Clinical Approach to Eating Disorders and Refeeding Syndrome

Question 1

who is likely to develop an eating disorder?

Answer 1

women and adolescents

western societies

Question 2

what ideology often accompanies eating disorders?

Answer 2

suicidality

Question 3

DSM5 criteria for anorexia nervosa (AN)

Answer 3

restriction of energy intake relative to requirements, leading to low body weight for age, sex and development

intense fear of gaining weight or becoming fat despite being underweight

distorted perception of body weight and shape or denial of low body weight

Question 4

screening questions for eating DOs

Answer 4

1. are you satisfied with your eating patterns?
2. do you ever eat in secret?
3. does your weight affect the way you feel about yourself?
4. have any family members suffered with an eating disorder?
5. do you currently suffer with or have suffered in the past with an eating DO?

Question 5

restricting type AN

Answer 5

3 months of no binging or purging (no vomiting or lax)

excessive exercising, fasting, dieting

Question 6

binge-eating/purging type AN

Answer 6

3 months of binging and purging behaviors

self-induced vomiting
misuse of laxatives, diuretics, or enemas

Question 7

AN cardiac complications

Answer 7

bradycardia
hypotension
QT dispersion
cardiac atrophy
mitral valve prolapse

Question 8

AN gynecologic complications

Answer 8

amenorrhea

decreased libido

Question 9

AN endocrine complications

Answer 9

osteoporosis
hypothermia
euthyroid
hypoglycemia

Question 10

AN GI complications

Answer 10

gastroparesis

constipation

Question 11

AN electrolyte complications

Answer 11

dehydration
hypokalemia
hypophosphatemia
hypomagnesia

Question 12

AN pulmonary complications

Answer 12

respiratory muscle atrophy

dyspnea

Question 13

AN hematologic complications

Answer 13

anemia
leukopenia
thrombocytopenia

Question 14

AN neurologic complications

Answer 14

brain atrophy

Question 15

AN derm complications

Answer 15

xerosis (dry skin)
lanugo (peach fuzz)
carotenoderma (orange skin)
acrocyanosis (blue ext)
seborrheic dermatitis

Question 16

Refeeding syndrome

Answer 16

clinical complication that occurs as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients

Question 17

complications of refeeding syndrome

Answer 17

hypophos
hypok
CHF
peripheral edema
rhabdomyolysis 
seizures
hemolysis

Question 18

how to avoid refeeding syndrome

Answer 18

limiting the amount of calories and fluid provided in early stages of refeeding

avoid rapid increases in the daily calories ingested

closely monitoring labs and the patient during the first few weeks of refeeding

Question 19

AN comorbidities

Answer 19

OCD
depression
impulse control DO
personality DO

Question 20

AN treatment

Answer 20

mental health clinician, registered dietitian and general medical clinician

nutritional rehab and psychotherapy

hospitalization to avoid refeeding syndrome, suicidality or starvation

hospitalization until normal weight achieved

meds may be used when depression/anxiety creating barriers to care

Question 21

AN nutritional rehab

Answer 21

supervised meals

2-3 lbs per week for inpatient

0.5-1 lb per week for outpatient

start at 30-40 Cals/kg and progressively increase

Question 22

AN psychotherapy

Answer 22

focus on helping patient confronting DO and change eating habits/thoughts of weight gain

cognitive behavioral therapy
specialist supportive clinical management
motivational interviewing
family therapy

Question 23

AN pharmacotherapy considerations

Answer 23

only for patients who have been resistant to other therapies

start at low doses

Question 24

AN meds

Answer 24

Olanzapine (anti-psych)
Lorazepam for anxiety
SSRI for anxiety or depression

Question 25

DSM5 criteria for bulimia nervosa (BN)

Answer 25

recurrent episodes of binge eating - eating large amounts of food in a discrete period of time

recurrent compensatory behavior to prevent weight gain (vomiting, lax)

binge/purge occurs at least 2x/week for 3 months

patients self-eval is influenced by body weight and shape

disturbance does not occur exclusively during an episode of AN

Question 26

BN considerations

Answer 26

patients vary between normal body weight, underweight or overweight

may use same weight loss tactics as AN

patients feel lack of control over binge eating but try to conceal it

dysphoria after binging

fearful of weight gain - may not want to become thin but just don’t want to become fat

Question 27

BN medical complications

Answer 27

similar to that of AN except:
Mallory-weiss syndrome/esophageal rupture

glandular hypertrophy

abd pain, bloating and constipation

tooth enamel erosion and caries

Russel’s sign - scar and callus on dorsum of hand

Question 28

BN comorbidities

Answer 28

anxiety
mood DO
substance abuse
personality DO

Question 29

BN treatment

Answer 29

combination of nutritional rehab, CBT psychotherapy and pharmacotherapy

Question 30

BN pharm considerations

Answer 30

less effective than CBT - best used in combo

avoid bupropion

Question 31

BN meds

Answer 31

fluoxetine

SSRIs

Question 32

DSM5 criteria for Binge Eating Disorder (BED)

Answer 32

episodes of binge eating

lack of control over eating

binge-eating marked by at least three of the following:
eating large amounts when not hungry
eating rapidly 
feels uncomfortably full after eating 
eating alone due to embarrassment
feeling of guilt after eating

episodes occur at least 1x/week for 3 months

Question 33

BED treatment

Answer 33

CBT and interpersonal therapy are most effective

pharmacotherapy used in combo with psychotherapy

Question 34

BED pharmacotherapy

Answer 34

Vyvanse
SSRIs

*anti-obesity drugs NOT recommended