Diagnosis and Management of Eating Disorders

1. Stephanie Bui MD FAAP Assistant Clinical Professor of Medicine and Pediatrics UCLA Health System – Brentwood Diagnosis and Management of Eating Disorders

2. Case Study #1 • K.P. is a 17 year old female presenting to your office for “irregular periods”. • Had been seen 8 months prior for a well visit. At that time height was 65 inches, weight 140 lbs (BMI 22.6). Menarche age 13, having normal menstrual cycles every 28-32 days • Today height is 65 inches, weight 115 lbs (BMI 18.6). Last period was 3 months previously

3. What Questions should you ask?

4. Case Study #1 (continued) • Patient denies sexual activity • Patient says that she has just been “getting healthy” by cutting out snacks • Patient says she started exercising as well to “get healthy” • Is very evasive and defensive when asked how much she eats/how much exercises

5. Case Study #1 (continued) • Mom asks to see you outside of the room • Has noticed that K.P. is eating less meals with the family • Has noticed a weight loss (unsure how much) • Scale is now moved from bathroom to K.Ps room • Mom has not been able to discuss this with K.P. as patient gets defensive • Worried that K.P. has an eating disorder

6. Physical Exam

7. As stated – weight 115 lbs. Blood pressure 100/60. Heart rate 50. Temp 96.7 • HEENT – Lanugo noted on face • Neck – Thyroid – normal size, no masses • CV: Bradycardia • Breasts: Tanner 4, Pubic Hair Tanner 4 • Abdomen: Soft/non tender/no masses • Extremities: Cool fingertips and Toes

8. Case Study #1 (continued) • What labs do you want?

9. Case Study #1 • Urine Pregnancy test – negative • CBC – WBC 3.1 otherwise normal • Chem 10 – Normal • Prolactin – Normal • TSH – Normal • FSH – 2.0 • LH – 2.0 • Estradiol <30 • EKG – Sinus bradycardia at 50 BPM otherwise normal

10. Case Study #1 (continued) • You tell K.P that her lack of periods is likely due to her weight loss • You begin to discuss healthy ways of gaining weight, she storms out of the room and says “No Way I’m doing that – I’m fine the way I am”

11. What’s your Diagnosis?

12. Anorexia Nervosa • DSM IV-TR Criteria • A. Refusal to maintain body weight at or above a minimally normal weight for age and height • B. Intense fear of gaining weight or becoming fat, even though underweight • Disturbance in the way in which one’s body weight of shape is experienced • Amennorhea (in post menarchal females) – absence of at least 3 menstrual periods • Type – Restricting Type or Binge-Eating/purging Type

13. Anorexia Nervosa: Etiology • Genetic: First degree relative 3x risk • Biologic: neurotransmitter abnormalities • Sociocultural: obsession with thinness • Psychological • Low self esteem • Conflict about identity, sexuality • Obsessive-compulsive • 40% history of abuse, being teased • Family: enmeshed, overprotective • Sports: gymnastics, ice skating ballet

14. Anorexia Nervosa: Epidemiology • Prevalence – Estimated at 1% • 90-95% are female • Bimodal peaks of onset at ages 13-14 and 17-18 • Prepubertal may be associated with more severe profile • Adolescent onset associated with better prognosis that prepubertal and adult onset • 30% of patients were obese

15. What to do now?

16. Anorexia Nervosa:Management • Determine Level of Care: • Medically Unstable: medical hospital • Heart rate <40, glucose < 60 mg/dl, potassium <3 mEq/l, orthostatic hypotension • Psych Unstable: psych hospital • Med/Psych stable: • <70% IBW: Inpatient • 70-85% IBW: Partial/Day treatment • >85%: Outpatient

17. Anorexia Nervosa:Management • Create treatment team • Therapist: individual and family • Nutritionist • Medical provider • Psychiatrist • Coordination between all providers is KEY • Start with therapeutic alliance

18. Anorexia Nervosa:Management • School – Consider reduced schedule • Exercise: limit activities, team sports, gym • Amennorhea: consider OCP >6-12 months • Calcium 1200-1500 mg • Vitamin D 400-800 IU • Dexa Scan if no menses > 6 months

19. Anorexia Nervosa:Target Weights • Standardized tables • Premorbid weight • Weight at which patient had last period • Progressive weight goals • Weight at which patient feels safe and healthy • May need to postpone discussion

20. Anorexia Nervosa:Management • Close monitoring: every 1-2 weeks • Standardized weights: gown, empty bladder • Weight gain: ½-1 lb per week • If faster risk refeeding syndrome • Ask patient if they want to know weight • Avoid comments about weight • During treatment constantly assess: • Resistance, denial, non-compliance, deception • Depression, anxiety • Purging activities • Treat psychiatric co-morbities

21. Anorexia Nervosa: Complications • Cardiac: Arrhythmias, prolonged QT, heart failure, pericardial effusions • Neurologic: cerebral atrophy • Endocrine:Osteoporosis • Renal: renal failure, nephrolithiasis • GI: gastric dysmotility • Dental: enamel erosions

22. Back to K.P. • Initial visit – after coaxing back into room, you explain your concerns about health • She reluctantly agrees to see a nutritionist, refuses to see a therapist • Follow-up one week later, weight is down 2 pounds – refused to implement changes suggested by nutritionist • Admitted to day treatment program

23. Anorexia Nervosa: Course and Outcome • < 50% achieve full recovery • Predictors of recovery: higher body weight at intake, shorter duration of intake episode, and atypical features • 1/3 improve with lingering symptoms • 1/5 remain chronically ill • Mortality • Mortality rate is 12x higher than that for age matched women • 24% of deaths due to suicide

24. Case Study – 5 years later • K.P. presents to your office 5 years since initial diagnosis of anorexia nervosa – since that time, she has had one inpatient admission and 3 partial hospitalizations – last at age 19. • Her weight has been stable at 135 for the past 2 years • On exam, you noticed parotid enlargement, and scars on her knuckles

25. What happened?

26. Bulimia Nervosa

27. Bulimia Nervosa: Diagnostic Criteria • Recurrent episodes of binge eating • Recurrent inappropriate compensatory behaviors in order to prevent weight gain (self induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting, excessive exercise) • At least 2 episodes of binge eating per week for 3 months • Two types: • Purging • Non purging

28. Bulimia Nervosa: Etiology • Similar to anorexia nervosa • Borderline personality disorder • Impulse Control • Perfectionism • Disturbances in family function • History of sexual abuse

29. Bulimia Nervosa: Epidemiology • Lifetime Prevalence 1%-4.2% • 90-95% femaile • Onset later than in anorexia nervosa • Less common in African Americans • 50% of patients with anorexia nervosa will migrate to Bulimia Nervosa

30. Bulimia Nervosa: History • Eating and Body image questions • Questions about binge eating • Frequency, amounts • Triggers – specific foods, situations, feeling • Facillitators • Questions about purging • Frequency, techniques • After purge, how do you feel? • Dental Care • Vomited Blood, reflux symptoms

31. Bulimia Nervosa: Management • Determine Level of Care • Create treatment team • Focus on the binge, not the purge • Dental Care • Rinse teeth immediately, don’t brush for 30 minutes • Sensitive toothpaste • Medications • SSRIs – most studied is fluoxetine 60 mgs/day • Bupropion – black box warning re: seizures

32. Bulimia Nervosa: Complications • Related to purging activity • Dental: erosion, false teeth • GI: esophageal tears, cathartic colon, GERD • Metabolic: electrolye imbalance, dehydration

33. Bulimia Nervosa – Prognosis • Mortality – low • 50% will achieve full recovery at 5 – 12 years • 1/3 of these will go on to relapse

34. Eating Disorder “not otherwise specified” Binge eating Disorder Disordered Eating And then there is everything else…..

35. Case Study #2 – J.J • 21 year old female, no past medical history • Height 5 ft 8 lb, weight 140 lbs • On routine history – exercises 7 days/week for 60 minutes – because “if I don’t I feel fat” • Counts calories • Eats same foods every day • Weighs herself daily • Physical exam normal, Labs normal

36. Eating Disordered Thinking • When thoughts about your body and/or eating interfere with your life • “If I were just 5 lbs thinner I would be happy” • “If I were thinner, then people would like me more” • “ I feel so fat; I am so fat; I will eat today and start my diet tomorrow”

37. Eating Disordered Behavior • Eating rituals – same food, same schedule • Cutting out fat, favorite foods • Weighing self a lot • Excessive exercising • Eating only if “good”

38. SCOFF Questionnaire • Do you make yourself Sick “purge” because you feel uncomfortalby full? • Do you worry that you have lost Control • Have you recently lost more than 14 lbs (One Stone) in a 3 month period • Do you think you are too Fat • Would you say that Food dominates your life

39. Remember Anorexia  Anorexia Nervosa

40. Case Study #3 – M.B. • 15 year old male new patient presented to office for “anorexia nervosa” • Recently discharged from inpatient eating disorder facility • Previous to his admission there, had lost 15 pounds with decreased intake. Vague complaints of abdominal pain • On review of labwork, had microcytic anemia prior to admission to eating disorder facility

41. Case Study #3 • Gained weight only with tube feeds in hospital (was refusing po) • Repeat labs after hospitalization – persistent microcytic anemia, low Fe levels, elevated ESR • Dad with “colitis”

42. Case Study #3 • Bottom line – severe Crohn’s disease • Ultimately required ileocecal resection.

43. Take Home Messages • If your patient says “I feel fat”, it is code for • I feel sad • I feel angry • I feel stupid • Don’t dismiss the feeling, normalize it • Emphasize health and fitness for patient and family • People are different shapes and sizes • Everyone can try to be healthy, fit and heave healthy body image

44. Take Home Messages • Routinely ask about body image • Set follow up appointments • For families • Be Direct: “I am worried about you” • Be prepared: show direct evidence • Be Firm • Don’t bribe or monitor • Get help – Earlier the diagnosis, better the prognosis