Eating Disorders - Physiology and Treatments Flashcards
1
Q
Anorexia diagnostic criteria as per the DSM-5 includes…
3 Primary criteria
A
- Intense fear of gaining weight or becoming fat
- Significantly low body weight in relation to age, sex, development; with denial of seriousness of low body weight
- Disturbance in the way one’s body weight/shape is experienced
Amenorrhea used to be in criteria but excluded males
2
Q
Severity of anorexia is determined by…
A
BMI ranges
3
Q
Bulimia diagnostic criteria based on the DSM-5 includes…
A
Recurrent episodes of binge eating and compensatory behaviour to prevent weight gain, at least 1x/week for 3 months
Self-evaluation disproportionately influenced by body shape and weight
4
Q
Severity of bulimia is based upon…
A
Frequency of inappropriate compensatory behaviours
DOES NOT INCLUDE A SPECIFIC BMI; people with BN are commonly normal to slightly overweight
5
Q
Binge eating disorder criteria includes…
A
Recurrent episodes of binge eating without compensatory behaviour to prevent weight gain; usually an amount of food much larger than most people would eat
1x/weekly for 3 months
6
Q
People with binge eating disorder often have lack of control over eating during their episode. This may include…
A
Eating rapidly
Eating until uncomfortably full
Eating large amounts when not hungry
Eating alone from embarassment
Feeling disgusted, depressed, guilty, or distressed after eating
7
Q
Etiology of anorexia/bulimia involves 3 realms:
A
Genetic predisposition
Physiologic state (imbalance of NT’s)
Environmental factors, complex bio-psychosocial
8
Q
Neurobiological dysfunction from AN/BN includes…
A
Increased release of cortisol from adrenal glands from stress, starvation, or exercise.
9
Q
The increased release of cortisol with AN/BN results in suppression of…
A
HPA, HPT, and HPG axes.
HPT = hypothalamic pituitary thyroid
HPG = hypothalamic pituitary gonadal
10
Q
Suppression of HPG axis may result in…
A
Decrease in estradiol, progesterone, and LH production - leading to amenorrhea and decreased libido
11
Q
HPT axis suppression may result in…
A
Reduced T4 to T3 - reduced resting metabolic rate
12
Q
Neurotransmitters that may be dysfunctional in AN/BN include…
A
5HT, DA, NE
13
Q
5HT is affected in eating disorders via…
A
Decreased intake in AN - regulates postprandial satiety, anxiety, sleep, mood, etc… so would result in other mood disturbances and obsessions
14
Q
DA is affected in eating disorders via…
A
Deficiency - lower energy, anhedonia, decreased feelings of reward
15
Q
NE is affected in eating disorders via…
A
Deficiency from starvation - leading to hypotension, bradycardia
16
Q
Regarding epidemiology of eating disorders, the rate of females to male is…
A
Higher
17
Q
Peak onset for eating disorders is usually around…
A
Adolesence/early adulthood
18
Q
Eating disorders are important to address due to…
A
High morbidity and high mortality rates, especially with AN
19
Q
BN has been associated an increase in ____ risk, which may be due to…
A
Cardiovascular risk, due to changes in lipids or endocrine abnormalities (low estrogen)
20
Q
Onset of eating disorders is usually related to…
A
Stressful events
21
Q
The course and outcome of AN is highly variable, referring to how…
A
There is no recovery after the 1st episode - fluctuating pattern of weight gain + loss, but will deteriorate without good supports
22
Q
Course of BN can be ____ or ____, with periods of ____ and ____
A
Chronic or intermittent, with periods of remission and reoccurrence
23
Q
AN co-morbid psych conditions involve…
A
Anxiety - OCD
Mood disorders
Personality disorders
Substance use disorders
24
Q
BN co-morbid psych conditions inclue…
A
Personality disorders
Mood disorders
Substance use
Anxiety disorders
Impulse control disorders
25
The general principles of treatment with BN include...
Emphasis on both helping with normalization of eating behaviours/symptoms, and attention to underlying psychological + social issues
## Footnote
Consider eating abnormality to be a coping mechanism
Identify stressors that predispose individual to eating disorder
26
Amenorrhea with AN increases risk of...
| Lack of estrogen + normal menstrual cycles
Osteoporosis/osteopenia
Decreased growth velocity
Lack of sexual desire
Unexpected pregnancies
## Footnote
Last point- ovulation occurs prior to menstruation
27
Eating disorders during pregnancy carries high risks, such as...
Micronutrient deficency
Hyperemesis
Poor weight gain
Higher rates of miscarriage or low birth weight
28
Periods usually return after amenorrhea within...
6 months of achieving a body weight of about ~90% average for age and weight.
## Footnote
Not related to amount of body fat, but with amount of serum estrogen levels
29
In a review of systems in a patient with AN, vitals will likely be impacted by...
Hypothermia, cold intolerance
30
In a review of systems in a patient with AN, electrolytes will likely be impacted by...
Lack of all electrolytes - dehydration
31
In a review of systems in a patient with AN, HEENT will likely be impacted by...
Loss of tooth enamel
Perioral dermatitis
Enlarged parotid glands
## Footnote
From continuous vomiting
32
In a review of systems in a patient with AN, neurology will likely be impacted by...
Seizures (large fluid shifts, electrolytes)
Brain atrophy on CT
Lethargy
## Footnote
Other organs can be used for energy
33
In a review of systems in a patient with AN, psych will likely be impacted by...
| This one is BIG
Mood disorders, anxiety, insomnia, OCD features
Substance abuse/dependence
Suicidal ideation
Eating behaviours, or fear of gaining weight
Cognitive impairment, decreased attention and concentration
34
In a review of systems in a patient with AN, pulmonary will likely be impacted by...
Atrophied vasculature
35
Cardiac complications of AN may include...
ECG changes - heart rate, QTc, arrythmias
Orthostatic hypotension, dizziness, lightheadednesss
Peripheral edema (cessation of laxative + diuretic abuse)
36
Prolonged QT associated with ED's are important because...
Predicts cardiac arrythmia and possible sudden death; QTc > 470 ms increases risk of Torsades and cardiac death
37
Cardiac atrophy from starvation causes cardiac complications such as QTc and ECG arrythmias because...
Changes in blood flow, muscle, and collagen fibers alter conduction and ventricular repolarization
38
Prolonged starvation leads to wasted cardiac muscle, which would then lead to...
Myofibrillar atrophy and destruction, secondary to malnutrition due to decreased preload
## Footnote
Decreased myocardial mass
Decreased ventricular cavity size
MV prolapse
Decreased contracile forces and cardiac output
39
Sinus bradycardia in AN may be due to...
Vagal hyperactivity to decrease energy utilization
Decreased level of T3
40
Cardiac arrythmias in AN may be caused by ____, due to...
Hypokalemia; due to malnutrition and diuretic abuse
41
A decrease in heart rate variability in AN may be due to...
Abnormal autonomic NS function
## Footnote
Predictor of sudden cardiac death
42
Hypotension with AN may be due to...
Chronic volume depletion
Decreased cardiac output
## Footnote
Orthostatic hypotension is very common since the body cannot compensate since it's already under so much stress
43
Most CV abnormalities in AN will normalize with...
Weight restoration
| QTc would return to baseline
44
Irreversible myocarditis may be occur in AN, and is usually seen with...
Chronic ipecac ingestion
45
Pharmacist role in caring for AN patients with cardiac complications includes...
ECG monitoring (arrythmias, HR, QTc)
Monitoring for electrolyte abnormalities
Monitoring for orthostatic hypotension
Avoiding medications that prolong QT
46
To avoid refeeding induced CV commplications, we should...
Refeed slowly
Offer phosphorus supplementation (+ other electrolytes)
Clinical surveillance in hospital
47
In a review of systems in a patient with AN, GI system will likely be impacted by...
Hypertrophy of salivary glands
Hypoactive bowel sounds, hypomotility
Gastritis
Abdominal pain/distension
Bloating, constipation
48
In a review of systems in a patient with AN, genitourinary systems will likely be impacted by...
**Amenorrhea**
Infertiliity
Low estrogen/testosterone levels
Low FSH/LH
49
Gastroparesis refers to...
No peristalsis evident; food stuck in stomach
50
For treatment of gastroparesis, we could use...
Domperidone
| Peripheral dopamine antagonist
51
Domperidone may help with gastroparesis via...
Reducing abdominal distension, pain and bloating
Increase GI motility and esophageal peristalsis
52
Domperidone should not be added if the patient has...
A high QTc interval - domperidone is QT prolonging
53
Domperidone should be used short-term due to...
Adverse effects
## Footnote
Even though it does not cross BBB
54
Metoclopramide should be avoided for gastroparesis treatment, because...
It crosses BBB and can cause EPS
55
For treatment of constipation, we could use...
PegLyte 250mL TID-QID
Peg 17g po daily
Milk of Magnesia 15-30 mL
Sennosides PRN
## Footnote
Individualize regimen based on individual patient
56
In a review of systems in a patient with AN, liver will likely be impacted by...
Hypoalbuminemia
Increase in INR and other LFT's
Petechiae and purpura (bruising)
## Footnote
Increase in GGT if alcohol abuse
57
In a review of systems in a patient with AN, renal will likely be impacted by...
Elevations in BUN (dehydration)
Decreased GFR
58
In a review of systems in a patient with AN, endocrine will likely be impacted by...
Reduction in T3 + T4
Increase in cortisol
Metabolic alkalosis if vomiting
Metabolic acidosis if laxative abuse
59
In a review of systems in a patient with AN, musculoskeletal system will likely be impacted by...
Osteoporosis, osteopenia
Muscle weakness + leg cramps (electrolyte imbalance)
Delayed linear growth
60
Osteoporosis early-on usually has no symptoms, but may lead to...
Increased risk of fractures
Kyphosis (curving of upper spine)
Pain
Reduced height
## Footnote
Loss of bone mass, breakdown of bone tissue
61
An eating disorder contributes to osteoporosis via...
| Hormones + external factors
Decrease in nutrition = decreased peak bone mass
Decreased body weight lowers estrogen levels due to amenorrhea
Decreased serum androgen levels, IGF-1 (bone formation + growth factors)
Increased cortisol levels
## Footnote
Smoking, ETOH abuse may contribute
62
Osteoporosis risk is important to address in AN, especially adolescents because...
Most bone is built during adolescent years - issues with bone formation during these years can result in permanent deficit
## Footnote
AN = highest risk
People with bulimia with amenorrhea can also be affected
63
Can estrogen replacement help increase BMD in eating disorders?
Has not been found to be helpful for increasing BMD in eating disorders
64
Are calcium + vitamin D supplements recommended in eating disorders?
## Footnote
If so, how much calcium + vitamin D?
No direct studies to show increase in BMD, but may be helpful since they have been shown to decrease fractures in post-menopausal women
## Footnote
Calcium 1200-1500mg
Vitamin D 1000IU
65
In studies of teenagers with eating disorders, bisphosphonates...
| Good? Not good?
Have not shown benefit in improving BMD
66
In adult women with eating disorders, bisphosphonates...
| Good? Not good?
Have no good quality studies -mixed results... Case by case basis, but not strong evidence
## Footnote
Could extrapolate results in women without anorexia (shown to prevent fractures)
67
The best method to prevent further bone breakdown and recover BMD is...
Weight recovery
68
To see an increase in BMD with sustained weight recovery, it may take...
As long as 1-2 years
## Footnote
Some people may still have permanent deficits so this is really important to treat
69
In a review of systems in a patient with AN, the skin will likely be impacted by...
Dry, scaling skin
Hair loss, or lanugo hair (fine hair growing on skin)
## Footnote
Calluses may be present on the back of the hand if patient has been hand-induced vomiting
70
AN patients are treated inpatient if...
Acute risks present - continued weight loss despite outpatient tx, severe hypotension, cardiac irregularities, severe electrolyte abnormalities, suicidality
71
Goals of therapy for AN include...
| (5)
Stabilize medical + nutritional status
Restore + maintain healthy body weight
Re-establish healthy eating patterns
Reduce distorted body image concerns, and identify and tx underlying psych conditions
Prevent relapse
72
The foundation of AN treatment is primarily...
Non-Pharm related
73
Nutritional rehabilitation refers to...
Restoration of weight gradually, to prevent re-feeding syndrome
74
Caloric intake levels usually start at ____ and may advance to ______
30-40 kcal/kg/day, advance to 70-100 kcal/kg/day
75
Nasogastric feeding may be preferred over IV when...
Life-preserving nutrition must be provided to a patient who refuses to eat
76
During nutritional rehabilitation, the following should be monitored...
ECG as needed
PO4, Mg, K, Na, Ca for first 5 days of refeeding then every other day for several weeks
## Footnote
Provide electrolyte replacements PRN
77
Refeeding syndrome occurs when...
Malnourished patients are fed high carbohydrate loads
## Footnote
Rapid uptake of electrolytes into cells; body retains fluid + extracellular space expands
78
Symptoms of refeeding syndrome may include...
Gastric bloating, nausea, diarrhea, edema
79
Refeeding syndrome is dangerous because it may...
Cause cardiac decompensation due to fluid and electrolyte shifts
| Morbidity can occur
## Footnote
Phosphorus incorporation into tissue; ATP depletion, depleted cardiac muscles
80
Supplementation to help prevent refeeding syndrome includes...
Phosphate supplementation
81
Other non-pharm treatment besides nutritional supplementation that is crucial includes...
CBT - address relationship among thoughts, affect, and behaviour
## Footnote
Restructure thought process and improve coping with life stressors
82
Adjunctive pharmacotherapy is ____ for malnourished, underweight patients
NOT effective
## Footnote
Increases risk
83
Options for AN pharmacological treatment includes...
Zinc
Antipsychotics
Antidepressants
84
Zinc is often suggested as pharm treatment because...
Individuals with zinc deficiency exhibit symptoms similar to AN
85
The evidence for zinc for AN is...
Mixed for weight/BMI restoration (1/3 trials = benefit)
May benefit mood/anxiety
## Footnote
Remains controversial
86
Evidence for AP usage in AN is...
Very limited evidence of effect with SGA's. No difference in BMI, psychopathology, or depressive sx's.
FGA does not help with eating attitudes/behaviours, or ADR's; no longer recommended
87
The only SGA that showed modest weight increase was...
Olanzapine
## Footnote
But still no benefit for ED cognitions or obsessionality; with ADE's involved
88
AN patients are more predisposed to the ADE's of AP's, such as...
EPS
Anticholinergic toxicity
**QTc Prolongation**
Tardive dyskinesia
## Footnote
More sensitive to cardiac and movement related ADE's
89
Antidepressant evidence in AN is...
Limited, not beneficial for weight gain/BMI increase
90
Risk of TCA includes...
Lethal risk with oerdose, and potential for fatal arrythmia at low body weight
## Footnote
Not currently recommended
91
SSRI's may be helpful in AN with...
Comorbid depression and OCD AFTER weight restoration has occurred
| Still limited + mixed efficacy data
## Footnote
Trial for 6-12 months
92
Complications of BN include...
| CV, bone, mental health, abused substances
## Footnote
Somewhat similar to AN
Consequences of abused substances (electrolyte, cardiac, nerve issues)
Amenorrhea
Osteoporosis/osteopenia
Orthostatic hypotension, bradycardia, ECG changes
Guilt + depression
93
Goals of therapy for BN include...
| Quite similar to AN goals:
**Decrease + eventually eliminate binging/purging behaviours**
Stabilize medical and nutritional status
Restore and maintain healthy body weight
Re-establish healhy eating patterns
Identify and treat any underlying psychiatric conditions
Prevent relapse
94
Treatment plans for BN includes...
Psychotherapy
Nutritional rehabilitation
Pharmacotherapy
95
CBT is ____ in efficacy to drug therapy
Superior; 50-60% symptom remission
96
Medical treatment with BN may involve correcting and preventing complications of low weight/purging, such as...
Electrolyte abnormalities
Constipation
Malnutrition
97
An ideal goal weight for BN is...
90% of IBW, or when menses start
## Footnote
Ideally improves dysphoric mood and OCD behaviours
98
The drug of choice for BN patients are...
SSRI's
99
Do BN patients need to be depressed to benefit from an SSRI?
No - at high doses, SSRI's decrease binge-purge episodes regardless of co-occurring depression
100
The SSRI's that are well studied for BN include...
Fluoxetine
Citalopram
Sertraline
## Footnote
Fluoxetine is the only FDA approved medication for BN
101
Onset of effect for BN treatment using SSRI is...
2-4 weeks
102
Duration of BN treatment with SSRI may be...
6-12 months
103
Topiramate has shown ____ in BN by ____, but use is limited by...
Short-term efficacy in BN by decreasing binge/purge episodes, but use is limited by ADE's; **Brain fog**
104
Important monitoring parameters for BN includes...
Frequency and severity of binge/purge episodes
Exercise patterns
Eating habits, daily caloric intake, weight & BMI
Mood and anxiety symptoms
Labs
Use of laxatives, enemas, ipecac, diuretics
