Eating Disorders and Refeeding Syndrome - Hill Flashcards
restriction of energy intake relative to requirements, leading to significantly low body weight for age, sex and development
- intense fear of gaining weight or becoming fat despite being underweight or persistent behavior that interfered with weight gain
- distorted perception of body weight
anorexia nervosa (AN)
- wt loss often viewed as a form of control, self esteem may largely revolve around weight and body image
- distortion of body image is described as an idea of overvaluation rather than a delusion
what is asked on an eating disorder screen for primary care?
- are you satisfied with your eating patterns?
- do you ever eat in secret?
- does your weight affect the way you feel about yourself?
- have any members of your family suffered with an eating disorder?
- do you currently suffer with or have you ever suffered in the past with an eating disorder?
3 months of NO binging or purging
- no self induced vomiting or use of laxative
- excessive exercising, fasting, dieting
restricting type AN
3 months of binging and purging behaviors
- self-induced vomiting
- misuse of laxative, diuretic, enemas
bind-eating/purging type AN
what are the medical complications of AN?
- cardiac: bradycardia, hypotension, PT dispersion, cardiac atrophy, MVP
- gynecologic: amenorrhea, decreased libido
- electrolyte: dehydration, hypokalemia, hypophosphatemia, hypomagnesemia
what is a serious complication of AN tx?
refeeding syndrome
- do NOT rehydrate of feed beyond their current capacity
- *can develop third spacing and other serious complications** d/t fluid/electrolyte shifts during aggressive nutritional rehabilitation of malnourished pts
- hypophosphatemia, hypokalemia, CHF, peripheral edema, rhabdomyolysis, seizures, hemolysis
how do you avoid refeeding syndrome?
- judiciously limit the amount of calories and fluid provided in the early stages of refeeding
- avoid very rapid increases in the amount of daily calories ingested
- closely monitor (labs) during the first few weeks of refeeding process
what are the most important comorbidities seen with AN?
- mood disorders: depression and dysthymic disorder
- anxiety disorders: OCD
- impulse control disorders
- personality: borderline, dependent
what is the tx for AN?
- interdisciplinary team including dietician, mental health, and general medical clinician
- nutritional rehab and psychotherapy
- hospitalization until normal weight is achieved
- usual intake of 30-40 kcal/kg that is progressively increased to match body tolerance and weight gain goals
what is the first line therapy for AN?
- *psychotherapy** that focuses on helping patients confront their disorder and change eating habits/thoughts
- choice based on pt preference: CBT, specialist clinical management, motivational interviewing
when should pharmacotherapy be considered for AN?
only for pts who have been resistant to other therapies and who are willing to take meds
- start at low doses d/t increased risk of side effects associated with low weight/dehydration
- AVOID BUPROPRION d/t increased seizure risk w/binging and purging
- caution with antipsychotics and antidepressants with risk of QT prolongation
which meds can be used in AN?
- olanzapine (only med shown to help with weight gain)
- if anxiety or depression is severe enough to create barriers to care, then consider SSRI
- SGA may be considered if depression is unresponsive to SSRI’s
recurrent episodes of binge eating, defines as eating an unusually large amount of food in a discrete period of time
- pts usually feel they cannot control their eating during the episode
- recurrent inappropriate compensatory behavior to prevent weight gain
- usually normal body weight, slightly underweight, overweight or obese (not usually underweight)
bulimia nervosa (BN)
- pts often excessively fearful of weight gain
- purging behaviors used to counteract weight gain from binge-eating
is BN divided into purging and non-purging categories similar to AN?
yes
what are the medical complications of BN?
- GI: mallory-weiss syndrome, esophageal rupture, parotid/submandibular gland hypertrophy
- dental/skin: tooth enamel erosion and dental caries, scar/callous on dorsum of hands (Russel’s sign)
what are the comorbidities seen with BN?
- anxiety, mood, substance use disorders
- PD: OC, avoidant, dependent, paranoid, borderline
- disordered personality traits: impulsivity, perfectionism, compulsivity, narcissism
what is the tx for BN?
best standard tx uses combination of nutritional rehab, CBT psychotherapy (tx of choice), and pharmacotherapy
what are the goals of CBT psychotherapy with BN?
- improve self-esteem
- decrease emphasis upon thinness
- eliminate dietary restrictions
- create pattern of regular eating
- eliminate binge and purge habits
what meds should be avoided in BN?
BUPROPRION d/t incraesed seizure risk with binging/purging
what is the first line med tx for BN?
fluoxetine (prozac)
- 2nd line: other SSRI’s at doses higher than starting dose used to treat major depression (recommend sertraline or fluvoxamine)
- third line: TCA’s
- episodes of binge eating, defined as consuming a large amount of food in a discrete period of time (w/in 2 hr period)
- episodes marked by at least 3 of the following:
- eating large amount of food when not hungry, eating rapidly, feeling uncomfortably full after eating, eating alone d/t embarrassment, feelings of guilt, depression, disgust after binging - episodes occur on average once a week for at least three months
- no regular use of compensatory behaviors (purging, fasting, excessive exercise - as seen in BN)
binge eating disorder (BED)
what is the tx for BED?
should focus on reducing:
- bing eating
- excess weight gain
- psychiatric comorbidities
- excessive body image concerns
- *CBT is 1st line tx**
- vivance is 1st and ONLY med approved to treat moderate BED
