large amount of food
individual feels “out of control”
Recurrent compensatory mechanisms
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self-induced vomiting
laxative use
Fasting
excessive exercise
DSM IV criteria:
Bulimia Nervosa
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Binge/Purge episodes occur, on average, at
least two or more times a week for at least
three months
Self-esteem unduly influenced by
weight/body shape
Current weight does not meet criteria for AN
(>85% IBW)
Bulimia Nervosa: subtypes
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Purging type: self-induced
vomiting, laxative abuse, diuretic
abuse
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Non-purging type: restricting,
over-exercising
Eating Disorder NOS
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Subsyndromal AN or BN
Current nomenclature for set of
criteria under investigation as “Binge
Eating Disorder”
DSM IV Research Criteria:
Binge Eating Disorder
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Recurrent episodes of binge eating:
large amount with subjective loss of control
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Associated with 3 or more:
eating rapidly, eating until uncomfortably full, eating in
private (embarrassment), eating when not physically
hungry, feeling guilty about eating
Marked distress regarding binge eating
 Binge eating occurs, on average, at least
twice/week for six months
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Binge Eating Disorder
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Usually associated with overweight or obesity
Approximately 30% of individuals presenting
to medical weight loss programs meet criteria
for BED
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Obesity itself is not a psychiatric illness,
but 8% of overweight women and almost
one third of those presenting for weight
loss treatment meet criteria for BED
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Often hard to diagnose – different from
emotional eating /grazing
Eating Disorders: Epidemiology
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Abnormal eating can be found in all
cultures but eating disorders are far more
common in industrialized countries
 EDs occur in all ethnic and
socioeconomic groups in the US,
although they are far more prevalent in
the caucasian community and seem to
have lowest rates in African American
community
Anorexia Nervosa: how common?
AN incidence around 8/100,000 per
year
 AN average prevalence among young
females around 0.3%
 About one third of AN population enters
mental health care
 Increasing incidence in past century
until 1970’s, particularly in 15-24 year
old age group; debate about increase or
decrease in rates since then
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Bulimia Nervosa: how common?
BN incidence 11-13/100,000 per year in
1980s then decreasing through 1990s
to around 6.6/100,000 per year in 2000
 BN prevalence around 1% of young
females
 BN population enters mental health
treatment at very low rate
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ED NOS: how common?
60% of the eating disorder cases in
outpatient settings
 Unknown incidence, changing definition
 BED prevalence in US 2-5% and
possibly occurring more frequently in
AA community than in caucasian
community
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All ages at risk, but . . .
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Eating disorders have onset most
commonly in teen and young adult
years, but may occur at other ages (BN
slightly later peak onset than AN)
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<10% have onset prior to puberty
Eating Disorders: Males
Up to 10% of AN & BN patients are male
 As many as 25% of BED patients are male
 Males with eating disorders are more likely
to have once been overweight and more
likely to have used exercise for weight
control
 Males may be less likely to pursue
treatment for an eating disorder, but eating
disorders are just as dangerous for males
as they are for females
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Survey
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Dieted in the past year: 62% of high
school girls, 40% of high school boys
Ever binged and purged: 13% of
adolescent girls, 7% of adolescent boys
At least one third of junior high school
girls admit concerns about weight
6% of 10th grade boys have used
laxatives
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Higher rates in those with alcoholism
Higher rates when not involved in athletics Or when
competing at elite level
Outcomes
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AN: mortality 5-6% per decade of follow-up;
SMR 9.6 in studies with 6-12 years of follow-up,
3.7 when 20-40 years of follow-up
Causes of death: suicide, starvation, cardiac
events
Risk factors for death: BMI<13, body weight
<60%, low serum albumin
Suicides do not occur exclusively during
significant underweight
Purging behaviors are worse prognostic sign
than restricting alone
Course
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AN: half will have full recovery; up to 20% with
chronic unremitting course
 BN: 80% recovery if treated within first 5 years
of illness; recovery falls to 20% by 15 years of
illness
 Much crossover between AN and BN
 Positive indicators for recovery: early onset,
early treatment, higher weight at discharge or
step-down, good social support, good
premorbid psychological functioning
Psychiatric comorbidity
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More than a quarter of ED patients have a
comorbid mood disorder
 Comorbid anxiety disorder in up to half of AN
patients, up to 75% of BN patients
 Comorbid alcohol abuse, drug abuse,
impulsivity common
 >90% have at least one additional psychiatric
diagnosis in lifetime, 50% at least one
concurrent with episode of AN
Morbidity: Mental health
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Poor sleep and Depressive symptoms
secondary to starvation itself
Antidepressants generally ineffective at low
weights
Cognitive impairment during underweight,
changes in brain volume
Increased anxiety during weight gain
secondary to changing hormonal milieu and
increasing serotonin
Adverse effects of major illness episode on
normal developmental trajectory
Morbidity: Reproduction
Reduced fertility at low weight
 Higher rates of obstetric difficulties
 Decreased intrauterine growth of baby
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Morbidity: Bone health
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Decrease in peak bone mineral density
Calcium supplements less effective at low
weight
Weight-bearing exercise helpful but cannot
offset adverse effects of underweight
Estrogen supplements alone do not preserve
bone density in underweight premenopausal
females
Bisphosphonates teratogenic potential
unknown
Morbidity: Body image, Self esteem
Initial weight gain truncal. Degree of
redistribution variable
 Lower rates of marriage and
childbearing
 Decreased achievement relative to
potential
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What causes an eating disorder?
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Multifactorial
Strong evidence of genetic
component from twin studies
BUT
 Higher incidence in industrialized
countries AND not everyone with a
weight concern develops an eating
disorder
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Genetic factors
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58-88% of risk for developing AN, and roughly
same for BN
Eating and Body-related behavioral and
attitudinal factors appear to have heritable
component
BMI highly heritable and independent of EDrelated heritable factors
AN and Chromosome 1
BN and self-induced vomiting and Chromosome
10
Other factors
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Developmental events
Family dynamics
Peer milieu
Cultural influences
“Genetics loads the gun . . .
Environment pulls the trigger”
(C. Bulik)
The assessment
Ask About:
 Weight History
 Highest and lowest adult weights
 Recent weight changes
 Perceived “ideal” weight
 Eating Behaviors
 Attempts to restrict intake (diet pill use, skip
meals, limit amounts or types of food,
counting fat/CHO grams, counting kcal)
 Binge Eating (objective vs subjective)
Ask About:
 Attempts to “compensate” for intake
 Self-induced vomiting (*ask about use of
Ipecac syrup)
 Laxative abuse
 Diuretic abuse
 Driven exercise
 Body Image
Ask About:
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Menstrual history
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Review of Systems (dizziness, fainting,
weakness, fatigue)
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Psychiatric Symptoms (depressed mood,
self-harm ideations, self-harm behaviors,
anxiety, neurovegetative symptoms)
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Substance Use, past and current
Medical assessment
Physical Exam, review of systems
 Medical history, weight history
 Medication use, substance use
 Vital signs, laboratory testing, EKG
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Common Medical Issues
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Cardiovascular
Orthostatic hypotension (starvation)
 Bradycardia (starvation)
 Prolonged QTc and T-wave abnormalities
on EKG (purging behaviors)
 Mitral valve prolapse (diminished muscle
mass)
 Cardiomyopathy (Ipecac)
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Medical Issues (continued)
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Cell counts
Low WBC (starvation and stress)
 Anemia (starvation)
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Fluid and electrolytes
Dehydration (starvation, purging)
 Decreased albumin (starvation)
 Peripheral edema and effusions
(starvation)
 Electrolyte disturbances (purging)
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Medical issues (continued)
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Renal
Acid-base disturbances (purging)
 Impaired concentrating ability
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Bone
Osteopenia
 Osteoporosis
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Medical Issues (continued)
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Endocrine
Hypoglycemia (starvation)
 Hypothermia (starvation)
 Thyroid abnormalities (starvation, stress)
 Amenorrhea and decreased sex hormone
levels (starvation, stress)
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Medical issues (continued)
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Gastrointestinal
Bloating, nausea (starvation)
 Elevated liver enzymes (starvation,
refeeding)
 Elevated cholesterol (starvation)
 Constipation and decreased motility
(starvation)
 Esophageal tears (purging)
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Medical issues (continued)
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Dermatologic
Hair loss (stress, starvation)
 Dull hair (decreased fat)
 Lanugo hair (starvation)
 Dry skin (decreased fat)
 Calloused or scarred knuckles (purging)
 Acrocyanosis (starvation)
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Dental (purging)
Other causes of weight loss . . .
Thyroid disease
 Adrenal disease
 GI disease (motility problems, IBD, celiac
disease)
 Malignancies
 Infection
 . . . and other rare entities . . .
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Nutrition needs
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Refeeding: start with 30-35 kcal/kg, then
increase by around 300 kcal every three days to
achieve gain of 1-2 kg per week as inpatient,
0.5-1 kg per week as outpatient. (Diet 55-60%
CHO, <30% fat, meet calculated protein needs)
Starved patients become hypermetabolic,
often requiring 60-100 kcal/kg per day to gain
and maintain.
 Hypermetabolic state may persist for 6-12
months after weight recovery
Assessment done. Now what?
Indications for Inpatient Care
Parameter
APA
AAP
% IBW
< 75% definite
<75% or ongoing wt loss
inpatient
despite intensive mgt
< 85% highly structured
Orthostatic
hypotension
> 20 bpm
> 20 mm Hg
> 20 bpm
> 10 mm Hg
Bradycardia
< 40 bpm
(in 40s for children)
< 50 bpm day
< 45 bpm night
Blood pressure
< 90/60 mm Hg
< 80/50 (children)
Systolic < 90 mm Hg
Temperature
< 97 deg
<96 deg
Body fat %
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< 10%
Other Indications for Inpatient Care
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Syncope
Serum potassium < 3.2 mmol/L
Serum chloride < 88 mmol/L
Esophageal tears
Cardiac arrhythmias, including prolonged QTc interval
Intractable vomiting
Hematemesis
Failure to respond to outpatient treatment
Severity of psychiatric comorbidities (Major
depression, anxiety disorders, substance abuse
disorders)
Indications for Partial Hospitalization
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Individual does not require inpatient
care but has not made progress in less
intensive treatment setting OR
transitioning from inpatient care
Indications for outpatient care
Individual is above 75% IBW, medically
stable, appropriate with self-care, and
motivated for treatment
 No adequate trial of outpatient care (a team
including Family/Individual therapist, PCP,
Psychiatrist and Nutritionist)
 Medical and psychiatric comorbidities are
stabilized or can be managed in an outpatient
setting.
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A word on medications . . .
Psychotropic Medication
 Stay away from
 Stimulants
 Buproprion
 TCA’s
 Megace/appetite stimulants
 Nutrition remains the key
“medication”
Anorexia Nervosa
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Some evidence of lower relapse rates with
use of SSRI’s once weight-recovered
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SSRI’s are ineffective at low weights, but may
begin to exert some effect once patient has
progressed beyond 80% of IBW
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Typical antipsychotics, lithium,
anticonvulsants, opioid antagonists, appetite
stimulants do not appear to be effective
Bulimia Nervosa
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SSRI’s at higher doses seem to
decrease binge/purge behaviors
independent of their efficacy with regard
to depressive symptoms
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Some data support decreased
binge/purge frequency with topiramate
but side effects are common, weight
loss common
Best Practices Treatment Guidelines
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American Psychiatric Association
http://www.psych.org/psych_pract/treatg
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American Academy of Pediatrics
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NICE guidelines (UK)
http://www.nice.org.uk
Resources
www.nationaleatingdisorders.org
 www.aedweb.org
 www.edauk.com
 www.anad.org
 www.somethingfishy.org
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UNC Hospitals ED program (919)966-7012