Eating Disorders Flashcards
A BMI of < ____ kg/m2 is considered to be extreme Anorexia.
15mg/m2
Define Bulimia Nervosa according to the DSM-V.
Episodes of binge eating & compensation (ie. Laxatives, Vomiting, Diuretics, Drugs, Exercise, Diet) at least once weekly x 3mths
What body type do Bulimic patients most typically present with?
Normal - Slightly Overweight
Mild Bulimia is classified as 1-3 episodes per week… What constitutes Extreme Bulimia?
> /= 14 episodes weekly
Does Bulimia Nervosa diagnosis or severity ranking require a specific BMI?
Nope
How does Binge Eating Disorder (BED) differ from Bulimia?
No compensatory behaviors after excessive eating.
Explain the neurobiological dysfunction in Anorexia & Bulimia.
Chronic stress, starving, excess exercise = Increased Cortisol, which suppresses HPA, HPT & HPG axes.
What are the repercussions of HPG axis suppression in AN / BN?
Reduced estradiol, progesterone & LH production (which leads to amenorrhea & reduced libido).
5HT deficiency in AN / BN is due to a deficiency in what dietary AA?
Tryptophan
5HT deficiencies in AN / BN causes what to occur?
-Dysregulated satiety
-Anxiousness
-Disrupted Sleep / Mood
-OCD
DA deficiencies in AN / BN cause what to occur?
-Reduced energy
-Reduced pleasure
-Reduced reward feelings
NE deficiencies in AN / BN can cause what to occur?
-Hypotension
-Bradycardia
TSH inhibition in AN / BN reduces T4 to T3 conversion & leads to what?
Reductions in one’s resting metabolic rate
In terms of gendered prevalence, describe the rates of each eating disorder.
Anorexia: F > M
Bulimia: F > M
BED: Close to =
What is the typical peak age of onset for the various eating disorders?
Mid to late adolescence (14 - 20yrs)
What eating disorder demonstrates the highest mortality rates of any mental health illness?
Anorexia
What fraction of deaths amongst Anorexia Nervosa patients are due to suicide?
1/5 (20%)
What are the major risk factors predicting death amongst Anorexia patients?
-Low presenting wt
-Long duration illness
-Alc use
What types of disorders do Bulimic patients tend to develop at an increased rate (especially those with recurrent hospitalizations)?
CVD
How does the course of disease progression differ for Bulimia (in comparison to Anorexia)?
Anorexia: More chronically deteriorating course, no periods of remission.
Bulimia: Can be chronic or intermittent, with periods of remission & reoccurrence.
Why is amenorrhea in various eating disorders problematic?
-Increased Osteoporosis
-Reduced growth velocity
-Reduced sex drive
Unexpected Pregnancies
If somebody becomes pregnant with an eating disorder, what are some complications that can arise?
-Micronutrient Deficiencies for baby (developmental issues)
-Miscarriages
-Low birth wt / premature birth
-Troubles breastfeeding
-Postpartum depression
What percentage of women have relapses with their eating disorders during pregnancy?
22%
Once eating disorders are resolved, how long does it take for a woman to get her period back?
Usually within 6mths
T or F: The return of a normal menstrual cycle is related to both the amount of total body fat & serum estrogen levels.
False… Estrogen levels yes, but body fat levels no.
How might one’s body temperature present in a case of Anorexia?
Hypothermic with potential for cold intolerances
How might an Anorexic patient’s cardiovascular assessment look?
-Prolonged QTc
-Bradycardia
-Ortho Hypotension
-Dizzy / Lightheaded
-Cardiac Muscle Atrophy
A QTc interval of > ____ ms increases the risk for Torsades De Pointes & premature cardiac death.
470ms
Cardiac arrythmias in AN are often preceded by what?
Hypokalemia (due to malnutrition & potential diuretic abuse)
What are the proposed reasons for sinus bradycardia development in those with Anorexia?
Reduced energy utilization (due to vagal hyperactivity), decreased T3 levels.
Chronic ingestion of ________ in Anorexia can lead to irreversible myocarditis.
Ipecac
What drug can be used to reduce abdominal distention, pain & bloating in Anorexic patients?
Domperidone
What is Domperidone’s MOA?
Dopamine Antagonist; delays gastric emptying, increases esophageal peristalsis & GI motility.
Why is Domperidone favored over Metoclopramide in treating Anorexia GI symptoms?
Does not cross BBB (so no EPS symptoms).
What limits Domperidone usage?
QT Prolongation
How might Liver / Renal system reviews look in a patient with eating disorders?
Liver: Hypoalbuminemia, increased INR (by ~1.5 due to decreased clotting factor production), petechiae (microbleeds), increased GGT (if comorbid alc abuse).
Renal: Increased BUN (due to dehydration), decreased GFR.
Patients with eating disorders who vomit profusely may demonstrate metabolic _________ (alkalosis / acidosis).
alkalosis
Patients with eating disorders who abuse laxatives may present with metabolic _______ (alkalosis / acidosis).
acidosis
What percentage of those with Anorexia present with osteoporosis?
40 - 66%
T or F: Estrogen Replacement Therapies have shown zero promise with regards to increasing BMD in women with eating disorders.
True! Zero evidence of improvements.
If we elect to supplement Anorexic / Bulimic patients with Ca2+ & Vit. D, what should we aim for in terms of a daily intake?
Ca2+: 1200 - 1500mg/d
Vit. D: 1000IU / day
Is it advisable to give a teenage patient with an eating disorder Bisphosphonate drugs?
Nope… Can actually worsen their bone status (as these drugs reduce bone turnover & there is a high turnover rate as we go through puberty).
What is the best strategy to address bone breakdown & recover BMD in those with eating disorders?
Wt Recovery!
A systems review of the skin in those with eating disorders might show what?
-Dryness & scaling
-Back of the hand calluses
-Hair loss
-Lanugo hair
When nutritionally rehabbing a patient, what kcal/kg/day target range should we aim to start at in order to avoid refeeding syndrome?
30 - 40kcal/kg/day
How often should we monitor serum electrolytes (ie. PO4-, Mg2+, K+, Na+, Ca2+) when first initiating nutritional rehab?
1st 5d, then EOD x several wks
What danger does ‘Refeeding Syndrome’ pose?
Precipitated CV changes / heart failure (as rapid cellular uptake of electrolytes from diet reduces serum levels & increases cardiac workload).
Explain why PO4- should be supplemented (additionally to diet) to those initiating nutritional rehab.
Rapid cellular uptake of PO4- means less is available extracellularly for cardiac muscles to use… ATP depletion in cardiac myocytes = HF. Supplementation offsets this!
In spite of its effects on wt gain, why is Olanzapine not a great agent to use in those with eating disorders?
Does not address negative thoughts around eating & increased drowsiness makes engaging with psychotherapies more challenging.
What are the two primary reasons for initiating AD therapies AFTER weight restoration has occurred?
1) 5HT depletion = not much NT present for drug to act upon.
2) Reduced eating drive with most ADs (hence why we add on after as we want normal eating to commence).
Which AD do we avoid (!!!) in eating disorders?
Bupropion (seizurrrrrrrrres)
In Bulimic patients, what are some symptoms of “purging”?
-Parotid Gland enlargement
-Dorsal hand calluses
-Dental Caries
-Gastric / Esophageal ruptures
What is the most effective treatment strategy for those with Bulimia (even more so than drugs)?
CBT (50 - 60% symptomatic remission)
How many CBT sessions are needed for those who have Bulimia?
20hr long sessions over 6mth period
90% of ideal BW is often a wt goal for those with Bulimia… What might be another treatment goal?
Menstrual re-initiation
What is the drug of choice for Bulimic patients?
SSRIs (particularly Fluoxetine, with Citalopram & Sertraline also being studied)
Fluoxetine is often initiated at starting doses of 10-20mg / day for Bulimia treatments… What is the target daily dose?
60mg / day
How long is the typical treatment length for Bulimic patients on Fluoxetine?
6 - 12mths
What are some signs in patients with eating disorders that indicate a medical emergency?
-Sudden onset delusions / hallucinations
-Self harming / suicidal thoughts
-Intense weakness / collapsing
-Blood in places it shouldn’t be
-Vomiting multiple x’s in a day
-Body temp < 35 degrees
