eating disorders Flashcards
which mental disorder has the highest mortality?
anorexia
what type of disorder is AN?
Restrictive or binge eating/purging type
AN subtypes
Restricting type:
No recurrent binge eating nor purging behaviors for the last 3 months
Binge eating/purging type:
Recurrent binge-eating and/or purging behaviors
Anorexia severity classifications
BMI 17 and +: mild
BMI 16 -16.99: moderate
BMI 15-15.99: severe
BMI less than 15: extreme
AN prognosis
Near 2/3 of patients normalize wt
AN prognosis: adults vs teens
Patients with illness onset before 17 y.o. achieve a better outcome than adult onset. Higher rate of full recovery and lower mortality rate in adolescents than in adults
Prepubertal onset confers a more difficult course.
In adults, time to complete remission is 5 to 6 years
Commonly observed dietary patterns in AN
Gradual decrease of food intake Removal of high energy food Gradual decrease of portion sizes Limited to bulky nutrient-poor foods Rigid schedule of eating Limited food choices/amount of calories Fat avoidance Food avoidance related to digestive symptoms Vegetarianism and veganism Fluid avoidance or excessive fluid intake
What are the characteristics of binge eating episodes?
Both of the following has to be present:
- Eating in a discrete amount of time (within a 2 hour period) large amounts of food.
- Sense of lack of control over eating during an episode.
behavioural characteristics of bulimia nervosa
Obsessive thoughts focused on restricting and bulimia
Excessive concerns about weight and shape
Body weight fluctuations
Inability to accurately identify and express feelings
Chaotic relationships and interactions
Impulsivity
Anxiety
Labile mood
Bulimia nervosa severity cut-offs
Speific severity based on average number of compensatory behavior episodes per week
- Mild 1-3
- Moderate 4-7
- Severe 8-13
- Extreme 14 or more
Binge eating disorder characteristics
Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
1. The binge-eating episodes are associated with three (or more) of the
following:
- eating much more rapidly
- until feeling uncomfortably full
- not feeling physically hungry
- eating alone
- feeling disgusted with oneself, depressed, or very guilty afterwards
2. NOT associated with the recurrent use of inappropriate compensatory behavior (for example, purging)
how often do binges occur with binge eating disorder
at least 1x/week for 3 months
severity cut-offs for binge eating disorder
Specific severity based on average number of binge-eating episodes per week Mild: 1-3 Moderate: 4-7 Severe: 8-13 Extreme: 14 or more
weight changes during binge eating and abstinence
No short term weight loss when reaching abstinence
Commonly observed dietary patterns in Bulimia and BED
Dieting history Removal of meals fasting Avoidance of high energy dense food Carbohydrates phobia Binge-eating forbidden food usually found in binge content
Other Specified Feeding or Eating Disorder (OSFED)
- Atypical anorexia nervosa: Weight within or above the average range for age and height
- Bulimia nervosa of low frequency and/or limited duration
- Binge-eating disorder of low frequency and/or limited duration
- Purging disorder: Persistent purging w/o binge-eating
- Night eating syndrome: excessive consumption of food following an evening meal or after waking from sleep in the night, which causes extreme psychological distress and interferes with daily functioning.
ARFID presentations for diagnosis
Avoidant Restrictive Food Intake Disorder (ARFID)
- An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
- Significant nutritional deficiency.
- Dependence on enteral feeding or oral nutritional supplements.
- Marked interference with psychosocial functioning. - The disturbance is not better explained by lack of available food or by an associated culturally
sanctioned practice. - The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced or shape is experienced
- The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention
when is ARFID more commonly seen?
in childhood
is ARFID characterized by body weight/size concern?
no
What may ARFID hide
AN
what mental condition is common in ARFID
anxiety
prevalence of various eating disorders
AN: 0.5-1.0%
BN: 1-3%
BED: women 3%
men 2%
overweight people 5-30%
bariatric surgery patients 40%is there an influence of environmental/ genetic factors in ED
both
Issues with laxative use
Dehydration and electrolytes disturbance
Hyperaldosteronemia and oedema
When abstinence-> expect weight gain
how does weight change after receiving treatment for ED
Moderate rate of BMI increase from intake to year 2
Modest increase of BMI from year 2 to year 5
Plateau from year 5 to 10
Settling in normal range for most
Body composition in adolescents and young adults with
AN - findings
- Significant reduction of body fat mass completely restored after short term weight normalisation
- central adiposity phenotype without negative influence treatment outcomes and appears to normalize after a year of weight maintenance
- Significant reduction in BMD
- Weight restoration associated with short term stabilisation of BMD and long term normalisation of BMD after normal weight maintenance
- Loss of lean and skeletal body mass (but can regaIn)
- Short-term weight restoration is associated with complete normalisation
Cardiovascular symptoms and complications in ED patients
- Hypotension
- Bradycardia, tachycardia
- Heart palpitations, dizziness, dyspnea, chest pain
- Loss of cardiac muscle mass
- Mitral valve prolapse
- Prolongation of QTc interval (your heart’s electrical system takes longer than normal to
recharge between beats) - Pericardial effusion
what are the most common causes of death in ED
cardiac failure and suicide
Gastrointestinal symptoms and complications
- refeeding syndrome
- Gastroparesis
- Early satiety/post prandial fullness
- Bloating/Abdominal pain
- Constipation /diarrhea
- Nausea
- Gastroesophageal reflux
- Spontaneous vomiting
- Superior mesenteric artery syndrome
- Swollen salivary glands
- Dysphagia (due to loss of lean mass)
- Hematemesis (Mallory-Weiss syndrome) - tear in oesophagus due to stomach acid irritation
- Hemorrhoids, rectal bleeding, incontinence
Endocrine adaptive response to low energy
availability
- Normal or high GH, low GHBP and low IGF-1
- High CRH and ACTH and high cortisol
- Low T3, normal or low T4 and normal TSH
- Impaired LH pulsatility
- low oestradiol and testosterone
- Low LH and FSH
- Low insulin
- Low leptine
- High ghrelin
- High total cholesterol ( HDL)
endocrine consequences
- feeling cold
- fatigue
- amenorrhea or irregular menses
- impotency
- sleep disturbance
- fasting hypoglycemia
- hyperactivity
- frequent bladder emptying
loss of bone mass density
- Underlying mechanism not well understood
- Duration of AN and amenorrhea seem to play a major role
- Weight recovery, main predictor of BMD gain for hip
- Resumption of menses, strong predictor for BMD gain in spine
- Significative improvements achieved in the long term
- Protective role of physical activity, still a matter of debate
- Ca and vit D supplements, essential in deficient patients
- Need for alternative pharmacological interventions
brain: structural and functional changes
Brain atrophy Neurocognitive functioning impairment Loss of concentration Loss of memory Difficulty to take decision Intense food preoccupation Irritability Loss of interest Social isolation O.C. behaviors Anxiety depression
lab abnormalities
Leucopenia
Anemia
Thrombocytopenia
Prealbumine ↓ (poor nutrition)
Total protein and Albumin ↓ in severe malnutrition ; until severe protein markers will be ok
Glucose: ↓ (poor nutrition)
Sodium: ↓ (water loading or laxatives)
Magnesium: ↓ (poor nutrition or refeeding)
Phosphorus ↓ (refeeding syndrome)
Potassium: ↓ (vomiting, laxative, diuretics)
Chloride: ↓(vomiting) ↑ (laxatives)
Bicarbonate: ↑ (vomiting) ↓ (laxatives)
Calcium : slightly ↓ (poor nutrition)
BUN: ↑ (dehydration)
Creatinine: ↑(dehydration, renal dysfunction, muscle wasting)
ALT↑ AST ↑(starvation)
Medical Comorbidity of binge eating disorder
Obesity Type 2 diabetes Hypertension Dyslipidemia Psychiatric comorbidities
Asthma Sleep disorder Chronic pain ʹ fibromyalgia - arthritis Digestive problems ʹ ulcers - IBS Menstrual abnormalities Polycistic ovary syndrome
Type 1 diabetes and eating disorders Warning signs:
ED are prevalent in DM T1 pts
- Disordered eating behaviors
- Poor glycemic control
- Frequent episodes of ketoacidosis
- Recurrent hypoglycemic episodes
- Frequent hospitalisations
- Poor glycemic monitoring
- Negative attitude toward diabetes
- Excessive preoccupation toward weight and body shape
- Low intake of carbohydrates
- Excessive exercise
- Wt fluctuations
- Amenorrhea or irregular menses
- Resistance to correct hypoglycemia
- Missing appointments at the diabetes clinic
- Poor interest and withdrawn
Family Based Treatment (FBT) for pediatric and young adult population
Parents are active agent in recovery;
Clinician enhance parents motivation and skills to take
action
Family issues are discussed and addressed
Getting the patient’s healthy development and autonomy
CBT-ED for bulimia and BED in adults
Focus on the maintaining mechanisms of ED
1. Engage patient in treatment and change
2. Develop a formulation to target features that need to be
addressed
3. Guide to normalize eating patterns;
4. Address emotional triggers for binge eating:
psycho-education, cognitive restructuring; food log; body issues
5. Relapse prevention strategies
Effective alternative treatments and approaches
DBT: Dialectical Behavioral Therapy:
- Mindfulness
- Interpersonal effectiveness
- Distress tolerance
- Emotion Regulation.
ACT: Acceptance and commitment therapy; used more in EN-> embrace thoughts (e.g. don’t fight the idea of u being fat)
ED among T1D population
- Multidisciplinary approach
- Psychoeducation about insulin misuse, ED and diabetes
- Get back to monitoring of blood glucose and ketones
- Address insulin misuse as part of any psychological treatment for ED
- Address low self-esteem, body dissatisfaction, personality variables
- Address psychiatric comorbidities
- Gradual increase of CHO in their diet and of insulin dose
- Adjust total glycaemic load and carbohydrate distribution to meet needs and prevent rapid weight gain
ED Nutritional treatment
To restore body weight (AN)
To correct physical complications of malnutrition
To reach abstinence of compensatory behaviors
To normalise dietary habits
To educate on nutrition and proper eating patterns
To develop healthier attitude toward food, weight and body image
ED Nutrition assessment:
Behavioral symptoms History of the eating disorder Comorbidity Clinical signs and symptoms of malnutrition Medical ATCD Detailed food intake assessment Diet history Personal and family wt history Anthropometric measures biochemical data Vital signs
Hospitalization Admission criteria:
Severe or rapid weight loss
Uncontrollable vomiting and purging
Medical complications: unstable vital signs, cardiac
abnormalities, electrolytes imbalance
Lack of response to outpatient treatment
Severe psychiatric co-morbidity
To clarify a diagnosis
A systematic review approaches to refeeding inpatients with AN
- In mildly and moderately malnourished, lower calorie re-feeding is too conservative;
- Higher calorie re-feeding not associated with increased risk for RS under close medical monitoring and electrolyte correction
- Both meal-based approaches or combined NGT+meals can administer higher calories
- Nutrient compositions within the recommended ranges are appropriate
- Long-term impact of approaches is unknown
- In severely malnourished inpatients, insufficient evidence to change the current standard of care
- In very malnourished: start faster and stronger to progress faster
Current standard of care in very malnourished patients
- Slow rate of refeeding especially for patients with very low BMI (<70% IBW)
- Increase calorie intake to allow gradual weight gain;
- No evidence for specific requirements for protein intake
- Thiamine supplements
- Multi vit and minerals
- Limit contribution of fluids
- Limit sodium intake
- Close monitoring for first 2 weeks
- Gain of 0.5-1.4 kg /week
what is the goal weight gain?
1kg/week
Refeeding during inpatient treatment
- Have a food environment that is planned and secure to attain a sense of control and consistency
- Place limitations on foods that patients may refuse to eat
- Food intolerance and allergy
- Differentiate true dislikes from feared foods
- Limit dietary exclusions such as veganism
- Prescribe water intake for patients who avoid it or abuse from it
- Limit coffee, tea or tisane consumption
- Revise food plan regularly to satisfy energy and nutritional requirement and for exposure to variety of foods
- Introduce food gradually with small frequent feedings to prevent bloating
- Avoid excessive sodium to limit risk of fluid and electrolyte overexpansion
- Reduce the use of raw fruits and vegetables to prevent discomfort or pain
- Provide sufficient fibers in the diet
Weight gain goal of _ /week if BMI < 20
Weight gain goal of 500g /week if BMI < 20
meal planning during nutritional counselling
- Introduce food that have been last removed from diet
- plan according to what a patient agree with
- increased gradually energy and take
- establish an organized approach to eating that gives patient confidence
- use portion controlled foods
- use a list of examples of portion size of foods
- exchange gradually dietary products for regular ones
