Anorexia, Bulimia, and Binge Eating Disorder

Feeding and Eating Disorders Part II

• The objective is to diagnose and initiate treatment for patients with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder by utilizing diagnostic criteria, clinical features, etiological factors, epidemiology, differential diagnosis, course of illness, and prognosis.

Specific learning objectives

• Identify the etiological aspects, including genetic, biological, psychological, and social factors in individuals with eating disorders.
• Identify the epidemiologic traits of these illnesses.
• Diagnose individuals with these eating disorders, including subtypes, based on diagnostic criteria.
• Distinguish the possible medical consequences and laboratory examination results from other medical problems.
• Explain the differential diagnosis, typical course, and prognosis for these eating disorders.
• Advocate for the best initial treatment options as well as the primary goals of therapeutic and pharmacological treatments for patients.

Types of Eating Disorders

• Pica is characterized by the persistent eating of nonnutritive, nonfood substances.
• Rumination Disorder involves the regurgitation of food that is then re-chewed, re-swallowed, or spit out.
• Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by a lack of interest in eating or food.
• Anorexia Nervosa the refusal to maintain body weight.
• Bulimia Nervosa, involves a cycle of binge eating followed by compensatory behaviors.
• Binge Eating Disorder, significant binge-eating episodes, followed by distress, disgust, or guilt, but without compensatory behaviors.
• OSFED refers to Other Specified Feeding or Eating Disorder.
• Orthorexia is an obsession with eating foods considered healthy.
• Diabulimia is the intentional misuse of insulin in patients with type 1 diabetes to lose weight.

Anorexia Nervosa Diagnostic Criteria

• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
• Fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain
• Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Anorexia Nervosa Specifiers

• Restricting Type: During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior.
• Binge-Eating/Purging Type: During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior.
• Severity is based on current body mass index (BMI) or BMI percentile for children and adolescents: Mild is a BMI ≥ 17 kg/m2, Moderate is 16–16.99 kg/m2, Severe is 15–15.99 kg/m2, and Extreme is < 15 kg/m2

Clinical Features of Anorexia Nervosa

• Insomnia
• Refusal to eat with others
• Hiding and cutting food into small pieces
• Dramatic weight loss
• Carrying candy around
• Constant preoccupation with food
• Decreased interest in sex and delay sexual development

Physical Exam Findings of Anorexia Nervosa

• Hypertrophy of the salivary glands
• Scars or calluses on the dorsal surface of the hand.
• Petechiae or ecchymoses.
• Dental enamel erosion.
• Yellowing of the skin.
• Dependent Edema.
• Fatigue.
• Lanugo hair growth.
• Hypothermia.
• Emaciation.
• Loss of muscle mass.

Problems Associated with Anorexia Nervosa: Cardiac

• Cardiac structural and functional abnormalities that can occur include:
• Hypotension and Bradycardia
• Mitral valve prolapse and Pleural effusions
• QT dispersion
• Decreased diastolic ventricular function
• Diminished heart rate variability

Problems Associated with Anorexia Nervosa: Laboratory

• Laboratory abnormalities that can occur include:
• Leukopenia and Anemia.
• Thrombocytopenia
• Low FBS and High cholesterol level.
• Xerosis (dry, scaly skin)

Problems Associated with Anorexia Nervosa: Reproductive

• The secretion of gonadotropin-releasing hormone is reduced.
• Functional hypothalamic amenorrhea and/or Amenorrhea.
• Pregnancy is still possible.

Problems Associated with Anorexia Nervosa: Endocrine

• Elevated growth hormone and plasma cortisol levels.
• Reduced Gonadotropin levels (LH and FSH)
• Reduced Triiodothyronine (T3) with normal TSH.
• Reduced Testosterone (men).

Problems Associated with Anorexia Nervosa: Gastrointestinal

• Gastroparesis (bloating)
• Heartburn
• Constipation
• Elevated liver function tests
• Oropharyngeal dysphagia

Problems Associated with Anorexia Nervosa: Respiratory

• Wasting of respiratory muscles
• Dyspnea
• Reduced aerobic capacity
• Decreased pulmonary capacity

Problems Associated with Anorexia Nervosa: Renal

• Reduced glomerular filtration rate
• Problems concentrating urine
• Diuresis
• Hyponatremia
• Dehydration

Problems Associated with Anorexia Nervosa: Musculoskeletal

• Low bone mineral density, with specific areas of osteopenia or osteoporosis
• Significantly elevated risk of fracture

Problems Associated with Anorexia Nervosa: Vomiting

• Hypokalemia
• Hypocalcemia
• Elevated LFT(AST ALT)
• ECG t wave flattening and inversion, ST segment depression, and lengthening of QT interval.
• Dehydration
• Hypomagnesemia
• Increased amylase
• Metabolic encephalopathy

Differential Diagnosis for Anorexia Nervosa

• Schizophrenia (fear of poisoning)
• OCD (obsessions not only related to eating)
• Acquired immunodeficiency syndrome (AIDS)
• Occult malignancies
• Substance use disorders (cocaine, amphetamines)
• Avoidant/restrictive food intake disorder
• Depression:
• Gastrointestinal-malabsorption syndromes
• Hyperthyroidism
• Bulimia (normal body weight)
• Midline tumors

Anorexia Nervosa Management

• Evaluate: Physical examination and determine BMI
• Test: CBC, U/A, BUN, and serum electrolytes.
• Malnourished: Check cholesterol and lipid profile, calcium, magnesium, phosphorus, amylase, LFT, and EKG.
• Rul out by using Laboratories and CT scan: other medical conditions
• Bone Mineral Densitometry: To evaluate osteoporosis.

Anorexia Nervosa Treatment

• Individual psychotherapy and family therapy.
• Medicines for co-existing mental ill health.
• Nutritional Rehabilitation and management of any medical complication.
• Treatment setting includes: Can be: Outpatient, Partial program, or hospital

Anorexia Nervosa Goals

• Restore nutritional state.
• Normalize eating behaviors.
• Change patients' cognitive distortions about food, weight loss and body shape.
• Involuntary hospitalization: May be necessary in case of risk of death from complications of malnutrition.
• Outpatient: Establish a contract to follow with the expectations and consequences

Anorexia Nervosa Hospitalization Guidelines

• Medical hospitalization or hospitalization on a specialized eating disorder unit should be considered with the following parameters:
  • Heart rate less than 50 bpm
  • Orthostatic change in heart rate is a sustained increase of >30 bpm
  • Blood pressure less than 90/60 mmHg
  • Orthostatic blood pressure drop of >20 mmHg in sBP
  • Glucose less than 60 mg/dL

Anorexia Nervosa Hospitalization

• Weighed in gowns in the morning with empty bladder daily.
• Monitor input and output.
• Check potassium and electrolytes multiple times daily.
• If vomiting, restrict the bathroom after eating for 2 hours
• Monor EKG for palpitations and if hypokalemic
• Monitor LFTs.

Anorexia Nervosa Additional Hospitalization Guidelines

• Stool softeners and bulk-producing agents are ok, but laxatives should never be given.
• Multivitamins and calcium should be administered.
• Refeeding should involve increasing the daily caloric intake by 500 kcal to maintain actual body weight, split into 6 meals or through liquid food supplements

Refeeding Syndrome

• Refeeding Syndrome occurs when severely malnourished individuals are rapidly reintroduced to nutrition.
• Electrolyte imbalances such as hypophosphatemia, hypokalemia, and hypomagnesemia and metabolic disturbances occur, posing significant risks to the body's organs and systems.
• Signs and Symptoms include: Confusion and Disorientation, Double Vision, Swallowing Problems,Trouble Breathing,Kidney Dysfunction,Muscle Weakness, Cardimyopathy, Nausea and Vomitting, Hypotension and Seizures

Strategies for Preventing Refeeding Syndrome

• Recognition and Screening
• Individualized Nutritional Plans
• Thiamine Supplementation
• Ongoing Monitoring and Support
• Gradual Refeeding
• Electrolyte Monitoring and Supplementation
• Multidisciplinary Approach

Pharmacological Treatment of Anorexia Nervosa

• Second Generation Antipsychotics (Off label): Increase appetite and help decrease cognitive distortions
  • Olanzapine improves weight and Aripiprazole reduces cognitive rigidity.
• Treat comorbidities:
  • Depression in 65% of cases, Social phobia in 34% of cases, OCD in 26% of cases.

Anorexia Nervosa: Course/Prognosis

• 25% recover and another 40% enter partial remission.
• 25% enter a chronic underweight state
• 10% die
• Mortality rate up to 5% to 18%
• Weight-related issues and suicide

Bulimia Nervosa Epidemiology

• 12-month prevalence of bulimia nervosa ranges from 0.14% to 0.3%
• Higher rates in women than in men (0.22% to 0.5% in women; 0.05% to 0.1% in men)
• Lifetime prevalence ranges from 0.28% to 1.0% (0.46% to 1.5% in women; 0.05% to 0.08% in men).
• Adolescents ages 13-18, lifetime prevalence rates were 1.3% and 0.5% in girls and boys, respectively.

Causes of Bulimia Nervosa

• Trauma
• Social Factors
• Genetic Factors
• Psychological Factors
• Dietary Factors

Bulimia Nervosa Diagnostic Criteria

• Recurrent episodes of binge eating and recurrent inappropriate compensatory behaviors in order to prevent weight gain.
• Episodes occur at least once a week for 3 months.
• Self-evaluation is unduly influenced by body shape and weight. Disturbances do not occur exclusively during episodes of anorexia nervosa.

Bulimia Nervosa: Specify current severity

• The minimum level of severity is based on the frequency of inappropriate compensatory behaviors.
  • Mild: An average of 1–3 episodes per week
  • Moderate: An average of 4–7 episodes per week
  • Severe: An average of 8–13 episodes per week
  • Extreme: An average of 14 or more episodes per week

Bulimia Nervosa: Clinical features

• Swollen Cheeks or Jawlines
• Fainting
• Irregular Menstrual Periods
• Muscle Weakness
• Bloodshot Eyes
• Dehydration
• Gastrointestinal Issues: These may include constipation and acid reflux.
• Scars, Scarpes, or Calluses on the knuckles

Bulimia Nervosa: Associated findings

• Associated findings include normal weight, sexually active.
• Additionally, after binging, patients will attempt to handle it by vomiting due to guilt and disgust.
• Other factors include the families tend to be rejecting and more chaotic.
• Alcohol Dependence
• Impulse control problems

Bulimia Nervosa: Comorbidity and Differential Diagnosis

• Comorbidity:
  • Anxiety disorders
  • Substance abuse disorders
  • Borderline personality disorders
  • Mood symptoms
• Differential Diagnosis:
  • Anorexia
  • CNS tumors
  • Klüvre-Bucy Syndrome
  • Kleine-Levin Syndrome
  • Binge eating disorder
  • Major depression with atypical features

Bulimia Nervosa: Complications

• Dental Cavities
• Dehydration
• Endocrine diabetes, Menstrual irregularities
• Irregular Heartbeat
• Mallory-Weiss syndrome
• Ipecac-induced myopathy

Bulimia Nervosa: Tests

• The symptoms and physical findings determine the laboratory assessment tests needed.
  • Electrolytes should be tested and abnormalities stabilized.
  • Additional tests should be administered such as serum creatinine, complete blood count, liver function and urine analysis.
• Severely ill patients should also have tested their serum calcium, magnesium, and phosphorous levels in addition to an ECG.

Bulimia Nervosa: Treatment Caveats

• Electrolyte abnormalities like hypokalemia and hypomagnesemia need stabilizing
• Monitor for hyperamylasemia.
• Outpatient care is utilized unless needed to treat medical problems.
• Supraventricular and ventricular ectopic rhythm Torsade de pointes monitoring.

Bulimia Nervosa Treatment

• Psychotherapy is first line specifically CBT: Control behaviors with proven effectiveness
• Nutritional Counseling: Control the amount of binge eating and compensatory behavior
• A combination drug therapy of fluoxetine, sertraline, escitalopram or fluvoxamine and is commonly seen to be the best treatment.
• Support Groups: Provide motivational interviewing.
• Bupropion is contraindicated due to the increased risk of seizures.

Bulimia Nervosa: Course / Prognosis

• Onset after puberty or 40 is uncommon.
• Binge eating and dieting can lead to bulimia
• Crossover to anorexia happens in 10-15% of cases
• Mortality risk is elevated
• Crude mortality is around 2% per decade

Bulimia Nervosa Outcomes

• 50% recover, while 20% become chronic patients.
• In contrast, 30% have fluctuating courses.

Binge Eating Disorder Epidemiology

• 12-month prevalence of binge-eating disorder ranges from 0.44% to 1.2%.
• Occurs two to three times more in women.
• Lifetime prevalence ranges from 0.85% to 2.8% (1.25% to 3.5% in women; 0.42% to 2.0% in men).

Binge Eating Disorder: Diagnostic Criteria

• Recurrent episodes of binge eating are characterized by the following:
  • Eating a large amount of food within a discrete period of time that is larger than what most people would eat under similar circumstances.
  • Experiencing a sense of losing control over eating during the episode.

Diagnostic Criteria: Binge Eating Disorder Association

• Eating rapidly, feeling uncomfortable and Eating large amounts when not feeling physically hungry.
• Eating alone due to embarrassment
• Feeling disgusted, depressed, and/or guilty after eating.
• Marked distress is common.
• Binge eating occurs at least once a week for 3 months
• Is not associated with compensatory behavior as in bulimia.
• BED cannot occur with anorexia or bulimia episode

Binge Eating Disorder: Specify current severity

• The minimum level of severity is based on the frequency of episodes of binge eating with the following parameters:
  • Mild: 1-3 binge eating episodes per week.
  • Moderate: 4-7 binge eating episodes per week.
  • Severe: 8-13 binge eating episodes per week.
  • Extreme: 14 or more binge eating episodes per week

Clinical Presentation: Binge Eating Disorder

• Binge-eating disorder occurs in normal-weight, overweight, and obese individuals (Striegel-Moore and Franko 2008).
• Dieting follows the development of binge eating in many individuals.
• Patients with BED have greater functional impairment, lower quality of life, more subjective distress, and greater psychiatric comorbidity (Hilbert 2019; Wonderlich et al. 2009).

Binge Eating Disorder: Management Steps

• Reduce binge eating episodes and excess weight.
• Target excessive concerns with body image.
• Treat psychiatric comorbidity and monitor obesity effects.
• Bariatric surgery can be evaluated.

Binge Eating Disorder: Treatment

• Psychotherapy is first line specifically CBT proven effective.
• Nutritional Counseling: Control the amount of binge eating
• A combination drug therapy with fluoxetine, topiramate, and lisdexamfetamine.
• Support Groups: Provide motivational interviewing

Binge Eating Disorder: Course / Prognosis

• Onset before puberty or after age 40 is uncommon.
• Binge eating and dieting can lead to the onset of bulimia nervosa
• Binge ED increases the risk of weight gain
• Suicide ideation has also been reported around 25% of cases