Eating Disorders & Obesity - Russeth Flashcards
What differentiates anorexia from avoidant / restrictive food intake disorder?
- Both feature weight loss and restricted food intake
- Anorexia also has disordered body image
What differentiates binge-eating disorder from bulimia?
- Both feature binging / overeating.
- Bulimia also features purging behavior (vomiting, excessive laxative use, etc.)
Describe some of the general features of anorexia nervosa.
- Intense pursuit of weight-loss & self-induced starvation
- fear of becoming obese
- dieting & excessive exercise
- paradoxically focused on food
- Disturbance in body image
- Believe they are fat even though they are thin
- Medical signs & symptoms of starvation
What are the DSM IV criteria for anorexia nervosa?
(Bonus: What changed from DSM IV to DSM V?)
- Weight loss to <85% of ideal body weight or failure to make expected weight gains in children & adolescents
- Changed to just “significantly low weight” in DSM V
- Intense fear of gaining weight or behaviors that interfere with weight gain
- Disturbance in how one perceives thier body
- Amenorrhea for 3 months in post-menarcheal females
- This criteria was removed in DSM V
What subtypes of anorexia nervosa exist?
- Restricting Type (most common)
- Binge-eating / purging type
- Differentiate from bulimia on basis of the patient’s weight and other classical symptoms of anorexia (e.g. amenorrhea)
What BMI corresponds to a cetegorization of anorexia nervosa as:
- Mild?
- Moderate?
- Severe?
- Extreme?
- Mild: >17
- Moderate: 16-16.99
- Severe: 15-15.99
- Extreme: <15
What is binging/purging?
- Eating a large amount in a short period
- Compensatory behavior ot get rid of the food/weight
- Feelings of loss of control during episode
What physiological signs of starvation would be noted when measuring a patient’s vitals?
- Hypotension
- Bradycardia
- Hypothermia
What physiological signs of starvation can be noted in the following organ systems? (1 of 2)
- Cardiac
- Skeletal
- Endocrine
- Cardiac
- Bradycardia
- Hypotension
- Syncope
- EKG changes
- Arrhytmias
- Sudden Death
- Skeletal
- Osteopenia
- Osteoporosis
- Endocrine
- Decreased LH, FSH, & estradiol, abnormal TSH
- Cold intolerance, hypothermia
- Decreased libido, amenorrhea
What physiological signs of starvation can be noted in the following organ systems? (2 of 2)
- Dermatologic
- Hematologic
- Gastrointestinal
- Neurologic
- Dermatologic
- Dry skin
- Alopecia
- Lanugo (fine baby-like hair over the body)
- Hematologic
- Pancytopenia
- Gastrointestinal
- Delayed gastric emptying
- Constipation
- Neurologic
- Fatigue, weakness
- Reduction in brain mass/volume
- Cognitive deterioration
Describe the demographics of anorexia nervosa.
What is the #1 risk factor for the disease?
- Females > Males, 10:1
- Onset typically in mid-teens. Increasing in preadolescents!
- 1% of the population
- 5% of population shows subclinical signs
- #1 Risk Factor: Dieting!
Are there believed to be genetic factors that contribute to developing anorexia nervosa?
Yes.
Higher rates in monozygotic twins.
Strong family history for mood disorders.
What type of psychological factors/features are often seen in anorexia nervosa patients?
- Perfectionist, harm-avoidant, high-achieving
- Feel helpless, not able to establish autonomy, demands to increase independence
- Focus on food vs. “normal” activities
- Maturation fears: fear of becoming an adult, being shapely or sexual
What other conditions should be ruled out (aka on your differential) before making a diagnosis of anorexia nervosa?
- Brain tumor or cancer
- Other psychiatric disorder:
- Depression
- Somatization
- Schizophrenia
- Bulimia
What is the **most lethal **psychiatric disorder?
Anorexia nervosa! 7-18% mortality rate.
(75% have good to moderate prognosis)
May require impatient medical stabilization
Key point: Don’t ignore weight loss in teenage patients!
Describe the treatment of anorexia nervosa.
- Food is the best treatment!
- Hospitilization if needed
- Correct dehydration, electrolyte abnormalities
- Reinstate nutrition, correct metabolic abnormalities
- Treatment team is key
- PCP, psychiatrist, dietician, psychotherapist
What is refeeding syndrome?
- Dangerous shift in fluid and electrolytes during nutritional rehabilitation
- Risk related to:
- Amount of weight lost
- Rapidity of weight restoration
- Can be life-threatening
- Hypophosphatemia
- Delirium
- Arrhythmias & Cardiac Arrest
What kinds of psychotherapy are used to treat anorexia nervosa? Name three specific methods.
- Family, individual, and group therapy
-
Maudsley Family Based Treatment:
- Parents play active role in restoring weight, gradually hand over control back to patient
-
Cognitive behavioral therapy (CBT):
- Address cognitive distortions
-
Dielectical behavioral therapy (DBT):
- Address behaviors that interfere with treatment
-
Maudsley Family Based Treatment:
What kinds of medications are used to treat anorexia nervosa?
- No medication has consistently shown benefit for the core symptoms of anorexia nervosa. None are indicated.
- Medications are used to treat psychic comorbidities
- Depression, social phobia, OCD, etc.
What are the DSM IV criteria for bulimia nervosa?
(Bonus: How did they change in DSM V?)
- Recurrent episodes of binge eating followed by inappropriate compensatory behavior in order to prevent weight gain
- Episodes occur at least twice a week for three months
- DSM V seperates binge eating and compensatory behaviors into two criteria and requires episodes of each occur at least once per week for 3 months
- Self evaluation is unduly influenced by body shape and weight
- The disturbance does not occur exclusively during anorexia nervosa
What are the DSM IV subtypes of bulimia nervosa?
- Purging type
- Nonpurging type
- These were removed in DSM V
How is the “severity” of bulimia nervosa ranked? What falls under each category?
- Mild
- Moderate
- Severe
- Extreme
- Based on # of compensatory behavior episodes per week
- Mild: 1-3
- Moderate: 4-7
- Severe: 8-13
- Extreme: 14+
What types of compensatory behaviors exist in bulimia nervosa? Name 5.
- Purging
- Vomiting
- Misuse of laxatives, diuretics, enemas
- Other
- Excessive exercise
- Restrictive dieting
- Skipping meals
What physical exam findings of bulimia can be noted by observation alone?
- Swollen cheecks
- Parotid gland hypertrophy or infection
- Metacarpal-phalangeal calluses (Russel’s signs)
- Abrasions on knuckles from scraping against teeth
- Dental erosions and caries from gastric acid in the mouth
- Front teeth that are chipped or ragged and “moth-eaten”
What are the findings in the following systems in bulimia nervosa?
- GI
- CV
- Endo
- Neuro
- GI
- GERD, esophageal varices/rupture
-
melanoisis coli
- From laxative overuse - discoloration of colon wall noted on colonoscopy. Benign with no sequelae in of itself.
- CV
- Arrhythmias & myopathies
- Endo
- Menstrual abnormalities
- Neuro
- Neuropathy, fatigue, cognitive slowing, seizures
What lab findings are noted in bulimia nervosa?
Which are specifically associated with vomiting and diuretic use?
With laxative abuse?
- From vomiting and diuretic use:
- Metabolic alkalosis: low K+, low Na+, high bicarb
- Also low Cl-
- From laxative abuse:
- Hyperchloremic metabolic acidosis: low K+, high Cl-, low bicarb
-
Other:
- Low Mg2+
- Elevated serum amylase
- Generally normal lipase
At what point is an inpatient evaluation indicated for bulimia nervosa?
- If purging more than 3x/day
- Excessive potassium loss can cause potentially lethal arrhythmias
Describe the epidemiology of bulimia nervosa.
- More common than anorexia nervosa: ~1-3% of population
- Generally later onset than AN: Late adolescence/early adulthood
- Up to 20-40% of college women report binging and purging
- Genetics: 1st degree relatives with BN or depression
- Endorphin release during purging reinforces vomiting
What type of psychological factors/features are often seen in individuals who develop bulimia nervosa?
- Overachiever, competitive
- Secretive, ego dystonic, self-critical
- Outgoing, angry, impulsive
- Associated with many psych disorders:
- Depression
- Sustance use disorders (incl. EtOH)
- Impulse control disorders
- Personality disorders
- Emotional lability
- Anxiety
- History of abuse
- Dissociative disorders
What other psych disorders should be ruled out before a diagnosis of bulimia nervosa is made?
- Seizures
- tumors
- Kluver-Bucy
- Klein-Levin
- Other psych diagnoses may be comorbid
What psych therapies are effective for treating bulimia nervosa?
- Cognitive behavioral therapy
- Dialectical behavioral therapy
- Family therapy
- Group therapy
- (esp. for inpatients, though most cases do not require hospitalization)
What medication is effective in treating bulimia nervosa?
What medication is contraindicated and why?
SSRIs - Fluoxetine is only FDA approved agents
Buproprion is contraindicated - increased seizure risk
How does the prognosis of BN compare to that of AN?
- Higher potential for full recovery than AN
- If untreated, remains chronic
- Poor prognosis if complicated by substance abuse issues
What are some other more atypical eating disorders?
- Specified:
- Atypical AN (normal weight)
- Low frequency/Limited duration BN or binge-eating disorder
- Purging disorder
- Night eating syndrome
- Unspecified - if it causes clinically significant distress or impairment, it can probably be called an eating disorder
What is the definition of obesity?
What is the definition of being overweight?
Is obesity an eating disorder?
Obese: >20% ideal body weight (IBW) or BMI > 30
Overweight: BMI 25-29.9
NO.
How common is obesity in the US?
Being overweight?
List numbers for both adults and children.
>1/3 US adults are obsese. >2/3 are overweight or obese.
25% of preschool and 35% of school-age children are overweight or obese.
Child obesity rates are leveling off recently after many years of increasing rates.
What percentage of Americans don’t meet activity level requirements?
What percentage are completely sedentary?
78%
25%
What general types of therapy are useful in treating obesity?
What’s the gold standard?
-
Gold standard: Sensible diet and exercise
- Caloric intake < Calories burned
- N.B. Commercial dieting & weight loss programs: regain weight in 5yrs
- Bariatric surgery
- For the extremely obese
- Initially effective, but questions regarding long-term efficacy
- Pharmacologic agents
- Variable efficacy & safety
Name three prescribed drugs useful in treating obesity.
-
Orlistat
- Pancreatic lipase inhibitor
-
Phentermine
- Sympathomimetic amine, decreases appetite
-
Lorcaserin HCl
- 5-HT2C agonist, increases satiety
- Previously: Sibutramine HCl
- Blocks monoamine reuptake, increases satiety
- Off market due to risk of MI and stroke
What is considered a reasonable rate of weight loss in adults?
- 5-10% of initial body weight over 6 months or 1-2lbs per week
- Cut back 500-1000 calories/day
- Focus on keeping the initial 10% off for the whole 6 months and then evaluate if further weight loss is needed
What is considered a reasonable rate of weight loss in children?
- Losing weight at this age is dangerous, so weight loss is typically not recommended unless child is very obese
- If so, focus on maintaining weight for 3mo and then slow weight loss, from 1lb/mo
- Focus on maintaining weight or slowing weight gain by healthy eating & exercise
What is most successful when it comes to making reasonable dietary changes in obese patients?
Behavioral modification
- Recognize external cues
- Keep food diary
- Eat slowly, chew food well, stay seated while eating
- Rewards/reinforcements
Also: do not skip meals. Limit portion sizes and limit calorie-dense foods/additives
