Continuity Clinic Eating Disorders. Continuity Clinic Objectives To identify the risk factors for eating disorders To perform an evaluation of the physical,

Continuity Clinic

Eating Disorders

Continuity Clinic

Objectives

• To identify the risk factors for eating disorders

• To perform an evaluation of the physical, emotional and nutritional status of a teen

• To establish the diagnosis of anorexia or bulimia

• To manage a patient with an eating disorder using a multi-disciplinary team

Continuity Clinic

The Drive for Thinness

• 63% of women feel that body weight determines how they feel

• Americans spend 33 billion dollars on dieting and diet-related products

• The average female starts dieting at age 9yrs

Continuity Clinic

The Drive for Thinness

• The average woman is 5’4 and 140 lbs

• The average model is 5”11 and 117 lbs

Continuity Clinic

Scope of the Problem

• Sense of normal:– The average woman is 5’4 and 140 lbs– The average model is 5”11 and 117 lbs

• The incidence of eating disorders has increased five times since 1955

• More than 1/2 of high school girls have dieted

• Anorexia is the third most common chronic disease in teens

Continuity Clinic

Scope of the Problem

• 10-50% of teens engage in binge eating or vomiting

• 1-5% have bulimia .5-1% develop anorexia

• 1 in 5 females 19-25yrs have an eating dx

Continuity Clinic

Culture and Eating Disorders

• There is an increase in eating disorders among Black, Hispanic and Asians

• Linked to the pressure to integrate and be a ‘smart,beautiful and thin career woman”

• In Argentina, China, and Japan similar pressures have developed

Continuity Clinic

Risk Factors for Eating Disorders

• Ethnic and socioeconomic status

• Cultural influence • Low

self-esteem/perfectionistic

• Difficulties with communication, separation and conflict resolution w/ family

• Anxiety or depressive disorder

• Family history• A drive to excel in

sports• Early puberty• Winter season• Sexual Abuse

Continuity Clinic

The Interview

• Perception of illness

• History of Illness

• Weight and height

• Body image

• Means of weight control

Continuity Clinic

The Interview

• Menstrual Function

• Past Medical History

• Family History

• Psychosocial History

Continuity Clinic

Differential Diagnosis

• Depression, OCD

• CNS tumors

• Endocrinologic disorders-IDDM, Hyperthyroidism, Addison’s

• GI disorders-IBD,malabsorption

• Chronic infections,SLE,Malignancy

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Diagnostic Criteria-Anorexia

• Refusal or inability to maintain body weight over a minimum normal weight

• Intense fear of gaining weight despite being underweight

• Disturbance in perception of body shape

• Absence of three consecutive menstrual cycles

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Diagnostic Criteria-Bulimia

• Minimum of 2 binge-eating episodes weekly for 3 months/recurrent binge eating

• A feeling of lack of control over binge-eating behavior

• Regular use of self-induced vomiting, laxatives,diuretics,strict dieting,fasting,or vigorous exercise to prevent weight gain

• Disturbance of body shape perception

Continuity Clinic

Diagnostic Criteria-Eating Disorder Not Otherwise Specified

1. All of the criteria for Anorexia Nervosa are met except the individual has regular menses or weight is in the normal range.

2. All of the criteria for Bulimia Nervosa are met except binges less than twice a week or less than 3 months.

3. Binge eating disorder- recurrent episodes of binge eating in the absence of the regular use of purging,etc

Continuity Clinic

Physical examination

• Vital signs

• Weight and height percentiles, BMI and weight percentile for ht

• HEENT-dental erosion,parotid swelling

• Thyroid

• Cardiovascular-poor cap refill,bradycardia

• Breasts-loss of fat

Continuity Clinic

Physical examination

• Genitourinary-tanner stage

• Abdominal-organomegaly

• Skin-color,loss of fat,edema,lanugo,bruises on mcp joint

• Mental state-apathy, depression, anxiety,obsessive-compulsive

Continuity Clinic

Laboratory evaluation

• CBC

• Urine dip

• Electrolytes,BUN,creatine, Ca,Mg,Phos

• T4 and TSH,serum protein and albumin

• EKG

• ?Stool for occult blood, ESR

• ?FSH,LH,Prolactin

Continuity Clinic

Management-Mild Stage• Set goal weight-usually BMI>18 • Refer to nutritionist• Aim for wt gain of .5-1 kg weekly• Check weights with gown,pt facing away from

scale and empty bladder. • Check hr,temp,and urine PH. If ph>7=metabolic

alkalosis• Consider calcium and iron supplementation• Reevaluate regularly

Continuity Clinic

Ways to Develop a Good Body Image

• Question whether there is one ideal body shape

• Cultivate the ability to appreciate uniqueness

• Take care of your body• Surround yourself with

people who feel good about their body

• Learn to respect internal cues

• Value body movement and competence

• Cultivate role models with appearances that are not the ideal

• Bond with friends on issues other than dieting

Continuity Clinic

Management-Moderate Stage

• Set goal weight• Refer to psychology/ psychiatry and nutrition• Provide structure to daily activities and meals.

– Consider restriction of excercise

• Increase calories by 200 every 2-3 days• Follow up frequently

– Stress medical markers of starvation, consequence of failure to gain wt to patient

Continuity Clinic

Indications for Hospitalization

• Electrolyte abnormalities– hypokalemia,hypophosphatemia

• Physiologic decompensation– Temp <36 degrees– Pulse < 45– Altered mental status

• Acute medical complications– arrhythmias,syncope,seizures

Continuity Clinic

Indications for Hospitalization

• Inability to break cycle as outpatient (>3-6mo’s)

• Acute psychiatric emergency- ie.suicidal

• Rapid or excessive weight loss– >10% in 2mos’s– weight <75% for IBW

Continuity Clinic

Medical Therapy

• Bulimia– Fluoxetine is the only drug which is approved-

60mg/day. Use w/ CBT

• Anorexia-– TCA’s may improve wt gain/has side effects– SSRI’s showed no change vs placebo on

hospitalized AN patients Did improve weight for outpt wt recovered patients

Continuity Clinic

Medical Concerns in Eating Disorders

• Cardiac-,bradycardia, arrythmias• Pulmonary-pneumomediastinum• GI-Delayed emptying, constipation,SMA

syndrome,Mallory-Weiss tear,dental erosion

• Metabolic-Osteoporosis (consider OCP’s, bone density), increased cholesterol, low bg, hypercarotenemia

Continuity Clinic

Medical Concerns in Eating Disorders

• Hematologic-Leukopenia, anemia, thrombocytopenia, decreased ESR, low wbc’s

• Dermatologic-Lanugo,dry skin,brittle nails,acrocynanosis

• Other-ammenorhea-need 90% of IBW to reestablish menses

Continuity Clinic

Prognosis

• Associated with length of illness

• Worsening occurs in 15-25% of patients

• Mortality is 5% for anorexia

• Poorer prognosis for bulimia with hx of sexual abuse,coexistent personality disorder or depression,substance abuse

Continuity Clinic

Summary

• Eating disorders are common in teens

• Screen for eating disorder risk factors

• Check physical exam for evidence of abnormalities,consider routine labs

• Rule out organic disease, use criteria to diagnose anorexia/bulimia

• Use a team approach in treating eating disorders!