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Eating Disorders

Eating Disorders. Anorexia Nervosa DSM-IV Definition 1) Refusal to maintain body weight within a normal range for height and age ( > 15% below ideal weight) 2) Fear of weight gain 3) Severe body image disturbances (self-worth and denial of serious illness)

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Eating Disorders

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  1. Eating Disorders • Anorexia Nervosa DSM-IV Definition • 1) Refusal to maintain body weight within a normal range for height and age ( > 15% below ideal weight) • 2) Fear of weight gain • 3) Severe body image disturbances (self-worth and denial of serious illness) • 4) Absence of menstrual cycle/ amenorrhoea (for > 3 cycles) • 2 subtypes = restricting + binge/purging

  2. Eating Disorders • Bulimia Nervosa DSM-IV Definition • 1) Episodes of binge eating (loss of control) • 2) Followed by compensatory behaviour of • Purging type (vomiting, laxatives, diuretics) • Non-purging (execise, fasting, diets) • 3) Occurring > 2x / week for 3/12 • 4) Dissatisfaction with body shape / weight

  3. Epidemiology • 1-2 million BN in USA • 1/2 million AN in USA • AN prevalence overall = 0.27% • AN prevalence in 15-19y = 0.48% • BN prevalence overall = 1.5% • BN is more common in the >18y • Women 10:1 Men • Many more have ED-NOS ( eating disorder not otherwise specified

  4. Pathogenesis • Social pressure • Female athelete triad (eating disorder, amenorrhoea, and osteoprosis) • Related to a combination of psychological, biological, family, genetic, environmental and social factors. • Decreased self esteem or self control then using dieting behaviour and weight loss as a way of providing stability/ control on life. • Genetics = Monozygotic twins and 1st degree relatives have higher rates of eating disorders, Xolism, affective disorders

  5. Pathogenesis • Sexual abuse - no evidence • Family characteristics = high parental expectations, difficulty managing conflict, poor communication skills, enmeshment, estrangement, devaluation of maternal role and maritial tensions. • CNS / Hormonal • Nad = bradycardia and hypotension in starvation • Serotonin = high in AN, affects the appetite and satiety centres

  6. Screening • SCOFF Score >2 • Sick • Control ( or rather loss of it ) • One stone in < 3/12 • Fat • Food dominates life

  7. Examination • Vital signs ( PR and BP) • Lanugo hair • Callous formation • Parotid gland hypertrophy • Erosion of dental enamel on anterior teeth • CVS ( bradycardia, arrhythmias, MVP ) • GI • Neuro

  8. Investigations • FBC (anaemia) • Ur + Cr (dehydration) • Electrolytes + K, Ca, Mg, PO4 • B- HCG • TFTs • Prolactin (prolactinoma) • FSH

  9. Complications • Osteoporosis • Cardiac impairment • Psychiatric + Cognitive Changes • Infertility • GI Dysfunction ( slow motility, N, bloating) • Electrolytes ( K, metabolic alkalosis ) • Endocrine • low LH and FSH • Sick euthyroid ( high rT3 ) • low DHEA + IGF-1 • high cortisol + GH

  10. Osteopenia / Osteoporosis • Women accrue 40-60% of their bone mass during the adolescent years • Seen in 90% of those with AN • Long term risk of fracture increases x 3 • Causes - oestogen deficiency • - inadequate Vitamin D and Ca • - Lean body mass and nutritional • Pathophysiology - increased bone resorption • - decreased bone formation • (differing from meopause)

  11. Osteopenia / Osteoporosis Rx • Ix with DEXA then; • 1) Weight gain • 2) Elemental Ca 1200 - 1500 mg/ day • 3) Multivitamins providing 400 IU Vit D / day • 4) Oestrogen/ Progestin • no proven benefit as process is different to menopause • some benefit if < 70% ideal body weight • 5) IGF-1 (short term effects) • 6) DHEA • increases formation and decreases resorption in the short term

  12. Cardiac Mx • MVP occurs in 30 - 60% (3Xpopulation) • this is partly due to enhanced ability to detect MVP in patients with intravascular volume depletion • Prolonged QT interval seen in 33% • independent marker for arrhythmias and sudden death • Heart Failure in the first 2/52 of Re-feeding • Reduced cardiac contractility • Refeeding oedema • Mx by slow refeeding, repletion of PO4, avoid high Na

  13. Amenorrhoea • Seen in 90% of AN • Low levels of LH + FSH = low Oestrogen • Mx = Increase weight • Menses restarts in 90% in < 6/12 after achieving 90% ideal body weight

  14. Multidisciplinary Mx • a) Medical Provider • Vital signs • Fluoxetine (proven benefits in BN>AN) • Anxiolytics in AN prior to eating • Metoclopramide (delayed transit = bloating + constip) • b) Mental Health Provider • Individual and cognitive behavioral therapy • superior to medication, but synergistic with it • c) Nutritionalist • Specific and meal plan requirements • Weight goals

  15. Hospitalisation • Severe malnutrition (<75% IBW) • Dehydration • Electrolyte Disturbance • Cardiac Dysrythmias • Physiological AbNs (eg brady, hypotensive) • Arrested Growth and Development • Failure of Outpatient treatment • Complications (medical of psychiatrical) • Admission long enough to increase weight >90% IBW improves eventual outcome

  16. Management • Nutritonal • IP Expected weight gain 0.9-1.4 kg/week • OP Expected weight gain 0.2-0.5 kg/week • Start intake at 30-40 kcal/day (1000-1600kcal/day) • Rapid early weight gain is related to fluid retention and to low metabolic rate • Refeed Syndrome • At risk are those > 10% beneath their ideal body weight • Hypophosphataemia • Decreased IC ATP = impaired enegy stores • Decreased rbc 2,3-DPG = tissue hypoxia

  17. Outcome • AN • 50% good outcome • 25% intermediate ( with relapses) • 25% poor ( associated with later age of onset, duration, lower minimum weight, strong maturity fears ) • 30 - 70% fully recovered at 20y follow up • 10% continue to meet criteria for AN at 12y • BN • 30% continue to meet criteria for BN at 10y • Low self esteem associated with a poor outcome • Dehydration • Mortality Rate in AN = 6.6% • 54% complications, 27% suicide, 19% others

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