Eating Disorders: Anorexia, Bulimia, and Binge Eating

Feeding and Eating Disorders Overview

• There are generally three categorized types of eating disorders; Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder
• Additional disorders include; Pica, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder, OSFED, Orthorexia and Diabulimia

General Objective for Treatment

• Diagnostic criteria, clinical features, and etiological factors are key when approaching treatments for Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder
• Epidemiology, differential diagnosis, course of illness, and prognosis are additional components for approaching treatments for Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder

Specific Objectives for Treatments and Diagnosis

• Summarize the etiological factors; genetic, biological, psychological, and social factors
• State the epidemiologic features
• Diagnose patients including subtypes, based on diagnostic criteria
• Differentiate the potential medical complications and laboratory examination findings from other medical conditions
• Describe the differential diagnosis, usual course, prognosis
• Recommend the best initial treatment interventions and major goals of treatment and pharmacological interventions

Anorexia Nervosa

• Characterized by the refusal to maintain body 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
• A significantly low weight is defined as a weight that is less than minimally normal, or less than expected
• Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even at a significantly low weight
• 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

• Can be specified as in partial vs full remission based on if weight is restored
• The restrictive subtype, 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 determined by BMI; Mild with BMI ≥ 17 kg/m2, Moderate with BMI 16–16.99 kg/m2, Severe with BMI 15–15.99 kg/m2, and Extreme with BMI < 15 kg/m2

Anorexia Nervosa: Clinical Features

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

Anorexia Nervosa: Physical Exam Findings

• Hypertrophy of the salivary glands
• Scars or calluses on the dorsal surface of the hand
• Petechiae or ecchymoses
• Yellowing of the skin
• Dental enamel erosion
• Lanugo
• Dependent edema
• Emaciation and loss of muscle
• Hypothermia due to always being cold
• Fatigue

Anorexia Nervosa: Cardiac Problems

• Hypotension
• Bradycardia
• Mitral valve prolapse
• Pleural effusions
• QT dispersion due to variability in QT interval between ECG leads
• Decreased diastolic ventricular function
• Diminished heart rate variability

Anorexia Nervosa: Additional Problems

• Leukopenia
• Anemia
• Thrombocytopenia
• Low FBS
• High cholesterol level
• Xerosis or dry, scaly skin
• Reduced secretion of gonadotropin-releasing hormone
• Functional hypothalamic amenorrhea, although pregnancy is still possible
• Amenorrhea
• Elevated Growth hormone and Plasma cortisol
• Reduced Gonadotropin levels (LH and FSH)
• Reduced Triiodothyronine or T3 with normal TSH, and Testosterone levels in men
• Gastroparesis/bloating, heartburn, constipation, elevated liver function tests, and oropharyngeal dysphagia
• Wasting of respiratory muscles, dyspnea, reduced aerobic capacity, and decreased pulmonary capacity
• Reduced glomerular filtration rate and problems concentrating their urine, can lead to diuresis, hyponatremia and dehydration
• Low bone mineral density can produce osteopenia or osteoporosis, and significantly elevated risk of fracture

Anorexia Nervosa: Vomiting

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

Anorexia Nervosa: Differentials

• Light-colored, foul-smelling stools, bloating, flatulence, or explosive diarrhea can be related to Gastrointestinal-malabsorption syndromes
• Enlarged thyroid gland, palpitations, trembling or shaking or tremor, warm, moist skin, and low TSH can be related to Hyperthyroidism
• Neck/head pain, loss of vision, and pituitary hormone deficiencies can be related to midline tumors
• Bulimia shows a normal body weight

Additional differentials include

• Decrease appetite, unplanned physical activity, and no concern for body image
• Depression
• Fear of poisoning associated with Schizophrenia
• Obsessions are not only related to eating habits or food in OCD patients
• Acquired immunodeficiency syndrome [AIDS]
• Occult malignancies
• Substance use disorders; cocaine amphetamines.
• Avoidant/restrictive food intake disorder

Anorexia Nervosa: Management

• Physical examination and determining BMI
• Blood tests include CBC, U/A, BUN, and serum electrolytes
• Labs determine Cholesterol and lipid profile, Calcium, magnesium, phosphorus, amylase, LFT, and EKG
• Other laboratory testing and CT scans can rule out other medical conditions
• Bone Mineral densitometry evaluates osteoporosis

Anorexia Nervosa: Treatment

• Individual psychotherapy and family therapy
• Medicines for co-existing mental ill health
• Nutritional Rehabilitation
• Management of medical complications

Anorexia Nervosa: Outpatient/Inpatient Treatments

• Settings can include outpatient, partial programs or hospitalized
• Goals include restoring nutritional state, normalizing eating behaviors, and changing 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 care includes establishing a contract to follow with the expectations and consequences

Anorexia Nervosa: Inpatient Guidelines

• Weighing with empty bladders with gowns daily in the morning
• Monitoring input and output
• Restricting bathroom usage for 2 hours after eating if vomiting
• Frequently checking potassium and electrolytes.
• Monitoring EKG for palpitations, if hypokalemic
• Multivitamins and calcium are fine and should be used
• Increase by 500kcal daily intake over caloric intake to properly maintain actual body weight
• Splitting into 6 meals or through liquid food supplements.

Refeeding Syndrome

• A potentially life-threatening condition
• Develops when severely malnourished individuals, especially those who have undergone prolonged fasting or starvation, are rapidly reintroduced to nutrition
• Involves electrolyte imbalances and metabolic disturbances, posing significant risks to the body's organs and systems
• Additional symptoms include; Confusion and Disorientation, Double Vision, Swallowing Problems, Trouble Breathing, Kidney Dysfunction, Muscle Weakness, Seizures, Cardiomyopathy or Heart Weakness, Nausea and Vomiting, and Hypotension or low blood pressure, hypophosphatemia, hypokalemia, and hypomagnesemia

Refeeding Syndrome: Prevention

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

Anorexia Nervosa: Medications

• Second-generation Antipsychotics can increase appetite and help decrease cognitive distortions
• Olanzapine improves weight
• Aripiprazole decreases cognitive rigidity
• Comorbidities include Depression in 65% of cases, Social phobia in 34% of cases, and OCD in 26 % cases

Anorexia Nervosa: Prognosis

• Mortality rates range from 5% to 18%
• Factors include weight-related issues and possible suicide

Bulimia Nervosa

• A condition in which someone repeatedly regurgitates undigested or partially digested food from the stomach

Bulimia Nervosa: Epidemiology

• 12-month prevalence ranges from 0.14% to 0.3%
• Occurrences are much higher 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% or 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

Bulimia Nervosa

Comorbidity

• Anxiety disorders.
• Substance abuse disorders. Borderline personality disorders. Mood symptoms .

Bulimia Nervosa: Causes

• Causes include trauma, genetics, body image issues, dietary factors, social factors, and psychological factors

Bulimia Nervosa: Diagnostic Criteria

• Recurrent episodes of binge eating, characterized by eating, in a discrete period of time or within any 2-hour period, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances
• Inappropriate compensatory behaviors include self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
• The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months
• Self-evaluation is unduly influenced by body shape and weight
• The disturbance does not occur exclusively during episodes of anorexia nervosa

Bulimia Nervosa: Specifiers

• Mild is an average of 1–3 episodes of inappropriate compensatory behaviors per week
• Moderate is an average of 4–7 episodes of inappropriate compensatory behaviors per week
• Severe is an average of 8–13 episodes of inappropriate compensatory behaviors per week
• Extreme is an average of 14 or more episodes of inappropriate compensatory behaviors per week.

Bulimia Nervosa: Clinical Features

• Swollen Cheeks or Jawline
• Fainting
• Irregular Menstrual Periods
• Muscle Weakness
• Bloodshot Eyes
• Dehydration
• Gastrointestinal Issues Like Constipation and Acid Reflux
• Scars, Scrapes, or Calluses on Knuckles

Bulimia Nervosa: Associated Findings

• Characterized by periods of Normal weight, but in reaction to binging, are Sexually active
• Have Alcohol dependence
• Suffer Impulse control problems and find that often, Families tend to be rejecting and more chaotic

Bulimia Nervosa: Co-morbidity

• Anxiety disorders
• Substance abuse disorders,
• Borderline personality disorders, and
• Mood symptoms

Bulimia Nervosa: Differentials

• Can be mistaken for Anorexia, CNS tumors, Klüvre-Bucy syndrome, Kleine-Levin syndrome, Binge eating disorder and Major depression with atypical features

Bulimia Nervosa: Complications

• Enamel erosion and Dental Cavities
• Irregular Heartbeat.
• Can lead to Mallory-Weiss syndrome and Endocrine irregularities
• Dehydration
• Ischemic-induced myopathy

Bulimia Nervosa: Treatment Caveats

• Blood tests should assess: serum electrolytes, blood urea nitrogen, Serum creatinine, complete blood count, Liver function and Urinalysis
• Severely ill patients with bulimia nervosa require tests for Serum calcium, mаgոeѕium, and phosphorous and Electrocardiogram or ECG

Bulimia Nervosa: Treatment Protocol

• Stabilize electrolyte abnormalities like hypokalemia and hypomagnesemia and monitor hyperamylasemia
• Only admit for inpatient if needed to to treat medical problems but outpatient is fine
• Watch for Supraventricular and ventricular ectopic rhythm to defend against Torsade de pointes
• Characterized by CBT therapy or first line of treatment as well as nutritional counseling and support groups
• Medication such as fluoxetine, sertraline, escitalopram or fluvoxamine is key
• Bupropion is contraindicated due to the increased risk of seizures

Bulimia Nervosa: Prognosis

• Onset before puberty or after age 40 is uncommon
• Binge eating frequently begins during or after an episode of dieting to lose weight
• Experiencing multiple stressful life events can precipitate the onset
• Diagnostic crossover from initial disorder to anorexia nervosa occurs in 10%-15% of cases.
• Significant mortality risks have been reported (all-cause and suicide)
• Crude mortality rate nearly 2% per decade.

Binge Eating Disorders

• Characterized by the recurrent episodes of binge eating

Binge Eating Disorders: Diagnostic Criteria

• Recurrent episodes of binge eating
• Eating, in a discrete period of time
• Eating an amount of food that is definitely larger than what most people would eat Has two or more of the following:
  • Eating much more rapidly than normal
  • Eating until feeling uncomfortably full
  • Eating large amounts of food when not feeling physically hungry.
  • Eating alone because of feeling embarrassed by how much one is eating
  • Feeling disgusted with oneself, depressed, very guilty afterward
• Marked distress occurs during the binge
• Eating occurs once a week for 3 months
• Does not participate in repeated poor compensatory behavior

Binge Eating Disorders: Episodes and Severity

• Severity of episodes can determine what binge eating disorder it is:
  • Mild: 1-3 binge episodes a week
  • Moderate: 4-7 binge episodes a week
  • Severe: 8-13 binge episodes a week
  • Extreme: 14 or more episodes a week

Binge Eating Disorders: Treatment

• Binge-eating disorder occurs in normal-weight/overweight and obese individuals and dieting follows the development of it
• Paitents have functional impairment, lower life quality, and more psychiatric comorbidity
• Reduce binge eating episodes and excess weight
• Treat excessive concerns with body image and psychiatric disorders while also monitoring for obesity
• Bariatric surgery is last resort
• Medication; fluoxetine, topiramate, lisdexamfetamine or CBT psychotherapy combined with Support groups
• Suicidal ideation has been reported to occur in approximately 25% of individuals with binge-eating disorder