Eating disorders

Question 1

Eating Disorders

general

Answer 1

Characterized by a persistent disturbance of eating behavior that impairs health or psychosocial functioning

Includes
Anorexia nervosa
Bulimia nervosa
Binge eating disorder

Lifetime prevalence
5% in females; 2% in males
Highest among individuals with obesity

Question 2

eating disorder

Pathogenesis

Answer 2

Multifactorial – combination of biological, sociocultural, and psychological factors
Genetic risk is strongest for anorexia nervosa

Question 3

Biological Risk Factors for Eating Disorders

Answer 3

Having a close relative with an eating disorder
Having a first-degree relative (like a parent or sibling) with an eating disorder increases a person’s risk of developing an eating disorder

Having a close relative with a mental health condition
Depression, anxiety, alcohol dependence

History of dieting
A history of dieting and other weight-control methods is associated with the development of binge eating

Type 1 (insulin-dependent) diabetes
Research has found that up to 39% of women and 15% of men with type one diabetes will develop an eating disorder
The most common pattern is skipping insulin injections, known as diabulimia, which can be deadly

Question 4

PsychologicalRisk Factors for Eating Disorders

Answer 4

Perfectionism (especially self-oriented perfectionism)
One of the strongest risk factors; involves setting unrealistically high expectations for oneself

Cognitive inflexibility
Difficulty with going back and forth between different tasks or mental states
Impulsivity
Taking actions without consideration of the consequences, especially when experiencing negative emotions, has been linked to an increased risk of binge/purge types of eating disorders

Body image dissatisfaction
Body image encompasses how you feel both about and in your body
People who develop eating disorders are more likely to report higher levels of body image dissatisfaction

Personal history of a mental health condition
A significant subset of people with eating disorders, experience mood disorders like depression and anxiety disorders before the onset of their eating disorder

Personal history of a substance use disorder
Up to 50% of individuals with eating disorders use alcohol or illicit drugs (5x higher than the general population)
~35% of individuals who were dependent on alcohol or other drugs also have eating disorders (11x greater than the general population)

Question 5

SocialRisk Factors for Eating Disorders

Answer 5

Weight stigma
Discrimination or stereotyping based on a person’s weight, and is damaging and pervasive in our society
The message that thinner is better is everywhere

Teasing or bullying
Individuals with eating disorders are up to three times more likely to have experienced bullying or teasing about their appearance than those without an eating disorder

Limited social networks
Loneliness and isolation are some of the hallmarks of anorexia nervosa and binge eating disorder

Personal experiences of trauma
A significant subset of people with eating disorders have experienced past trauma, such as physical, sexual, or emotional abuse

Question 6

eating disorder

Screening
Questionnaire

Answer 6

Eating disorders are often undetected
Eating disorders demonstrate significant transdiagnostic drift (patients with anorexia nervosa often crossover to bulimia nervosa or diagnostic crossover between bulimia nervosa and binge eating disorder)

Screen for eating disorders in primary care patients who are at increased risk:
Patients with a history of trauma
Young adults
Females
Transgender individuals
Athletes
Patients presenting with:
Sign/symptoms of eating disorders
Anxiety and/or depressive disorders
Perfectionism

SCOFF questionnaire is recommended by the U.S. Preventive Services Task Force

Question 7

SCOFF Questionnaire

Answer 7

Consists of five clinician-administered questions:
Do you make yourselfSick because you feel uncomfortably full?
Do you worry you have lostControl over how much you eat?
Have you recently lost more thanOne stone (14 pounds or 6.35 kg) in a three-month period?
Do you believe yourself to beFat when others say you are too thin?
Would you say thatFood dominates your life?

Answering “yes” to two or more questions is generally regarded as a positive screen

A positive screen should prompt further assessment to establish or rule out a diagnosis

Question 8

Anorexia Nervosa

general and epi

Answer 8

Eating disorder characterized by self-imposed starvation and inappropriate dietary habits due to an intense fear of weight gain and disturbedperceptionof body shape and weight

Epidemiology
Prevalence: ~1%
3x more common in women
Women aged 15–25 years are most commonly affected; median age of onset is 17 years
Highest death rate of any mental illness (5%–20%)

Question 9

Anorexia Nervosa

Pathophysiology

neurotransmitters

Answer 9

Complex interaction between biological, psychological, and social factors PLUS neurobiological factors
Abnormalities inbrainareas involved in appetite and habitual behavior (corticolimbic reward circuits)

Abnormalities in neurotransmitters
Dopamine - eating behavior, motivation, and reward
Serotonin - mood, impulse control, and obsessional behavior

Question 10

Anorexia Nervosa

Level of Severity

Answer 10

The minimum level of severity is based on current BMI
BMI = weight in kilograms (kg) divided by height in meters squared (m2)

Mild:BMI ≥ 17 kg/m2
Moderate:BMI 16 to 16.99 kg/m2
Severe:BMI 15 to 15.99 kg/m2
Extreme:BMI < 15 kg/m2

Question 11

Anorexia Nervosa

Symptoms

Answer 11

Difficulty concentrating and making decisions
Depressed mood andanxiety
Deliberate self-harm/suicidality
Headaches
Fainting or dizzy spells
Lethargy
Cold intolerance (decreased thyroid hormones)
Epigastric pain,gastroparesis
Constipation

Question 12

Anorexia Nervosa

Signs

Answer 12

Emaciation (body weight less than 85 percent of ideal body weight)
Hypotension,bradycardia, arrhythmias
Hypothermia (core temperature < 35°C or 95°F)
Xerosis,dehydration
Brittle hair and hair loss
Lanugo (fine, soft hair)
Physical signs consistent with self-induce-vomiting
Swellingof thesalivary glands
Dental caries, gum recession
Scars or calluses on thehandfrom contact with theteeth(Russell sign)
Proximal muscle weakness
Amenorrhea
Edema – around the eye; lower extremities

Question 13

Answer 13

lenugo top left,
descrution on enamel and dental caries,

Question 14

anorexia nervosa

labs

Answer 14

Nutritional deficiency
↓Iron
↓Folate
↓ Vitamin B12
↓Vitamin D

Anemiasecondary to nutritional deficiencies
Cytopenias

Serum electrolyte abnormalities due to recurrentvomiting
↓Potassium
↓Calcium
↓Magnesium
↓Phosphate
Disturbances inalbumin(lowalbumin indicate a chronically low protein intake)

Hypercholesterolemia- due to high cortisol

Elevatedliverenzymes

Urinalysisshowing increased sedimentation rate

Disruption ofthyroidhormone level

Secondaryamenorrhea
↓ Luteinizing hormone (LH)
↓ Follicle-stimulating hormone (FSH)

Question 15

eating disorder

ECG and DEXA

Answer 15

ECG: showssinus bradycardia

DEXAscan
Decreasedbonemineral density (due to insufficient calcium, phosphate, andvitamin Din diet)

Question 16

eating disorder

DSM-V Criteria

Answer 16

Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health

Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain, even though at a significantly low weight.

Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

Subtypes
Restricting type
During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
Weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise
Binge-eating/purging type
During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Question 17

Eating disorder

complications

Answer 17

Malnutrition
Delayed puberty
Amenorrhea
Arrested growth
Osteoporosis

Electrolyte imbalances
Hypokalemia, Hypophosphatemia, and Hypomagnesemia

Cardiovascular effects
Cardiomyopathy
Prolonged QT syndrome
Bradycardia

Question 18

Anorexia

Tx

Answer 18

Treatment involves a combination ofpsychotherapyand pharmacotherapy for the anorexia and associated comorbidities

Psychotherapy
Cognitive behavioral therapy is the mainstay of treatment
Family therapyis also recommended for thosepatientswho reside with their families

Pharmacotherapy
Limited role
Olanzapine (atypical antipsychotic)may be indicated in some cases (helpspatientsto gain weight)
Antidepressants can also helppatientsto gain weight (paroxetineor mirtazapine)

Question 19

eating disorder

Inpatient hospitalization

Answer 19

Recommended for patients with any one or more of the following:

Unstable vital signs:
Bradycardia less than 40 beats per minute
Blood pressure < 80/60 mmHg or symptoms of lightheadedness
Cardiac dysrhythmia or any rhythm other than normal sinus rhythm or sinus bradycardia
Weight < 70 percent ideal body weight or BMI
Cardiovascular, hepatic, or renal compromise requiring medical stabilization
Marked dehydration
Serious medical complication of malnutrition (syncope, seizures, cardiac failure, liver failure, pancreatitis, hypoglycemia, or marked electrolyte disturbance)
Refeeding syndrome
Poor response to outpatient treatment

Question 20

Refeeding Syndrome

Answer 20

Constellation of critical acid-base and electrolyte disturbances that may occur due to refeeding of malnourished patientswho are persistently starved

Sudden reintroduction of caloric intake (carbohydrates) results in:
Increasedinsulin→ causes a sudden shifting of fluid and electrolytesinto cells

Hypokalemia,hypomagnesemia, andhypophosphatemia→ arrhythmia
Salt and water retention →edema

Prevention of refeeding syndrome with a slow introduction of calories and vitamin supplementation

Question 21

Bulimia Nervosa

general and epi

Answer 21

Eating disorder characterized by recurrent episodes ofbinge eating (consuming a larger-than-appropriate amount of food in a set period of time) accompanied by inappropriate compensatory behavior (purging)

Excessive concern with body weight and shape with abnormal view of weight on self-worth

Epidemiology
More common in women
Women aged 18–35 years are most commonly affected
Prevalence: ~1%

Question 22

buliimia nervosa

Pathophysiology

Answer 22

Complex interaction between biological, psychological, and social factors PLUS neurobiological factors

Hunger and satiety states are not accurately recognized by the anterior insula

Alterations in hormones and neuropeptides (ghrelin and leptin)

Question 23

bulimia

level of severeity

Answer 23

Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week

Moderate: An average of 4 -7 episodes of inappropriate compensatory behaviors per week

Severe: An average of 8 -13 episodes of inappropriate compensatory behaviors per week

Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week

Question 24

bulimia nervosa

Clin man

Answer 24

BMI> 18.5kg/m2
Orthostatic hypotension
Physical signs consistent with self-inducedvomiting
Swellingof thesalivary glands
Dental caries, gum recession
Scars or calluses on thehandfrom contact with theteeth(Russell sign)
Dehydration
Menstrual irregularities
Mallory-Weiss syndrome
Bloating
Constipation

Question 25

Question 26

bulimia nervosa

Labs

Answer 26

Suggestive, but not diagnostic of bulimia

Increased serumamylase due toparotid glandhypertrophy
Electrolyte abnormalities (hypokalemia,hypochloremia) due to vomitingand excessive renal loss ofpotassium
Metabolicalkalosis(due to recurrent acid loss in vomitus)

Question 27

Bulimia nervosa

DSM-V Diagnostic Criteria

Answer 27

Recurrent episodes of binge eating an episode of binge eating is characterized by both of the following:

Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances

A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months

Self-evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during episodes of anorexia nervosa

Question 28

bulimia nervosa

Tx

Answer 28

Treatment involves a combination ofpsychotherapyand pharmacotherapy for the bulemia and associated comorbidities

Psychotherapy
Cognitive behavioral therapy is the mainstay of treatment
Goal is to normalize patient’s eating behavior and avoid destructive binge-eating episodes.

Pharmacotherapy
Selective serotonin reuptake inhibitors(SSRIs) are preferred
Other options
Tricyclic antidepressants
Monoamineoxidaseinhibitors
Mood stabilizers
Bupropionis contraindicated in bulimia nervosa (may induceseizures
Adjunct therapy
Nutritional rehabilitation to help replace nutritional stores

Question 29

Binge Eating Disorder

General and epi

Answer 29

Eating disorder in which the patient has recurrent episodes of binge eatingwithoutinappropriate compensatory behavior
Involves consuming an amount of food in a specified amount of time that greatly exceeds what most people would consume in that same amount of time
Comorbid psychopathology often occurs (major depression and anxiety)

Epidemiology
Women are affected more than men
Lifetimeprevalenceis 2%–3%
Prevalence increases with increasing weight
Median age of onset is ~21 years

Question 30

binge eating

DSM-V criteria

Answer 30

Recurrent episodes of binge eating (eating a larger than usual amount of food in a discrete period) with lack of control (in both eating or amount of food)

Marked by 3 or more of the following features:
Eating more quickly than normal
Eating uncontrollably to the point of discomfort
Eating large amounts of food when not hungry
Eating alone due to embarrassment
Feeling disgust (over oneself) or guilt after overeating

Inappropriate compensatory behaviors such aspurging, fasting, or excessive exercise (as seen withbulimianervosa) are NOT seen
On average, episodes occur ≥ once a week for 3 months

>1000 kcal in a discrete period of time (less than two hours)

Question 31

binge eating

Level of Severity

Answer 31

Mild: 1-3 binge-eating episodes per week
Moderate: 4-7 binge-eating episodes per week
Severe: 8-13 binge-eating episodes per week
Extreme: 14 or more binge-eating episodes per week

Question 32

Binge eating

Tx

Answer 32

Evaluation and treatment to address nutritional needs, psychiatric issues (depression,anxiety, low self- esteem) and comorbidities (obesity, HTN,etc.)

Psychotherapy
Cognitive Behavioral Therapy
First-line treatment
Rapid improvement in binge eating symptoms is associated with goodprognosis
Interpersonalpsychotherapy: useful in long-term treatment by addressing root causes
Group therapy - Overeaters Anonymous
Lifestyle modification
Low-calorie diet and consistent exercise are best for long-term management
Nutritional consult may be beneficial

Pharmacotherapy
Antidepressants, such asselective serotonin reuptake inhibitors(SSRIs) help with mood and binge eating symptoms
Mood stabilizers, such astopiramate(ananticonvulsant)
Stimulantssuppress appetite but have little impact over the long term