Anorexia/Bulimia/eating disorders Flashcards
Categories of eating disorders according to DSM-5
- anorexia
- Bulimia
- binge-eating disorder
- avoidant/restrictive food intake disorder {ARFID}
Common features of anorexia and bulimia
- dysfunctional eating patterns
- underlying psychosocial issues
- low self-esteem
- depression
- family dynamics
- body image disturbance
- weight changes/fluctuations
DSM-5 criteria for anorexia
- restriction of energy intake
- intense fear of weight gain even though underweight
- distortion in body weight/shape experience
- removed amenorrhea and below 85% threshold of expected body weight
DSM-5 criteria for bulimia
- cycles of binge eating
- recurrent inappropriate compensatory behaviors to prevent weight gain
- frequency of episodes: at least one time per week
Eating disorders variants
anorexia and bulimia on one extreme also includes binge eating, frequent dieters/obsessive dieters
Mild variants of eating disorders can threaten
growth and development
mild variants of eating disorders can progress into
full-blown eating disorders or remain static
mild variants of eating disorders need to be
monitored
who is more likely to develop eating disorders
severe dieters
Significance of primary care in eating disorders
- often delay between onset and treatment
- unrecognized in clinical setting up to 50% of time
Eating disorders affects
5 million Americans yearly
what is the 3rd most common chronic adolescent illness
eating disorders
occurrence of eating disorders
- predominantly in females
- often onset at age 15-19;
- increased risk in athletes, diabetics, and obese adolescents
- most common among caucasians
Peak onset of anorexia
between 15 and 19 years
peak onset of bulimia
between 18 and 23 years;
- bulimia may arise out of anorexia
Risk factors for eating disorders
- family history of obesity, affective disorders
- biologic contributors such as serotonin dysfunction and onset of puberty
Psychological risk factors of eating disorders
- psychiatric diagnoses
- concerns about self-control, low self-esteem, or self- efficacy;
- stress from developmental tasks
- history of abuse
Social risk factors of eating disorders
- obesity
- media impact on body image norms
- modeling or specific sports
- family hx of disordered eating or alcoholism
etiology of eating disorders
- dieting is common entry point
Hypothesis of etiology of eating disorders
- genetic: familial transmission
- biochemical factors
- family functioning
- avoidance of sexual pressure
physiological disturbances of anorexia
- speculation that anorexia is biological condition for example investigations into disruptions in pituitary, hypothalamus, neurotransmitters;
- many conditions resolved with normalized body weight but probably not prime cause
Serotonin and eating disorders
- plays role in mood, stress response, eating behaviors
- major serotonin metabolite low in anorexics is 5-hydroxyindoleacetic acid
Leptin and eating disorders
- hormone produced in fat cells
- closely involved with satiety signaling
- one hypothesis: anorexics have abnormality in leptin receptors but current research disproves this
Assessment for eating disorders
- look for clues
- ask questions
- screen
SCOFF Screening
- do you make yourself sick because you feel uncomfortably full?
- do you worry you have lost control over how much you eat?
- have you recently lost more than 14# in 3 months
- do you believe yourself to be fat when others say you are thin?
- would you say food dominates your life?
screening questions for eating disorders
- how much would you like to weigh
- how do you feel about your present weight
- do you or anyone else have concerns about your eating
evaluation for eating disorders
- previous weight and height
- maximum/minimum weight
- history of cycling
- current and desired weight
- BMI
- body image concerns and fears
what BMI is considered anorexic
below 17.5
what BMI is considered underweight
17.5-20
what BMI is considered normal weight
20-25
what BMI is considered overweight
25-30
what BMI is considered obese
over 30
what BMI is considered morbidly obese
over 35
Differential diagnosis for eating disorders
- intentional weight loss
- depression
- central nervous system lesions
- new-onset diabetes
- GI conditions
- infection
- malignancy
- adrenal insufficiency
Nutritional history for eating disorders
- be careful, direct, nonjudgmental
- detailed info on weight changes
- ideal weight
- target weight
- food restrictions/history
- parental observations
- eating rituals
- exercise history
- social/family history
- menstrual history
- medications
Review of systems for eating disorders
- dizziness, blackout, weakness
- pallor, easy bruising
- cold intolerance
- hair loss, dry skin
- vomiting, diarrhea, bloating, abdominal pain
- muscle cramps, joint pains, chest pains
- menstrual irregularities
- s/s of differentials in question
Initial psychological assessment for eating disorders
- level of obsession with food/weight loss
- willingness to receive help
- home/school functioning
- comorbidities/psychological illness
- parental evaluation/reaction
Clues for anorexia
- rapid/severe weight loss
- dieting, taboo foods, calorie counting
- excessive exercise
- focus on body image
- symptoms such as weakness or fatigue
physical assessment for eating disorders
- vital signs
- skin/extremities
- cardiac exam
- abdominal exam
- neurological exam
- evaluate for other causes of weight loss
Cardiac complications from eating disorders
- bradycardia
- hypotension
- EKG abnormalities
- Syncope
- mitral valve prolapse
GI complications from eating disorders
- hypomotility/constipation
- abdominal pain
- elevated liver enzymes
Metabolic/endocrine complications from eating disorders
- cold intolerance
- hypothermia
- amenorrhea
- delayed puberty
- hypoglycemia
Musculoskeletal complications from eating disorders
- muscle wasting
- loss of sub-Q fat tissues
- low weight
- low body mass index and low bone density
- pathologic/stress fractures
Neurological complications from eating disorders
- seizures
- cognitive and memory dysfunction
- depression
- anxiety
- abnormal EEG
Hematologic complications from eating disorders
- easy bruising
- leukopenia
- anemia
- thrombocytopenia
Lab testing for eating disorders
- dx is clinical and doesn’t require labs
- baseline needed
- can be affected by state of nutrition and weight-control behaviors
- routine tests:
- CBC with differential
- sed rate
- electrolytes
- urine, serum protein, and albumin
Other labs to differentiate eating disorder from other causes
- T2 and TSH
- stool
- HIV
- pregnancy
- PPD
- EKG
- chest X-ray
- bone density
Findings for eating disorders
- falsely elevated hemoglobin
- elevated or low BUN
- hypokalemia
- acidosis
- electrolytes normal when purging stops
- hypoglycemia
- increased cholesterol
What is the main characteristic of bulimia
binge eating
Essential diagnostic features of bulimia
- binging and purging
- inappropriate methods used to prevent weight gain
Definition of binging
in a dicrete period of time, eating an amount of food that is definitely larger than most individuals would eat under similar circumstances
Length of time that binge eating usually occurs
less than 2 hours
binge eating usually involves what types of food
food that is very caloric and high in carbohydrates
Binge eating often occurs
in secrecy
binge eating is triggered by
dysphoric mood states or lack of control
Manifestations of bulimia
- weight cycles (gain/loss)
- trips to bathroom after meals
- vomiting, laxatives, enemas, and excesive exercise
Physical signs and symptoms of bulimia
- Russell’s sign - calluses or scars on backs of hands
- parotid swelling bilateral
- loss of dental enamel
- GERD
- constipation
- bruises/lacerations of palate and post-pharynx
- cardiomyopathy if using ipecac for vomiting
- esophageal rupture (emergency)
Presentation of patient with bulimia
- often normal weight
mean duration of bulimia before diagnosis
6 years
Psychiatric signs and symptoms of bulimia
- suicidal ideation
- depression
- anxiety
Physical findings of bulimia
- Electrolyte imbalances on labs
- ## EKG abnormalities (QTc prolongation);
complications of bulimia
- pancreatitis
- constipation
- loss of gag reflex (GERD)
- seizures
- cognitive and memory problems
- depression
- anxiety
The majority of bulimics meet criteria for what comorbidites
at least one of the following personality disorder
- obsessive compulsive disorder
- borderline personality disorder
- depression
Comorbidites found in bulimics
- hx of highesubstance abuse rate
- hx of sexual conflicts
- hx of impulsive behaviors;
- promiscuity
- self-mutilation
Lab studies performed for bulimia
- electrolytes;
- hypocalcemia
- hyponatremia
- hypochloremia
- metabolic acidosis from loss of stomach acid from vomiting
Detection of bulimia
- serum electrolyte screen +
- exam of teeth, hands, and salivary glands
- *together can detect 85% of bulimia with normal weight
Mortality rate of anorexia
4%
What % of anroexia will become chronic
10-31%
What % of anorexic patients will develop bulimia
50%
Mortality rate of bulimic patients
3.9%
50 % of bulimic patients will have full recovery within _____
2 years
55% of pts with bulimia will develop
mood disorders
Prevention of eating disorders
- be sensitive to weight issues
- use nonjudgmental tone
- focus on education in community and office for pt and family
- watch for key warning signs
- implement regular screening
Challenges for diagnosing eating disorders
- late presentation (often missed in primary care)
- denial, secretive, and manipulative behaviors
- noncompliance of pt and family
- difficulty with insurance reimbursement
