Eating Disorders

Question 1

Outline some of the risks from Anorexia Nervosa and Treatment complications from this?

Answer 1

1) Starvation
- get bradycardia
- prolonged QTc
- inability to maintain postural BP/increased HR - (arrhythmia/sudden death)

2) Refeeding Syndrome - longterm malnutrition switch to fat metabolism. Krebs cycle increases increasing phosphate demand - so rapid shifts in electrolytes (especially phosphate)
- increased insulin forces K, MG and phosphate into cell (arryhtmias)
- within 3-4days of refeeding

• minimal intake risks - >1kg/week if BMI less than 16, low electrolytes before, loss >15% wiwthin 3-6months.

graduated meal, thiamine supplements, ECG monitoring

Question 2

Diagnostic criteria for Anorexia Nervosa?

Answer 2

Classified by behaviour in last 3mo 
	• Restricting type = Ø recurrent episodes of binge-eating/purging (LOW through diet/fasting, laxatives, diuretics, enemas, excessive exercise…) 
	• Binge-eating/purging type = recurrent episodes of binge eating/purging (e.g. vomiting, laxatives, diuretics, enemas…) 
Classified by severity (BMI)  
	• Mild = ≥17
	• Moderate = [16-17)
	• Severe = [15-16)
	• Extreme = <15 

A) restricted calory intake
B) intense fear of weight gain
C) Body dysmorphia

Question 3

What are some RFs for Anorexia Nervosa?

Answer 3

• Female
• Adolescent / YA = mean age of onset 15-19
• Obsessive / perfectionist traits
• Western media exposure = or thin ideal
• Identical twin affected
• Odd family behaviours about food
• Emotional instability / difficulty w. emotional regulation
Trauma

Question 4

What is the common triad associated with presentation of Anorexia Nervosa?

Answer 4

• disordered eating
• amenorrhea
• OP

Question 5

What is the treatment for Anorexia Nervosa?

Answer 5

Summary:
BMI <12 considered medical
BMI <16 considered psychiatric
physical symptom consideration (e.g. postural drop)
Immediate - rule out organic, starvation (QTc, brady), Refeeding syndrome, albumin/anaemia
Medium - psychotherapy - family based therapy. CBTE, challenge.
LT - rehabilitation, prevention, supports, lifestage.

• Restore healthy weight
• Target weight = agree on target weight – reassure that this will not be surpassed
• Nutritional rehabilitation
○ Urgent re-feeding may be needed it pt is significantly underweight
○ Normalising 3 meals / day + snacks
○ 4000-6400 kJ/day → up to 10,000 - 16500kJ/day
○ Target ↑weight
§ Outpt = 0.25-0.5kg/week
§ Inpt = 0.5-1kg/week
§ Should see stable ↑weight
§ Saw-tooth pattern suggests purging
• Monitor during re-feeding
○ Nutrition
§ Serum electrolytes
□ Mg = can ↓during 5-10d → cramps, weakness, impaired ST memory, visual Δ → IV suppliment (20mmol for 5-10d)
□ Phos = ↓over first few days (dangerous if ≤30-50% lower limit) → delirium / cardiac failure
® IV glucose can worsen
® 500mg TDS PO/IV supplements if needed
® If worse / ↓, may need to temporarily cease re-feeding
□ K = usually gradual ↓ → weakness, palpitations, polyuria
§ Thiamine = Wernicke’s encephalopathy
§ ↓BSL = 1mg IV glucagon (may take 10-20 days to restore hepatic glucagon)
§ Dietician advice = crucial
○ Vitals
○ Re-feeding syndrome = possibly lethal metabolic response to refeeding in severely malnourished pts → shift in fluids + electrolytes
§ Cx
□ ↓Phos
□ CCF / arrhythmias
□ Delirium
□ Death
§ Prevention
□ Slow re-feeding
□ Gradual ↑nutritoin
□ Supplemental phos
□ Close monitoring of electrolytes + ♥
• Bloods =
• Pancytopenia = BM suppression
• ↓albumin
• ± some renal failure = if v. severe → start digesting kidneys
• Psychotherapy
• Education = healthy nutrition + eating patterns + health effects
• Address food + body perceptions (psychological interventions for maladaptive thoughts + attitudes + feelings)
• Explore + challenge underlying psychological issues
○ Self-esteem / worth
○ Body image
○ Other thinking disturbances
• Coping mechanisms
• CBTE = CBT for eating disorders has biggest body of evidence in adults
• Family based therapy = best evidence for adolescents
• Social support
• Involving family
• Formal family therapy - esp. younger pts
• Family-based rx = esp. adolescents
• Rx comorbid disease
• Psychiatric conditions = e.g. depression, anxiety
• Physical cx of disease
• Pharmacological
• ↓evidence
• Some evidence for some medications in ↓anxiety around ED congnitions
○ ↑dose fluoxetine
○ Olanzapine
• ± DBS
• ± depot antipsychotics…
• Setting
• Outpt
• Inpt = rare unless concurrent psychiatric reason for admission
○ Indicated if
§ ↓↓ weight
□ <65% standard body weight
□ <85% in adolescents
§ Dangerous hypovolemia (IV fluids needed)
§ Adults
□ HR <40
□ BP < 90
□ Postural drop >20
□ Compensatory ↑HR (when standing - usually ~>20)
□ Δ serum chemistry
□ Actively suicidal
□ T <36
§ Children
□ Rapid LOW
□ HR < 50
□ BP <80/50
□ Proximal myopathy
□ Hypoglycemia
□ Electrolyte Δ
□ Petechial rash

Question 6

Diagnostic Criteria for Bulimia Nervosa?

Answer 6

Simplified dx criteria
• Binge episodes = excess intake + lack of control of eating in discrete period
• Inappropriate compensatory behaviour to prevent weight gain (vomiting, laxatives, restriction…)
• Body image unduly influences self-esteem
• Ø occurring during episode of AN

Severity classified according to # binge / purge episodes per week 
	• Mild = 1-3
	• Moderate = 4-7
	• Severe = 8-13
Severe ≥14

Question 7

What can be the presentation of someone with Bulimia Nervosa?

Answer 7

• Usually begins w. dieting behaviour → develops into binge/purge cycle
• Feel once they start, they cannot Ø eating → shame + guild afterwards

Ex findings / Cx 
	• ↓concentration 
	• Fluctuating weight 
	• Cx of vomiting 
		○ Fatigue + muscle weakness (electrolyte Δ) + swollen appearance around angle of jaw + eye sockets (fluid retention)
			§ Hypokalemic alkalosis 
			§ Cardiac arrhythmias
			§ Constipation  
		○ Russel's sign = reddened / callused knuckles 
		○  oesophageal erosions / rupture 
		○ Dental erosion 
		○ Parotid gland swelling

Question 8

Talk through the physical exam for anorexia nervosa

Answer 8

· General inspection
		o Body habitus 
		o Anxious/agitated 
		o Loose clothing 
		o Skin/rash 
	· Vitals (include BSL, BP, HR, temperature) 
	· Hands 
		o Russel's sign (calluses on knuckles from induced vomiting) 
		o Nail changes 
	· Eyes 
		o Anaemia 
	· Mouth 
		o Angular stomatitis 
		o Dentition 
		o Tongue 
		o Dry 
		o Parotid enlargement with recurrent vomiting 
	· Heart 
		o JVP 
		o Auscultation - Mitral valve prolapse (auscultate - might hear systloic murmur) 
	· Abdo 
		o Palpation (tenderness - gastritis - epigastric pain) 
		o Feel for liver 
	· Legs 
		o Peripheral oedema 
Proximal myopathy test  (cross and do a squat)