Eating Disorders and Refeeding Syndrome

Question 1

What is an indication for hospitalization in reference to suicide in eating disorders?

Answer 1

hospitalize when patients have specific suicide plan or intent

–> high lethality

Question 2

Does bulimia nervosa or anorexia nervosa have higher suicide rates?

Answer 2

bulimia–> 7x higher than general population
—- 25-40% hx attempt

anorexia–> 5x higher than general population
—— 8-27% hx attempt

Question 3

What should you screen for with a patient with bulimia or anorexia?

Answer 3

suicide ideation

Question 4

Describe anorexia nervosa

Answer 4

restriction of energy intake–> low body weight for age, sex, and development

intense fear of gaining weight or becoming fat, despite being underweight

distorted perception of body weight and shape–> decreased self-worth, denial of medical seriousness of low body weight

Question 5

What are the types of anorexia nervosa?

Answer 5

Restricting:
-3 months of no binging or purging via self-induced vomiting or laxatives
~~~excessive exercising, fasting, dieting

Binge eating/purging:
- 3 months of binging and purging behaviors
~~~self-induced vomiting; misuse of laxatives, diuretics and enemas

-how to distinguish from bulimia: AN has low body weight

Question 6

Describe a person with anorexia nervosa

Answer 6

constant viewing in mirror

weight body or body parts constantly

deny starvations sx even when emaciated

weight is form of control–> self esteem centers around it

Question 7

What worsens as anorexia patients lose weight?

Answer 7

fear of weight gain rises as they lose weight–> out of control

Question 8

Medical complications of anorexia

Answer 8

arrhythmias, brady, hypotension, QT dispersion, mitral valve prolapse

amenorrhea and decreased libido (losing weight starts to attract others, out of control loses interest in partners and sex)

osteoporosis, hypothermia, euthyroid, hypoglycemia

gastroparesis and constipation d/t excessive laxative use

dehydration, hypokalemia, low phosphate, low magnesium (huge electrolyte disturbances)

respiratory muscle atrophy and dyspnea

anemia, leukopenia, thrombocytopenia

brain atrophy

skin issues

refeeding syndrome

Question 9

Describe refeeding syndrome

Answer 9

result of fluid and electrolyte shifts during aggressive nutritional rehab of malnourished patients

complications are potentially fatal:
low phosphate and potassium, CHF, peripheral edema, rhabdo, seizures, hemolysis

Question 10

How to avoid refeeding syndrome?

Answer 10

limit amount of calories and fluid in early stages of refeeding

avoid very rapid increases in daily calories

closely monitor labs and patient during first few weeks of refeeding

Question 11

Comorbidities of anorexia

Answer 11

OCD
impulse control disorders
depression
personality disorders
perfectionism, compulsivity, narcissism

Question 12

Anorexia treatment

Answer 12

when in doubt–> hospitalize

interdisciplinary team of mental health, dietician, IM

minimum first line of care: nutrition rehab, psychotherapy

hospitalize d/t SI, resistance to refeeding–> stay until normal weight to reduce re-hospitalization

anorexia and associated psych usually resistant to meds, only use with depression/anxiety that create barriers to care

Question 13

Range for gaining weight in anorexia patients

Answer 13

2-3lb per week for inpatients

0.5-1lb gained per week for outpatients

initial intake of 30-40 calories more, progressively increase to match weight goals and avoid refeeding syndrome

Question 14

First line therapy for anorexia

Answer 14

nutrition rehab AND psychotherapy (CBT, motivational interview, family therapy in adolescents)

Question 15

Pharm considerations for anorexia

Answer 15

consider only in patients who are resistant to other therapies and are willing to take meds

low dose d/t increase side effects a/w low weight, dehydration, etc

AVOID BUPROPION d/t increased seizure risk with binge/purge subtype

AVOID TCA d/t cardiotoxicity

Olanzapine helps weight gain
Lorazepam reduces anxiety around meals
SSRI if severe anxiety/depression
–> second generation antipsychotics if not responsive

Question 16

Criteria for diagnosing bulimia nervosa

Answer 16

recurrent episodes of binge eating (large in discrete period of time, can’t control eating during this time)

inappropriate compensatory behavior to prevent gaining weight (purging)

at least 2 times per week for 3 months

weight is normal, slightly under or over, or obese

Question 17

Do bulimics focus on weight as much as anorexics?

Answer 17

anorexia obsessed with staying thin and not gaining weight

bulimics fearful of gaining weight but don’t need to be thin (just don’t want to be fat)
—————> feel like shit after binging

Question 18

Medical complications of bulimia

Answer 18

same as anorexia with:

Mallory-Weiss syndrome/esophageal rupture
parotid or submandibular gland hypertrophy
abd pain/bloating/constipation

tooth enamel erosions and caries, Russel’s sign (callus on dorsum of hand from self-purging)

Question 19

Comorbidities of bulimics

Answer 19

anxiety, mood, substance use disorders

personality disorders

impulsivity, perfectionism, compulsivity, narcissism

Question 20

Treatment for bulimia

Answer 20

nutrition rehab

CBT (treatment of choice)–> stop binge/purge but not reducing weight

pharm (less effective if used alone)

pharm and CBT appropriate if can’t get nutrient rehab

AVOID BUPROPION d/t seizure risk

Question 21

Pharm for bulimia

Answer 21

Fluoxetine first line

SSRIs at higher starting doses second line (sertraline or fluvoxamine)

third line: TCA, topiramate, trazadone, MAOIs

Question 22

Criteria for binge eating disorder (BED)

Answer 22

episodes of binge eating, lack control
–> large amounts when not hungry, rapid eating, uncomfortable after eating, eating alone, guilt and depression or disgust after episode

once a week for at least 3 months

• ***** no regular use of inappropriate compensatory behaviors (purging, fasting, excessive exercise)
• -> how to differentiate between this and bulimia

Question 23

Treatment for binge eating disorder

Answer 23

reduce binge eating, excess weight gain, comorbidities, body image concerns

psychotherapy first line treatment (CBT and IPT)

Vyvanse only med to treat

SSRIs with CBT but not more effective than CBT alone

anti-obesity drugs not recommended d/t side effects