Anorexia

Question 1

What is abnormal weight loss?

Answer 1

Unintentional weight loss is a decrease in body weight that is not voluntary.

Weight loss is a very nonspecific symptom but may be indicative of a serious underlying pathology.

Weight loss will occur with inadequate food intake, malabsorption, increased metabolism, or a combination of factors.

Question 2

What are the causes of abnormal weight loss and loss of appetite?

Answer 2

Dysphagia
Painful mouth sores
Newly applied orthodontic appliances or loss of teeth

Question 3

What are the causes of abnormal weight loss and persistent vomiting?

Answer 3

Pyloric stenosis

Hiatus hernia

Question 4

What are the causes of abnormal weight loss and malabsorption?

Answer 4

o	Coeliac disease. 
o	Chronic pancreatitis.
o	Crohn's disease.
o	Gastrointestinal infection.
o	Gastrointestinal fistulas.
o	Carcinoid disorders.
o	Intestinal hypermotility.
o	Hepatobiliary disease.
o	Food intolerance.

Question 5

What are the endocrinoogical causes of abnormal weight loss?

Answer 5

DM
Addison’s disease
Guy hormone tumours such as VIPoma
Hyperthyroidism

Question 6

What are systemic causes of abnormal weight loss?

Answer 6

Heart failure 
Chronic respiratory disease 
CKD 
Liver failure 
Rheumatoid arthritis 
SLE

Question 7

Psychological causes of abnormal weight loss

Answer 7

Stressful life events 
Depression 
Anorexia nervosa 
Psychoses 
Manipulative behaviour 
Food phobias

Question 8

Other causes of weight loss

Answer 8

Medication- polypharmacy in the elderly 
Malignancy 
Acute and chronic infections 
Drug abuse and heavy smoking 
Malnutrition and social isolation 
Parkinson’s disease

Question 9

Which conditions cause rapid weight loss?

Answer 9

Coeliac disease
Type 1 diabetes mellitus
Hyperthyroidism
Malignancy
Anorexia nervosa
Inflammatory bowel disease
Oesophageal problems e.g. achalasia
Severe depression/OCD/autism
Juvenile arthritis
Addison’s disease

Question 10

What is the presentation of abnormal weight loss?

Answer 10

Patients may realise themselves that they have lost weight or this may be brought to their attention by friends or family.

A clinician may note that the patient has dramatically lost weight or notice that their clothing is loose-fitting.

The clinical assessment includes both consideration of possible physical causes as well as careful evaluation of possible psychological causes such as depression. It is very important to avoid inappropriate, unnecessary and potentially harmful investigations.

The presentation will depend on the underlying cause.

A thorough history and examination are essential in establishing the underlying cause and identifying appropriate investigations.

Associated symptoms may include:
o Gastrointestinal symptoms.
o Lethargy, weakness.
o An underlying condition - eg, respiratory, neuromuscular.
o Alcohol or drug abuse.
o Dementia - mental state assessment may be indicated.
o Anorexia nervosa.

Question 11

What are the investigations for abnormal weight loss?

Answer 11

FBC: reduced haemoglobin may occur with chronic disease, malabsorption, chronic kidney disease, liver failure.

Raised erythrocyte sedimentation rate (ESR): nonspecific indicator of disease, malignancy, infection, connective tissue disorder.

Renal function and electrolytes: may indicate chronic kidney disease, Addison’s disease.

Fasting blood glucose: diabetes mellitus.

LFTs, clotting screen: liver failure.

TFTs: thyrotoxicosis.
CXR: malignancy, tuberculosis.

Other investigations will depend on the context of the weight loss. Possible further investigations may include HIV serology, endoscopy and autoimmune disease screen.

Question 12

What is the management of abnormal weight loss?

Answer 12

Any suspicion of cancer as the underlying cause should prompt urgent referral for further assessment in secondary care.

Management is otherwise directed at the cause of weight loss and may include physical, psychological and social (eg, ‘meals at home scheme’, respite care) interventions.

The elderly are particularly at risk and nutritional evaluation should be part of any routine geriatric assessment.

Question 13

What are the complications of rapid weight loss?

Answer 13

Rapid weight loss leads to:
o Impaired immune response and increased risk of infection.
o Refeeding syndrome risk
o Hypoglycaemia
o Cardiac arrhythmias
o Poor quality of life and health outcomes

Question 14

What is anorexia nervosa?

Answer 14

People with anorexia nervosa maintain a low body weight as a result of a preoccupation with weight, construed as either a fear of fatness or a pursuit of thinness.

In spite of this, they believe they are fat and are terrified of becoming what is, in reality, a normal weight or shape.

Question 15

How is a diagnosis of anorexia nervosa made?

Answer 15

A diagnosis of anorexia nervosa is based on features including low body weight, rapid weight loss, weight loss measures (particularly extreme dieting), and psychological features (usually including distorted body image), along with physical and endocrine sequelae.

Anorexia nervosa can cause widespread physical and psychological morbidity and it can result in death.

Question 16

What is the cause of anorexia nervosa?

Answer 16

The aetiology of anorexia nervosa is thought to be multifactorial, involving biological, psychological, developmental and sociocultural factors.

It is not known whether a neurobiological vulnerability predisposes to anorexia nervosa or if this is associated with maintenance of symptoms once the illness develops.

Common co-morbidities include OCD and depression.

Question 17

What are the risk factors for anorexia nervosa?

Answer 17

Female gender.
Age.
Living in a Western society.
Family history of eating disorder, depression or substance misuse. Results of twin studies are inconclusive, with some suggesting a strong link, and others none.

Premorbid experiences. These include:
o Sexual abuse.
o Dieting behaviour within family or personal experience.
o Occupational or recreational pressure to be slim (dancers, gymnasts, jockeys, models).
o Onset of puberty.
o Criticism or perceived criticism about weight or eating behaviour.

Personal characteristics:
o	Perfectionism.
o	Low self-esteem.
o	Obsessional traits.
o	Premorbid obesity.
o	Early menarche.
o	Difficulty with resolving conflict.
o	Anxiety.
o	Emotionally unstable personality disorder (formerly borderline personality disorder).

Question 18

What is the presentation of anorexia nervosa?

Answer 18

• Suspicion and diagnosis are based on history, suggestive clinical features and often concerns raised by a relative or friend. No single measure such as body mass index (BMI) can be used for either diagnosis or a decision about the need for treatment.

Clinical features include:
o Refusal to maintain a normal body weight for age and height.
o Weight below 85% of predicted. This means in adults a BMI below 17.5 kg/m2. For those under 18 years of age, BMI centile charts should be used. In young people there may be a lack of appropriate weight gain, rather than weight loss.
o Dieting or restrictive eating practices. Friends or family may report a change in eating behaviour.
o Rapid weight loss.
o Having a dread of gaining weight.
o Disturbance in the way weight or shape is experienced, resulting in over-evaluation of size. Disproportion in concern about weight or shape.
o Denial of the problem.
o Lack of desire for intervention, or resistance to it.
o Social withdrawal; few interests.
o Enhanced weight loss by over-exercise, diuretics, laxatives and self-induced vomiting.
o Problems managing pre-existing chronic diseases which involve dietary control, such as diabetes or coeliac disease.

Other physical features include:

• In women, amenorrhoea for three months or longer.
• Gastrointestinal symptoms are common, such as constipation, a feeling of fullness after meals, dysphagia and abdominal pains, and may hinder diagnosis and treatment.
• Symptoms such as fatigue, fainting, dizziness and intolerance of cold.
• Delay in secondary sexual development if pre-puberty.

Question 19

What are the examination findings for anorexia nervosa?

Answer 19

Examination can be normal but findings could include bradycardia, hypotension, peripheral oedema, gaunt face, lanugo hair, scanty pubic hair, and acrocyanosis (hands or feet are red or purple), lethargy, hair loss, dry skin, constipation and headaches.

Lanugo hair - response to loss of the insulating effect of fat tissue.

Question 20

Which questions should you ask a patient presenting with abnormal weight loss?

Answer 20

Abdominal pain, malaena, diarrhoea, joint pains, bloating, fever- all suggestive of organic disease.

Body image, ‘feeling fat’, pre-occupation with calories, wont eat, vegan, exercising, perfectionist shape, clothes now loose, new clothes size

Family history of eating disorder, family history of major mental illness. Drugs alcohol in family.

Menstrual history. Vomiting, bingeing. Laxative use. Amount being eaten and drunk. Hiding food, excess exercise. Safeguarding issues.

Behaviour: severe restriction of calorie intake, moderate to high levels of excessive exercise, fluid restriction, vomiting, purging, poor insight, violent rebellion against parental input, suicidal behaviour and self-harm.

Question 21

What are the investigations for anorexia nervosa?

Answer 21

An ESR and TFTs are useful screens for other causes of weight loss.

Other tests will depend on the individual presentation.

U&Es should be checked in all those with behaviours such as vomiting, taking laxatives or diuretics or water loading.

In patients with eating disorders and BMI below 15, a history of purging or high risk markers, frequent testing for FBC, ESR, U&Es, creatinine, glucose, LFTs and TFTs is required.

Consider a dual-energy X-ray absorptiometry (DXA) scan after a year of being underweight in those below 18 years of age (earlier if fractures or bone pain) and after two years in adults. Consider ongoing monitoring with DXA scans if they remain underweight, but no more often than every year.

An ECG may show bradycardia or a prolonged QT interval in those with more severe anorexia.

Weight for height ratio is usually used to assess how appropriate a person’s weight is for their height. BMI is less reliable in growing young people.

Core temperature: <36°C suggests medium risk; <35.5°C high risk.

Blood tests: low potassium, sodium, calcium, phosphate, albumin or glucose.

Squat test: unable to get up from a lying down position or from squatting without using arms for balance or leverage.

Question 22

What is the management of anorexia nervosa?

Answer 22

NICE recommends that if an eating disorder is suspected, immediate referral be made to a community-based, age-appropriate eating disorder service for further assessment or treatment.

The role of the GP is early detection, risk assessment, initial coordination of care, and sharing of ongoing monitoring. Latest guidelines stress the importance of early referral. Helping people with anorexia to reach a healthy body weight or BMI for their age is the key goal.

Monitoring of U&Es and regular ECGs may be required in severe cases.

Oral supplementation may be required to correct abnormal electrolyte balance, or IV if severe.

Advise regular assessment by a dentist if the person is vomiting regularly.

Seek specialist advice if reduced bone mineral density is diagnosed on DXA scan.

Oestrogen treatment is not advised routinely for females with anorexia by NICE, but may be considered for girls aged 13-17 years who have long-term low body weight and low bone mineral density with a bone age over 15, and in physiological dosage in those with delayed puberty and a bone age under 15. Bisphosphonates may be useful in adults.

Age-appropriate multivitamin-and-mineral supplements should be advised as long as diet is inadequate to provide all necessary nutrients.

Dietary advice should be given as part of the multidisciplinary specialist approach.

Medication is not advised as the sole treatment for anorexia.

Advise avoidance of excessive exercise.

Psychological therapy

Question 23

Psychological therapy in anorexia nervosa

Answer 23

Under 18:
o Anorexia-nervosa-focused family therapy (FT-AN) for children and young people is currently considered first-line treatment for children and adolescents.
o This typically involves 18-20 sessions over a year and consists of three phases. It makes the role of the family key in the individual’s recovery and gives control of the young person’s eating in the first phase to the parents or carers. This allows individual tailoring of diets and eating regimes within the normal context of the young person. No blame should be attributed to either the person or their family.
o In the second phase, once weight has been restored, the person with anorexia is encouraged to take back some independence in managing their eating habits, and in the final phase planning is made to maintain recovery and prevent relapse.
o Individual CBT if family therapy is inappropriate or ineffective.

Adults:
o Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED). This typically involves 40 sessions over 40 weeks, starting more often than once per week.
o Maudsley Anorexia Nervosa Treatment for Adults (MANTRA). This usually involves 20 sessions, weekly for the first ten weeks, then depending on response.
o Specialist supportive clinical management (SSCM). This also involves 20 or more weekly sessions with a specialist practitioner.

Question 24

When is hospital admission indicated in anorexia nervosa patients?

Answer 24

Urgent admission may be required if there is:
o Electrolyte imbalance or hypoglycaemia.
o Severe malnutrition.
o Severe dehydration.
o Evidence of incipient organ failure.
o Bradycardia (below 40 beats per minute) or a prolonged QT interval on the ECG.
o Very low BMI. Levels of risk are detailed above. BMI alone is not usually enough as a measure of high risk and other factors should be taken into consideration.
o Rapid weight loss (eg, more than 1 kg per week for more than two consecutive weeks).
o Need for medical stabilisation and refeeding.
o Inability or incapacity of parents or carers to provide the support needed.
o Significant suicide risk.

Admission is ideally to a specialist eating disorder unit with expertise to avoid deaths particularly from under-feeding or refeeding syndrome.

Question 25

What are the complications of anorexia nervosa?

Answer 25

• Hypokalaemia
• Hypotension
• Arrhythmias, mitral valve prolapse, peripheral oedema and sudden death.
• Anaemia and thrombocytopenia
• Hypoglycaemia
• Osteoporosis
• Constipation
• Infertility
• Infections
• AKI/ CKD
• Anxiety and mood disorders
• Alcohol dependency
• Social difficulties
• Suicide
• Chronic emaciation and pneumonia

Question 26

What is refeeding syndrome?

Answer 26

Refeeding syndrome is the potentially fatal shifts in fluids and electrolytes that can occur in malnourished patients receiving artificial refeeding, whether parenteral or enteral.

If uncorrected, it can lead to respiratory and cardiac distress, as well as hepatic, gastrointestinal and neuromuscular disturbances which can be potentially fatal

A drop in phosphate is a marker of refeeding syndrome and may precipitate respiratory arrest.

Question 27

What are the biochemical features of refeeding syndrome?

Answer 27

o	Fluid-balance abnormalities
o	Abnormal glucose metabolism
o	Hypophosphataemia
o	Hypomagnesaemia
o	Hypokalaemia
o	Thiamine deficiency

Question 28

What are the risk factors for refeeding syndrome?

Answer 28

Anorexia nervosa.
Chronic alcoholism.
Cancer.
Postoperative debilitation.
Elderly patients with comorbidities and decreased physiological reserve.
Uncontrolled diabetes mellitus.
Chronic malnutrition:
o Marasmus.
o Prolonged fasting or low-energy diet.
o Morbid obesity with profound weight loss.
o A high-stress patient unfed for >7 days.
Malabsorptive syndrome (eg, inflammatory bowel disease, chronic pancreatitis, cystic fibrosis, short bowel syndrome).
Long-term use of antacids.
Long-term use of diuretics.

Question 29

How do you prevent refeeding syndrome?

Answer 29

Refeeding should be started at no more than 50% of energy requirements in “patients who have eaten little or nothing for more than five days”, with the rate increasing if no refeeding problems are detected on clinical and biochemical monitoring.

Oral, enteral or intravenous (IV) supplements of potassium, phosphate, calcium and magnesium should be given unless blood levels are high before refeeding.

Check electrolyte levels once daily for one week and at least three times in the following week.

Question 30

What is bulimia nervosa?

Answer 30

Bulimia nervosa is an eating disorder characterised by repeated episodes of uncontrolled overeating (binges) followed by compensatory weight loss behaviours.

Question 31

What are the clinical features of bulimia nervosa?

Answer 31

Excessive preoccupation with body weight and shape.
Undue emphasis on weight in self-evaluation.
Feeling of lack of control over eating.
Compensatory weight control mechanisms which can be:
-Self-induced vomiting.
-Fasting.
-Intensive exercise.
-Abuse of medication such as laxatives, diuretics, thyroxine or amfetamines.

Question 32

What are the risk factors for bulimia nervosa?

Answer 32

Parental and childhood obesity, female gender, family dieting, hx of severe life stresses and possibly sexual or physical abuse.
Perceived pressure to be thin, early menarche.
Premorbid characteristics such as perfectionism, anxiety, obsessional traits, low self-esteem, emotionally unstable personality disorder (formerly borderline personality disorder), difficulty in resolving conflict.

Question 33

What are the differentials of bulimia nervosa?

Answer 33

Binge eating disorder
•Depression
Anorexia nervosa with bulimic features

Eating disorder not otherwise specified (EDNOS):
o Fulfils some but not all the features of anorexia nervosa. Outlook better than classical anorexia nervosa

Question 34

What are the investigations for bulimia nervosa?

Answer 34

These are usually normal apart from serum potassium, which is often low.

Renal function and electrolytes should be checked in view of frequent self-induced vomiting.

Question 35

What is the management for bulimia nervosa?

Answer 35

• CBT- Eating Disorder
• Regular dental reviews and dental hygiene ( rinse mouth after vomiting)
• Reduce laxatives slowly
• Screen for osteoporosis

Question 36

What are the complications for bulimia nervosa?

Answer 36

• Haematemesis
• Dental erosions
• Development of anorexia
• Painless enlargement of the salivary glands, tetany and seizures.