Eating disorders

Question 1

What are the basic DSM-5 characteristics for the diagnosis of anorexia nervosa?

Answer 1

1. restriction of caloric intake relative to energy requirements, despite having significantly low weight
2. An intense fear of weight gain or engaging in behaviors to interfere with weight gain, despite having significantly low weight
3. Having an altered perception of own’s weight or shape and/or disregard for th seriousness of one’s own significantly low weight.

Question 2

What are the subtypes of anorexia nervosa?

Answer 2

1. restricting: weight loss is primarily achieved through dieting, fasting, and/or excessive exercise
2. Binge eating/purging: engaging in repeated episodes of consumption of large quantities of food or purging through self-induced vomiting, misuse of laxatives, etc.

Question 3

True or false: Amenorrhea and specific weight %-iles are required for the diagnosis of anorexia nervosa

Answer 3

False

Question 4

What are the indications for hospitalization for a patient with an eating disorder?

Answer 4

o < 75th %-ile median BMI for age and sex
o Presence of dehydration and/or acute food refusal
o Electrolyte disturbances
o ECG abnormalities – prolonged QTc, severe bradycardia
o Physiologic instability
o Arrested growth/development
o Failure of outpatient treatment
o Uncontrollable binge-eating and purging
o Complications of malnutrition
o Comorbid psychiatric or medical conditions that prohibit/limit participation in outpatient therapy

Question 5

Below what heart rate is an indication for hospital admission for a patient with an eating disorder?

Answer 5

Severe bradycardia: < 50 bpm/day or < 45 bpm/night

Question 6

What blood pressure findings would indicate a need for hospital admission for a patient with an eating disorder?

Answer 6

Hypotension: < 90/45 mm Hg
Orthostatic changes: increase in HR > 20 bpm or decrease in BP

Question 7

What is refeeding syndrome?

Answer 7

A potentially life-threatening metabolic change in the setting of aggressive (fast) nutritional rehabilitation, resulting in fluid and electrolyte shifts

Question 8

What is the most concerning electrolyte abnormality seen in refeeding syndrome?

Answer 8

Hypophosphatemia: when refeeding begins, glucose intake causes insulin release, which leads to cellular uptake of phosphate. Phosphate is also used for ATP, which further exacerbates hypophosphatemia, which may lead to multisystem organ dysfunction.

Note: hypokalemia and hypomagnesemia may also be seen in refeeding, but these are not as worrisome.

Question 9

Which patients are at greatest risk of developing refeeding syndrome?

Answer 9

The risk of developing refeeding syndrome is greatest in:
- individuals who weigh <70% of ideal body weight,
- those with significant, rapid weight loss (>10% in 3-6 months),
- and those with little/no intake in the past 5-10 days.

Question 10

Patients are at highest risk for refeeding syndrome during which time frame?

Answer 10

During the first 1-2 weeks of nutritional rehabilitation.

Question 11

What are signs of refeeding syndrome?

Answer 11

Cardiac: arrhythmias, impaired contractility, HTN and edema
Respiratory: respiratory distress (from impaired diaphragmatic contractility)
MSK: tetany, weakness
GI: elevated transaminases, diarrhea
Neuro: tremors, paresthesia, Wernicke encephalopathy may develop if thiamine-deficient

Question 12

How is refeeding syndrome treated?

Answer 12

If refeeding syndrome develops, decrease the caloric intake and correct electrolyte abnormalities.

Question 13

How can refeeding syndrome be prevented?

Answer 13

“Start low and go slow” - consider starting as low as 1400 kcal/day (however, some centers have reported safely starting at 2200 kcal), avoid rapid increases in caloric intake, and monitor electrolytes daily.

Question 14

What are the basic DSM-5 characteristics for the diagnosis of bulimia nervosa?

Answer 14

1) Engaging in binge eating (eating large quantities of food within a distinct period of time + lack of self control
2) Engaging in behaviors to prevent weight gain (excessive exercise, self-induced vomiting)
3) Self value influenced by body weight an shape
4) Occurs at least 1x/week x 3 months

Question 15

What are the basic DSM-5 characteristics for diagnosis of avoidant restrictive food intake disorder (ARFID)?

Answer 15

1) disrupted eating pattern for reasons other than concern for body weight. Lack of interest, sensory issues and or concern for unpleasant events (choking, vomiting). Can result in weight loss, nutritional deficiencies, reliance on nutritional supplements and/or interference with psychosocial functioning
2) Behavior NOT otherwise explained with poor access to food, culture, or a coexisting medical condition or mental health disorder.

Question 16

What are the basic DSM-5 characteristics for the diagnosis of Other Specified Feeding and Eating Disorder (OSFED)?

Answer 16

Generally: Do not fulfill criteria for another eating disorder, still result in significant distress/impairment
1) atypical anorexia nervosa - associated with nutritional restriction, weight loss, decreased self worth, but weight is within normal range
2) bulimia nervosa, all criteria met but binge eating / compensatory behaviors occurred less that once a week for < 3months
3) Binge frequency of less than once a week and duration < 3 months
4) Purging disorder: recurrent purging behavior (self induced vomiting, laxative misuse) in the absence of binge eating with the intent to influence weight or body shape

Question 17

What vitamin deficiency is important to prevent/treat neurologic complications in eating disorders?

Answer 17

Thiamine deficiency (vitamin B1)
Implications: dry or wet beri beri or wernickes korsakoff
Important to replete in initial phase of presentation

Question 18

What treatment can improve bone health and prevent osteoporosis in eating disorders?

Answer 18

Vitamin D and calcium alone have been shown to be effective (in conjunction with resumption of menses)

Question 19

What medication management options are available for eating disorders?

Answer 19

There is very little pediatric evidence/data supporting the use of medications.
Anorexia Nervosa: Some case reports suggest use of atypical antipsychotics can support compliance and weight gain
Bulimia: SSRIs, specifically fluoxetine, has proven effective for reducing binging/purging in adults and a small trial with children
ARFID: No specific therapy has been studied

Question 20

What mineral deficiency should be suspected in eating disorders?

Answer 20

Zinc
Providing supplementation can address deficiency and can improve rate of recovery by improving depression and anxiety as well as weight gain