Eating Disorders

Question 1

How many people are estimated to have eating disorders in the UK?

Answer 1

1.25 million

Question 2

Who is affected by eating disorders?

Answer 2

• Can affect anyone of any age, gender, culture or ethnicity.
• Can affect anyone at any time, but girls and young women aged 12-20 are most at risk.
• It is the commonest cause of weight loss in teenage girls and the commonest cause of inpatient admision to child and adolescent services.
• 95% of eating disorder cases occur in people ages 12 through 25.
• Of children who have anorexia, 25% are male and 75% are female.

Question 3

What are the different DSM-5 diagnoses?

Answer 3

• Anorexia nervosa (AN).
• Bulimia nervosa (BN).
• Binge Eating Disorder (BED).
• Avoidant-Restrictive Food Intake Disorder (ARFID).
• Other Specified Feeding or Eating Disorder (OSFED).
• Eating disorders are complex and some eating issues will not meet diagnostic criteria. All must be taken seriously.

Question 4

Describe Avoidant-Restrictive Food Intake Disorder (ARFID).

Answer 4

• Characterised by lack of interest in food, fears of negatice consequences of eating, and selective eating.
• A - feeding or eating disturbance leading to a persistent failure to meet appropriate nutritional requiremets and one or more of:
  
  • Significant weight loss / failure to gain / faltering growth.
  • Significant nutritional deficiency.
  • Dependence on supplements.
  • Interference with psychosocial functioning.
• B - not explained by cultural practice / lack of food.
• C - no disturbance of perception of body weight / shape.
• D - not due to a medical condition or better explained by another MD.

Question 5

What is Anorexia Nervosa?

List the warning signs.

Answer 5

• Characterised primarily by self-starvation and excessive weight loss.
• Warning signs:
  
  • ​Dramatic weight loss
  • Preoccupation with weight, food, calories and dieting
  • Refusal to eat certain foods, progressing to restrictions against whole categories of food.
  • Consistent excuses to avoid mealtimes or situations involving food.
  • Withdrawl from usual friends and activities.
  • Inappropriate and / or extreme exercise.

Question 6

Describe the diagnostic criteria for anorexia.

Answer 6

• A - 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. Significantly low weight is less than that minimally expected.
• B - Intense fear of becoming fat or gaining weight; persistent behaviour interfering with weight gain despite being low weight.
• C - Disturbance in the way one’s body weight or shape is experienced; undue influence of body weight on shape or self-evaluation, or persistent lack of recognition of the seriousness of current low body weight. Subtypes: restriting vs binge-eating / purging.

Question 7

What is bulimia nervosa?

List the symptoms.

Answer 7

• Characterised by binge eating and compensatory behaviours, such as self-induced vomiting, in an attempt to undo the effects of binge eating.
• Symptoms include:
  
  • ​Frequent episodes of consuming very large amounts of food followed by behaviours to prevent weight gain, such as vomiting, laxative abuse, and excessive exercise.
  • Feeling of being out-of-control during the binge-eating episodes.
  • Extreme concern with body weight and shape.
  • Most people are of a normal weight.

Question 8

Describe the diagnostic criteria for bulimia.

Answer 8

• A - Recurrent episodes of binge eating:
  
  1. Eating more than what most people would eat in a similar circumstance in a discrete period of time.
  2. Lack of control over eating during the episode.
• B - Recurrent inappropriate compensatory behaviours to prevent weight gain.
• C - A and B occur on average once a week for 3 months.
• D - Self-evaluatory is unduly influenced by body shape and weight.
• E - The behaviour does not occur exclusively during episodes of AN.

Question 9

Describe the diagnostic criteria for Binge Eating Disorder.

Answer 9

• A - Recurrent episodes of binge eating characterised by:
  
  1. Eating more than what most people would eat in similar circumstances in a discrete perios of time.
  2. Lack of control over eating during the episode.
• B - Binge eating episodes associated with 3 or more of:
  
  1. Eating more repidly than normal
  2. Eating until uncomfortably full
  3. Eating large amounts when not hungry
  4. Eating alone due to embarrassment
  5. Feeling disgusted, depressed or guilty afterwards
• C - Marked distress over binge eating.
• D - Occurs on average once a week for 3 months.
• E - No inappropriate compensatory behaviours nor exclusively during the course of BN or AN.

Question 10

What are the biological risk factors for development of an eating disorder?

Answer 10

• Gender: females more likely than males.
• Genetics:
  
  • Concordance: mono > dizygotic twins
  • Those with a mother or sister who has had AN are 12x more likely to develop and eating disorder than those with no family hx. (Biological or environmental?)
  • Comorbidities: depression, anxiety, OCD, T1DM

Question 11

What are the psychological risk factors for development of an eating disorder?

Answer 11

• Low self-esteem / poor relationship with self.
• Poor coping mechanisms.
• Personality traits: perfectionism, obsessive thinking, rigidity.
• Anorexia: family with high perfectionistic and obsessive traits.
• Bulimia or bingeing: family with obesity, depression, substance misuse.

Question 12

What are the social risk factors for development of an eating disorder?

Answer 12

• Historical trauma - bereavement, sexual abuse, trauma.
• Peer pressure - frequent negative comments, bullying or body shaming.
  
  • Bullying: 60% of those affected by eating disorders said that bullying contributed to the decelopment of their eating disorder.
  • Body shaming / weight stigma: can increase body dissatisfaction, a leading risk factor in the development of eating disorders.
• Media / modern culture - what is the media’s idea of perfection?
  
  • Promotion of idealistic and unrealistic body shapes.
  • Airbrushing / photoshop being used in magazines.
  • Social media - need for ‘likes’.
  • Proana

Question 13

What are the essential details to include in a referral for eating disorders?

Answer 13

• What are you worried about?
• Why?
  
  • Current eating and its progression.
  • Current weight (and height).
  • Past weights and idea of how quickly weight is being lost.
  • Impact on physical health.
• Cognitions around eating / weight.
• Stressors.
• Comorbidities (physical or mental health e.g. depression).
• Done decent physical health assessment including bloods.

Question 14

What are the questions in the SCOFF questionnaire?

Answer 14

• Do you make yourself Sick because you feel uncomfortably full?
• Do you worry you have lost Control over how much you eat?
• Have you recently lost Over 1 stone (14lb) in a 3-month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?

Yes = 1 point; score of >2 suggests AN or BN

Do not use screening tools as the sole method to determine whether or not people have an eating disorder.

Question 15

What are the health consequences of eating disorders?

Answer 15

• Cardiovascular
  
  • ​Muscle loss, low or irregular heartbeat.
• Gastrointestinal
  
  • ​Gastroparesis = bloating, nausea, feeling full after only small amounts.
  • Constipation
• Neurologial
  
  • ​Brain consumes up to 1/5th of the body’s calories.
  • Difficulty concentrating. sleep apnoea.
• Endocrine
  
  • ​Hormonal changes - oestrogen, testosterone, thyroid.
• MSK
  
  • ​More prone to fractures.

Question 16

What are the effects specifically of anorexia nervosa on the different body systems?

Answer 16

Question 17

What are the effects specifically of bulimia nervosa on the different body systems?

Answer 17

Question 18

What is the framework used to risk assess young people with eating disorders?

Answer 18

Junior MARSiPAN

• ​History
  
  • Recent weight loss
  • Syncope
  • Food and fluid intake
  • Exercise habits
  • Acute comorbidity
  • Suicidal ideation
• Examination
  
  • % ​Weight for height
  • Heart rate
  • BP
  • ECG
  • Electrolyte disturbance
  • Muscle weakness - SUSS test

Question 19

What are the issues to consider when managing AN?

Answer 19

• Challenging management of acute physical risk.
  
  • Precipitous weight loss >1kg / week
  • Purging
  • Substance use
  • Weakness in emaciated patients
• Behavioural risk.
• Urgency refeeding underweight children.
• Consequences of starvation on developing brain and cognition.
• Importance of family / caregiver education.
• Specialist dietetic input.
• Family-based therapy most effective.
• Individual therapy for depression before re-nutrition likely ineffective.

Question 20

Describe family behavioural therapy for management of AN.

Answer 20

• Family encouraged to take illness very seriously.
• Anorexia externalised ~life threatening illness.
• Therapy NOT focused on causes / avoids blaming family.
• Responsibility for recovery IS placed with family and professionals.
• Family assumed to know best how to feed child.
• Adults re-take control until child can feed self.
• Appropriate autonomy encouraged ONLY when adequately nourished.

Question 21

Describe the role of motivation in the management of AN.

Answer 21

• Help children see the links between anorexia and symptoms they dislike:
  
  • ​Tiredness
  • Agitation
  • Obsessionality
  • Preoccupation with food and its avoidance
  • Sleep problems
  • Feeling cold
  • Lost friendships
  • Inability to join in socially
  • Falling sport and academic performance
  • “Fussing” by parents
• Help children see the benefits of weight gain:
  
  • ​More energy
  • Clear headedness
  • Resistance to cold
  • Growing in height
  • Capacity for fun with friends
  • Being well enough to join in games

Question 22

Describe the role of medication in the management of AN.

Answer 22

• Food is medicine.
• Food must be taken in amounts prescribed and at the times specified.
• Choice for the child is how they take the medicine:
  
  • Orally as food
  • Orally as supplement drink
  • NG tube
• Little evidence for psychoactive medication.
• Important to avoid medication with QTc prolongation.
• Some evidence for Olanzapine or other antipsychotic to help with rumination and aid weight gain in anorexia.

Question 23

When is it appropriate to admit in patients with AN?

Answer 23

• Outcome better in outpatient clinics with eating disorder specialists.
• Even general outpatient child and adolescent psychiatrists brought about better outcomes than inpatient care.
• Guidelines now recommend outpatient care if patients with anorexia are medically stable.
• NICE reccomend to only admit people with an eating disorder whose physical health is severely compromised to a medical inpatient or day patient service for medical stabilisation and to initiate refeeding, if these cannot be done in an outpatient setting.

Question 24

Describe refeeding syndrome in the context of AN management.

What are the signs of refeeding syndrome?

Answer 24

• Potentially fatal shift in electrolytes and fluids.
• Malnourished patients are fed too quickly.
• Hypophosphataemia, hypomagnesaemia, hypokalaemia, gastric dilation, congestive cardiac failure, severe oedema, confusion, coma and death.
• Signs include:
  
  • ​Bradycardia
  • Hypotension
  • Hypophosphataemia
  • Delirium
  • Oedema
  • Cardiac arrhythmia

Question 25

Who is most at risk for refeeding syndrome?

Answer 25

• Patients with very low weight for height.
• Minimal or no nutritional intake for more than a few (3-4) days.
• Weight loss of over 15% in the last 3 months.
• Those with abnormal electrolytes prior to refeeding.

Question 26

Describe the management of Bulimia.

Answer 26

• Cognitive behavioural therapy targeting bulimic symptoms = gold standard.
• Interpersonal therapy model for bulimia.
• Fairburn’s CBT-E for patients 15 and older and with BMI=15.

Question 27

What is the prognosis for patients with AN and BN?

Answer 27

• Research into recovery suggests that around 46% of AN patients fully recover with the average time to recovery being 6-7 years.
• A third will improve and 20% will remain chronically ill.
• Similar research into bulimia suggests that around 45% of sufferers make a full recvery, 27% improve considerably and 23% suffer chronically.