Eating Disorders Flashcards
Define anorexia nervosa (AN)
An eating disorder where there is a DELIBERATE weight loss that is induced and sustained BY THE PATIENT
What age does highest incidence of AN occur?
15-19
What are some at risk professions for AN?
Models, dancers, sportspeople
What are some comorbid mental health disorders that sometimes are seen alongside AN?
Depression
Anxiety
OCD
Obsessive/perfectionnist personalities
What may be apparent when taking a patient with AN’s history?
Preoccupation with food and calories
Starvation via restricting intake, purging (through induced emesis, diuretic or laxative abuse) or excessive exercise
Poor insight (i.e. lack of insight into severity)
Overvalued, intrusive obsession with weight, shape and fear of becoming fat
Weight/calorie goals in mind regardless of their impact on physical health
What BMI defines AN?
BMI <17.5 kg/m2
How does a definitive BMI separate AN and BN?
AN - BMI <17.5 kg/m2
BN - where there may be many similar features, but the BMI is normal (a key distinguishing feature)
Give some signs of AN on examination
- Hypotension
- Bradycardia
- Enlarged salivary glands
- Lanugo hair (fine hair covering skin)
- Amenorrhoea (hypogonadotropic hypogonadism)
Blood test results in AN?
deranged electrolytes – typically low calcium, magnesium, phosphate and potassium
low sex hormone levels (FSH, LH, oestrogen and testosterone)
leukopenia
raised growth hormone and cortisol levels (stress hormones)
hypercholesterolaemia
metabolic alkalosis
What electrolyte abnormalities are typically seen in AN?
Typically low calcium, magnesium, phosphate and potassium
How are the sex hormones affected in AN?
Low sex hormone levels (FSH, LH, oestrogen and testosterone)
How is the white cell count affected in AN?
Leukopenia - decreased
How are GH and cortisol (stress hormones) affected in AN?
Raised
How is cholesterol affected in AN?
Hypercholesterolaemia
What causes metabolic alkalosis in AN?
Due to vomiting or use of diuretics
What pharmacological drug may be used in management of AN?
SSRIs - these have not been shown to be effective at treating the AN directly, but may be effective for comorbid mental health issues, commonly depression and anxiety
Psycohological management for AN?
Treatment involves aiming to return to a healthy weight and using psychological therapies, such as eating disorder-focused CBT for eating disorders (CBT-ED), to treat the underlying thought processes
What is refeeding syndrome?
A potentially fatal disorder that occurs when nutritional intake is resumed too rapidly after a period of low caloric intake
What increases the risk of refeeding syndrome?
The lower the BMI and the longer the period of malnutrition, the higher the risk.
What occurs in refeeding syndrome?
Metabolism in the cells and organs dramatically slows during prolonged periods of malnutrition. After feeding, rapidly increasing insulin levels lead to shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces:
- Hypomagnesaemia
- Hypokalaemia
- Hypophosphataemia
These NEED to be replenished.
Symptoms of refeeding syndrome?
- Oedema
- Confusion
- Tachycardia
Can lead to:
- Heart failure
- Cardiac arrhythmias
- Fluid overload
What drug can be administered as a preventative method for refeeding sydrome?
Pabrinex
What is Pabrinex?
A high potency dose of vitamins (mainly B vitamins)
How can refeeding be managed to reduce risk of refeeding syndrome?
Slowly reintroducing food with restricted calories (NICE recommends no more than 50% of calorie requirement in ‘patients who have eaten little or nothing for more than 5 days’)
Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods
Fluid balance monitoring
ECG monitoring may be required in severe cases
Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
What is a long term complication of AN?
Osteoporosis
What ECG signs are typically seen in AN (NOT refeeding)?
Bradycardia
Prolonged QTc
How does a patient’s age at presentation affect prognosis of AN?
Negative prognostic indicator if presentation after the age of 20 years – difficult to reverse fixed beliefs
Give some negative prognostic indicators of AN
- Presentation after the age of 20 years
- BMI <16 kg/m2
- Marked anxiety when eating in front of others, which indicates issues with socialisation
-Bingeing/vomiting responds less well to CBT than starvation
Define bulimia nervosa (BN)
Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating followed by compensatory behaviours, typically self-induced vomiting or laxative abuse.
What is a distrnguising feature between AN and BN?
In BN, patients often have a normal BMI (>17.5)
What is the female:male ratio for BN?
10:1
Give some pyschological symptoms see in BN
- Binge eating
- Purging
- Body image distortion
What is purging?
Binge episodes often lead to feelings of shame and guilt, leading to attempts to ‘undo the damage’ through behaviours such as induced vomiting, misuse of laxatives or diuretics, and excessive exercise
What is binge eating?
Characterized by a loss of control, consumption of enormous amounts of food with high caloric content, often with a sense of urgency and compulsion
Give some physical signs seen in BN
- Dental erosion
- Parotid gland swelling
- Russell’s sign
- Mouth ulcers
What salivary gland is affected in BN?
Parotid gland typically swollen
What is Russell’s sign?
Scarring on the back of the hand or knuckles caused by repeated self-induced vomiting (where knuckles have scraped against teeth)
What metabolic imbalance is seen in BN?
Alkalosis
What causes alkalosis in BN?
Due to vomiting hydrochloric acid from the stomach
A teenage girl with a normal body weight presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas. The presenting complaint may be abdominal pain or reflux.
What is diagnosis?
BN
Investigations in BN?
A detailed medical history –> To evaluate for recurrent episodes of binge eating and compensatory behaviours
A comprehensive physical examination –> To identify potential physical signs of bulimia, including dental erosion, parotid gland swelling, or Russell’s sign
Psychological assessments –> To evaluate for associated psychological conditions and body image distortion
Management of BN?
Specialist referral
Cognitive-behavioral therapy (CBT): CBT is the first-line treatment for bulimia nervosa and focuses on altering destructive eating behaviours and thought patterns, as well as improving body image and self-esteem
What is binge eating disorder (BED)?
Frequent, recurrent episodes of binge-eating
NO regular compensatory behaviours
Who is BED typically seen in?
Often normal weight, overweight, or obese
What is avoidant-restrictive food intake disorder (ARFID)?
Avoidance/restriction of food leading to insufficient quantity or variety of food to meet nutritional requirements
What is the difference between AN and ARFID?
ARFID is NOT motivated by preoccupation with body weight or shape where AN is
What are the 3 main profiles typically seen in ARFID?
1) Apparent lack of interest in eating or food
2) Avoidance based on the sensory characteristic of food
3) Concern about aversive consequences of eating (vomiting/choking/discomfort/traumatic association)
Biological risk factors for eating disorders?
- Genetics (adoption studies show a significant link)
- Perinatal factors – low levels of Vit D, maternal drug use etc
- Oestrogen surge in puberty – younger age of menarche linked with disorder eating
- Autoimmune disorders (T1DE)
How is age of menarche implicated in EDs?
younger age of menarche linked with disorder eating
Sociocultural factors in EDs?
- Family dynamics
- Early life
- Body objectification
- Social support and comparison
- Bullying
- Adverse life event
- Hobbies/professions which emphasise weight
- Religion
- Tripartite influence mode
Psychological factors in EDs?
- Body Dissatisfaction
- Perfectionism
- Low self-esteem
- Negative affectivity
- Impulsivity and urgency
- Comorbid psychiatric disorders
- Emotional trauma
