1 / 29

Eating Disorders in Adolescents

Eating Disorders in Adolescents. Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College. Anorexia Nervosa (DSM-IV). Body weight less than 85% of expected Intense fear of gaining weight even though underweight Disturbance in body image

Télécharger la présentation

Eating Disorders in Adolescents

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Eating Disorders in Adolescents Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College

  2. Anorexia Nervosa (DSM-IV) • Body weight less than 85% of expected • Intense fear of gaining weight even though underweight • Disturbance in body image • In post-menarchal females absence of at least three consecutive menstrual cycles • Two types are defined: • Restricting type • Binge-eating or purging type

  3. Bulimia Nervosa (DSM-IV) • Recurrent episodes of binge eating • A sense of lack of control over eating during these episodes • A regular cycle of self-induced vomiting, laxatives, diuretics, exercise or dieting • Two binge-eating episodes per week for at least three months • Two types identified: • Purging type • Non-purging type

  4. Epidemiology • Anorexia Nervosa • Incidence1/100,000worldwide, in white females in western countries 1/200 • Incidence in adolescent females 0.5-1% • Female predominance of 9-10:1 • Becoming more diverse • Mean age 13.75 (range 10-25 yrs)

  5. Epidemiology • Bulimia Nervosa • Prevalence 1-3% in young females • Prevalence of 3-10% in college aged females • 90-95% female • Onset is usually during late adolescence, age range of 13-58 years

  6. Family Risk Factors • Achievement oriented • Intrusive, enmeshed, overprotective, rigid • Unable to resolve conflicts • Frugal with support or encouragement • Maternal preoccupation with diet, weight and appearance • Positive family history of Eating Disorder

  7. Individual Risk Factors • Perfectionist- “good little girls” • Feeling of low self-esteem • Obsessional style • Early puberty • Overweight • History of sexual abuse • Athletes

  8. Eating Behaviors • 40-60% girls in high school have dieted • 18% reported fasting >24 hrs to control weight • 30-40% of Jr. high school girls were concerned with wt. • 42% of college women diet, 10% purge, 7% use diet pills • 80% of girls in LI HS reported they would be happier at a lower weight

  9. Comorbidity • Major depression and dysthymia in 50-75% AN/BN • Bipolar 4-13% of AN/BN • OCD in 25% of AN • Substance abuse 30% of BN, 15% of AN • Personality disorders 42-75% of AN/BN • Sexual abuse 20-50% of BN • Anxiety disorders high in AN/BN

  10. History –Eating Disorder Symptoms • Pinpoint exact time • Reinforcement of behavior • Food faddism, rituals and para-eating behaviors • Family characteristics • School behavior • Peer contacts • Lack of concern • Food as a battleground

  11. History • Parental concern or patient concern? • Weight loss- highest wt, lowest wt, patients personal goal wt. • Menstrual history • Exercise • Binging, purging, laxatives, diet pills or diuretics • Body image • Family conflicts over food • 24 hour food recall

  12. History • HEADS assessment • Home • Education • Activity • Drugs/Depression • Suicide/Sexual Activity • ROS- dizziness, syncope, cold intolerance, constipation and abd pain, dry skin and hair, fatigue

  13. Physical Exam- Vital Signs • Bradycardia • Hypothermia • Orthostatic hypotension- HR inc. 20, BP dec. 20 • Weight and height

  14. Physical Exam • General-cachectic, depressed, dehydrated • HEENT- dental enamel erosion, parotid hypertrophy • Breasts- atrophic • Abdomen- scaphoid, palpable stool • Extremities- acrocyanosis, Russell’s sign, peripheral edema • Skin- lanugo hair, yellow skin discoloration, bruising

  15. Laboratory Evaluation • CBC- leukopenia, anemia, thrombocytopenia • ESR- low • UA- specific gravity, ketones • Chemistries- hypokalemia, hyponatremia, BUN high, low Ca, Mg, Phos, LFT’s and chol high, carotene elevated • TFT’s- TSH nl, T4 low or nl, T3 low • Hormones- estradiol low in females, testosterone low in males, prolactin nl, LH and FSH low or low nl

  16. Complications • Cardiac • EKG- bradycardia, low voltage, t wave changes, prolonged QTc • Echocardiography- decreased cardiac size, reduced myocardial contractibility, increased prevalence of MVP, Ipecac CM, pericardial effusion

  17. Complications • Gastrointestinal • Delayed gastric emptying- abdominal bloating/pain • Hypomotility- constipation • Fatty infiltration of the liver • Superior mesenteric artery syndrome • Esophagitis • Mallory-Weiss tear

  18. Complications • Neurologic • Poor attention and concentration • Poor problem solving skills • Cerebral atrophy • Cerebral ventricular enlargement • Atrophy correlates with degree of malnutrition and is reversible with weight gain

  19. Complications • Osteoporosis • Related to amenorrhea and hypoestrogenism • Can lead to increased fracture risk • DEXA (Dual Energy X-ray Absorptometry) if amenorrheic >6months • Exercise not protective • Adequate Ca intake necessary • NOT completely reversible even with weight gain and resumption of menses

  20. Treatment • Multidisciplinary approach • Physician • Psychiatrist • Therapist- individual, group, family • Nutritionist • Family involvement a must!!!!

  21. Out-Patient Management • Multidisciplinary approach • Weekly visits- UA, Wt in gown, Food records • No exercise until Wt gain • Behavioral contract can be used • Medications-SSRI’s • Weight gain- expect about 1-2lbs per week until goal weight-90% of IBW-resumption of menses • Parents and family need to avoid food conflicts • Bulimia- focus on binging not purging

  22. Indications for Admission • Weight <75% of IBW • Dehydration or Electrolyte disturbances • EKG abnormalities • HR<40, SBP<70, T<35C, Orthostatic • Failure of outpatient management • Acute food refusal • Uncontrollable binging and purging • Medical/ Psychiatric emergencies

  23. In-Patient Management • Multidisciplinary approach • Daily weights after voiding and in hospital gown • Behavioral Modification Protocol: Privileges- phone, TV, visitors • Start at 1400 Kcal and increase calories slowly, 200Kcal/day • Follow electrolytes carefully for the first week • If food refusal use supplements or NGT • Day treatment program as a transition

  24. The Refeeding Syndrome • Starved state- catabolic breakdown of fat and muscle- Inc. nutrients in blood • Refeeding- Carbohydrates inc Insulin leading to anabolic protein synthesis and inc uptake of glucose, phosphorous, and water into cells • Combo of TBD of phosphorous during catabolic phase and intracellular influx during anabolic phase leads to severe extracellular phosphorous depletion

  25. Refeeding • Severe phosphorous depletion leads to decrease in ATP production • Leads to muscle problems- cardiac, hepatic, neuromuscular, respiratory • Most lethal- altered myocardial function/arrhythmia

  26. Recommendations to Avoid the Refeeding Syndrome • Be aware of the syndrome • Recognize the patient at risk • Cardiac monitoring during refeeding • Increase caloric delivery slowly • Administer multivitamins routinely and neutrophos if phosphorous drops <3.0 • Carefully monitor electrolytes daily for the first week and then biweekly

  27. Prognosis • 50% good outcome, 25% intermediate outcome, 25% poor outcome • Mortality less than 4% • Of those that recover- 1/3 recover over 3yrs, 1/3 by 6yrs, 1/3 by 12yrs • Adolescents better prognosis than adults

  28. Prognosis • Poor prognosis • Early Onset • Longer duration of illness • Lower weight • Failed previous treatment • Personality disorder/ depression • Difficult family relationships • Social Isolation

More Related