Eating Disorders In Adolescence. Adolescence From the Latin Ad Olesco : to grow up Most adolescents have VORACIOUS APPETITE A response to the increased.

Eating Disorders

In Adolescence

Adolescence

From the Latin Ad Olesco : to grow up

Most adolescents have VORACIOUS APPETITE

A response to the increased energy requirement generated by the GROWTH SPURT

Body Mass Index

• Weight in kg divided by height in m2

• NORMAL BMI : 18 to 24 years of age

BMI < 18 : suspect malnutrition

BMI 24 to 30 : overweight

BMI 30 to 40 : obesity

BMI above 40 = morbid obesity

Why do we eat?

The hypothalamus is the controller stimulated by:

• OREXIGENIC PEPTIDES (appetite inducers) e.g. agouti-protein and neuropeptide Y

• ANOREXIGENIC PEPTIDES (appetite suppressants)

e.g. melano-cortin which, with effects on specific receptors (MC1R), decreases food intake and increases energy expenditure

Central Controls are Influenced by Circulating HORMONES:

• INSULIN: provides signals related to blood glucose levels

• LEPTIN: signaling consistency of body fat stores

and, in addition

• The GUT HORMONES

The GUT HORMONES• GRELIN: secreted by the stomach fundus (when empty)

increases appetite and hence food intake• NO: nitric oxide (not a hormone but dilates the empty stomach

hence very orexigenic)• CHOLECYSTOKININE and PEPTIDE YY3-36: secreted by

endocrine lining cells of the distal gut and colon when food present hence appetite suppressants (anorexigenic)

Can these hormones be manipulated therapeutically?

Not easily!ANY LOSS OF BODY FAT stimulates a defensive system

which acts in order to RESIST THE LOSS OF FAT

IN CONCLUSION: the GUT TALKS to the BRAIN

Anorexia Nervosa: A Classic Eating Disorder

• A disease of the mid-adolescent period characterized by:– INTENSE FEAR OF GAINING WEIGHT– DENIAL OF THE SERIOUSNESS of the CURRENT

LOW WEIGHT– PRESENCE of AMENORRHEA in post-menarchal

females for at least 3 consecutive periods

periods occurring following estrogen administration DO NOT COUNT

Anorexia Nervosa: Clinical Aspects

• WEIGHT: very decreased

• FEMALE to MALE ratio = 10 : 1

• MENSTRUATION : absent

• BINGE-EATING: 25 to 50% of patients

• MORTALITY : 5% per decade

Anorexia Nervosa:Clinical & Laboratory Findings

• LANUGO and EDEMA of the skin, bradycardia and hypotension, constipation, normochromic anemia and leukopenia, hyponatremia, hypoglycemia, low hormonal levels (estrogen or testosterone, LSH, FSH) but normal TSH and increased cortisol

• SKELETAL CHANGE: OSTEOPENIA

Anorexia Nervosa: Signs of Malnutrition

• Easy pinching in the posterior region of the arms, due to to loss of fat

• Hollowing temporal muscles

• Wasting of the thigh muscles

• Easily plucked hairs

MEMO: the laboratory signs of malnutrition are HYPOALBUMINEMIA and HYPOPREALBUMINEMIA

Anorexia Nervosa

• Definite neuro-psychiatric disorder

• More frequently encountered in young post-pubertal females of college age

Bulimia Nervosa

• Characterized episodes of binge eating alternating with purging

• Female to male ratio 10:1

• Some genetic factors may be involved, but and above all cultural attitudes toward standards of physical attractiveness

• 3 modalities are the most frequent:– Self induced vomiting via “fingers” or ipecac– Abuse laxatives (e.g. bisacodyl, cascara or senna)– Misuse diuretics

• In addition to diuretics also diet pills (containing ephedrine)

Bulimia Nervosa: Complications• Oral: loss of enamel of the anterior teeth and

dental caries

• GI tract: frequent vomiting can induce GE-reflux (occasionally tears in the esophagus). The abuse of laxatives can lead to constipation due to damage of the myo-enteric plexus

• Abnormalities of the electrolytes:– Metabolic alkalosis due to frequent vomiting– HYPOKALEMIA present in 5% of the patients

Bulimia Nervosa: Treatment

• Replenish potassium losses

• Eventually I.V. fluids and lytes

• Monitor lytes frequently

and, of course

• Refer for psychiatric or psychologic counseling

The Female Athlete Triad

• Dysmenorrhea or amenorrhea

• Dietary inadequacy or disordered eating

• Osteopenia and eventually osteoporosis

The Female Athlete Triad:The Risk Profile

1) Athletes in the elite and highly competitive levels: e.g. gymnastics, figure skating, ballet dancing, distance running

2) Individual sports more at risk than TEAM SPORTS

3) During adolescence and young adulthood skeletal integrity is at significant risk due to the rapid growth occurring at this time

MEMO: Some male sports (such as wrestling) place athletes at risk due to pressure “to make weight.” Some males may become affected also by delayed puberty and anorexia (especially in long distance runners) in parallel to the

female triad (but incidence is 9 : 1)

The Female Athlete Triad:Prevention and Treatment

• Prevention: Develop educational models and evaluate all women with changes in menstruation and weight

• Medical care: Remove athletes at risk from competition and develop guidelines for hormonal-nutritional treatment and bone mass assessment

• Education: Facilitate development of educational material and courses

Obesity

• In the USA in the year 2000:– 97 million overweight (BMI < 24)– 50 million obese (BMI < 30)– 15 million morbid obese (BMI < 40)

• An overall increase of 30% in 7 years and the ever more frequent presence of obesity in children

Types of Obesity

The APPLE

The PEAR

The TRUNCAL

The PEAR type much less related to eventual complications

Obesity and Related Morbidities:

CAD - DJD - CANCER- GOUT

Type 11 DM (66% of diabetics Type II are obese)

The deadly triad: diabetes II + obesity + smoking

Sleep APNEA - Pulmonary embolism

Obesity Treatments

• Caloric restrictions: with necessity to restrict fats to less than 30% of the total caloric intake

• Modification of lifestyle and exercise:– A walk of 1 mile (1.5 m) burns 100 Kcal

Walk 2 - 3- or even 4 miles, 4 or 5x weekly, and add some resistance exercise 2 or 3 times weekly (all under some supervision).

• The dietary variations: The Atkins Diet or the high protein low carbohydrate (only 20 grams of CHO/day)

Comments• Even if the Atkins Diet permits a gradual increase in CHO after

the initial weight loss (5g per week after a loss of 10 lbs. or 4.5 kg) still it provokes:– Calciuria– Not indicated in renal or hepatic diseases– Atherogenic (high in saturated fats, trans-fats and cholesterol

while in adequate for fruits, vegetables, whole grains

• Drug treatments: Redux, Meridia, Leptin, Orlistat, etc., etc.

• And finally surgery shunts and/or restrictive today

• Even with laparoscopic procedures

Final Comments

The recipe for effective weight loss is a combination of:

• Motivation

• Physical activity

• Caloric restriction

And all this with a lifelong adherence

BUT

MEMO: Prevention of weight gain is the first step EVEN IN CHILDREN