Eating Disorders: Anorexia, Bulimia & Binge Eating

Feeding and Eating Disorders

• Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder can be diagnosed and treated using diagnostic criteria, clinical features, etiological factors, and epidemiology.
• Differential diagnosis, the course of illness, and prognosis can also be used in diagnoses.
• Genetic, biological, psychological, and social etiological factors should all be summarized in patients with eating disorders.
• Potential medical complications and lab examination findings should be differentiated from other medical conditions.
• Treatment interventions and major goals of treatment with pharmacological interventions can improve the outcomes of patients with eating disorders.

Types of Eating Disorders

• Feeding disorders include Pica and Rumination Disorder
• Eating disorders include Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder, as well as Avoidant/Restrictive Food Intake Disorder, OSFED, Orthorexia, and Diabulimia.

Anorexia Nervosa Criteria

• Restriction of energy intake relative to requirements leads to a significantly low body weight given a person's age, sex, developmental trajectory, and physical health
• Low weight is defined as less than minimally normal, or less than minimally expected for children/adolescents.
• Intense fear of gaining weight or becoming fat is present, as is persistent behavior that interferes with weight gain.
• Disturbance occurs in the way one's body weight or shape is experienced resulting in an undue influence of body weight or shape on self-evaluation, or a lack of recognition of the seriousness of current low body weight.

Anorexia Nervosa Specifiers and Subtypes

• Anorexia Nervosa has "in partial vs full remission" specifiers, based on whether weight is restored
• A BMI greater than or equal to 17 kg/m2 indicates a mild case
• A BMI of 16–16.99 kg/m2 indicates a moderate case
• A BMI of 15–15.99 kg/m2 indicates a severe case
• A BMI less than 15 kg/m2 indicates an extreme case
• In the Restrictive Subtype, the individual has not engaged in recurrent episodes of binge-eating or purging behavior during the last 3 months
• Binge-Eating/Purging Type involves recurrent episodes of binge-eating or purging behavior during the last 3 months
• Binge-eating/purging type may include self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Anorexia Nervosa: Clinical Presentation

• Insomnia
• Refusal to eat with others
• Hiding and cutting up food into small pieces
• Dramatic weight loss
• Carrying candy around
• Constant preoccupation with 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
• Dental enamel erosion
• Dependent edema
• Petechiae or ecchymoses
• Yellowing of the skin
• Lanugo
• Fatigue
• Hypothermia (always cold)
• Emaciation
• Loss of Muscle

Anorexia Nervosa: Problems

• Cardiac structural and functional abnormalities include hypotension, bradycardia, mitral valve prolapse and pleural effusions
• QT dispersion, decreased diastolic ventricular function, and diminished heart rate variability can coincide
• Leukopenia, anemia, thrombocytopenia, low FBS, high cholesterol level, and xerosis may present
• Reproductive problems include reduced secretion of gonadotropin-releasing hormone, functional hypothalamic amenorrhea, and possible Amenorrhea
• The patient can still get pregnant
• Endocrine problems include elevated growth hormone and plasma cortisol, and reduced gonadotropin levels, triiodothyronine (T3), and testosterone in men
• Gastrointestinal issues include gastroparesis, heartburn, constipation, elevated liver function tests, and oropharyngeal dysphagia
• Respiratory problems include wasting of respiratory muscles, dyspnea, reduced aerobic capacity, and decreased pulmonary capacity
• Renal problems include reduced glomerular filtration rate, diuresis, hyponatremia, and dehydration
• Musculoskeletal problems include low bone mineral density, osteopenia or osteoporosis, and elevated risk of fracture
• Vomiting can result in hypokalemia, hypocalcemia, elevated LFT, ECG t wave flattening and inversion, ST segment depression, and lengthening of QT interval, dehydration, hypomagnesemia, an increase in amylase, and metabolic encephalopathy

Differential Diagnosis for Anorexia Nervosa

• Light-colored and foul-smelling stool, bloating, flatulence, or explosive diarrhea
• Decreased appetite, unplanned physical activity, and no concern for body image
• Enlarged thyroid gland, palpitations, trembling, warm, moist skin, and low TSH with hyperthyroidism
• Bulimia with normal body weight
• Neck/head pain, loss of vision, pituitary hormone deficiencies
• Schizophrenia with feat of poisoning
• OCD with obsessions unrelated to eating habits
• Acquired immunodeficiency syndrome [AIDS]
• Occult malignancies
• Substance use disorders (cocaine amphetamines)
• Avoidant/restrictive food intake disorder

Anorexia Nervosa Management Steps

• Evaluate
• Check CBC, U/A, BUN, and serum electrolytes in tests
• Assess malnourished status
• Monitor cholesterol and lipid profile, calcium, magnesium, phosphorus, amylase, LFT, and EKG
• Rule out other medical conditions with labs and CT scans
• Check bone mineral density to evaluate osteoporosis

Anorexia Nervosa Treatment

• Medicines for co-existing mental illnesses and individual/family psychotherapy
• Normalize eating behaviors and change patients' cognitive distortions about food, weight loss and body shape
• Treatment can include outpatient, partial program, or hospitalization
• Restore nutritional state
• Involuntary hospitalization may be necessary if death may occur due to complications of malnutrition
• Establish a contract as an outpatient to follow expectations and consequences
• Antipsychotics can help decrease cognitive distortions
• Olanzapine can help with weight and Aripiprazole may decrease cognitive rigidity
• Comorbidities should be recognized and may include depression, social phobia, and OCD

Anorexia Nervosa: Hospitalization Guidelines

• Weigh patients in the morning in gowns and with an empty bladder
• Monitor input and output
• Restrict bathroom use for 2 hours after a patient vomits
• Check potassium and electrolytes frequently
• Monitor EKG for palpitations and hypokalemia
• Monitor LFT

Refeeding and Preventing Refeeding Syndrome

• Never give laxatives- stool softeners and bulk-producing agents are ok
• Multivitamins and calcium are ok
• Increase by 500kcal daily intake over caloric intake to maintain actual body weight
• Split intake in 6 meals or through liquid food supplements.
• Refeeding Syndrome is life-threatening and involves electrolyte imbalances and metabolic disturbances and poses risks for the body's systems
• Confusion and disorientation
• Double vision
• Swallowing problems
• Trouble breathing
• Kidney dysfunction
• Muscle weakness
• Seizures
• Cardiomyopathy
• Nausea and vomiting
• Hypotension
• Hypophosphatemia, hypokalemia, and hypomagnesemia

Strategies for Preventing Refeeding Syndrome

• Recognition and screening
• Gradual refeeding
• Individualized nutritional plans
• Electrolyte monitoring and supplementation
• Thiamine supplementation
• Multidisciplinary approach
• Ongoing monitoring and support

Anorexia Nervosa: Course and Prognosis

• Up to 5% to 18% mortality rate because of weight-related issues and suicide
• Anorexia may result in individuals recovering, having a partial remissions, and having a chronic underweight presentation.

Bulimia Nervosa

• Lifetime prevalence ranges from 0.28% to 1.0% overall
• Higher rates in women than men
• Adolescents ages 13-18, lifetime prevalence rates were 1.3% and 0.5% in girls and boys, respectively (Swanson et al. 2011).
• Can be caused by trauma, genetic factors, psychological factors, social factors and dietary factors.

Bulimia Nervosa: Criteria

• Recurrent episodes of binge eating occur, with an episode being characterized by eating within any 2-hour period, an amount of food that is definitely larger than what most individuals would eat and a sense of lack of control.
• Recurrent inappropriate compensatory behaviors will follow to prevent weight gain, such as self-induced vomiting, misuse of laxatives/diuretics/medications, fasting, or excessive exercise
• The binging and compensatory behaviors both occur at least once a week for 3 months, on average.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify current severity:
• The minimum level of severity is based on the frequency of inappropriate compensatory behaviors
• Levels of severity may be increased as needed to reflect other symptoms and the degree of functional disability.
• Mild is 1-3 episodes per week, moderate is 4-7 episodes per week, severe is 8-13 episodes per week and extreme is 14 or more episodes per week.

Bulimia Nervosa: Signs and Symptoms

• 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
• Frequent bathroom visits
• Excessive exercising
• Preoccupation with body image and fear of gaining weight
• Feeling out of control, depression, anxiety, or substance abuse
• Feeling guilty or shameful about eating, or withdrawing socially from friends and family

Bulimia Nervosa: Associated Findings

• Bulimia Nervosa: Normal weight
• Sexually active
• Alcohol dependence
• Impulse control problems
• Families tend to be rejecting and more chaotic

Bulimia Nervosa: Treatments and Caveats

• Comorbidity with anxiety disorders, substance abuse disorders, borderline personality disorders, and mood symptoms are common
• Differential Diagnosis considerations include anorexia, CNS tumors, Klüvre-Bucy syndrome, Kleine-Levin syndrome, binge eating disorder and major depression with atypical features

Bulimia Nervosa: Complications

• Dental Cavities
• Dehydration
• Endocrine diabetes and Menstrual irregularities
• Irregular Heartbeat
• Mallory-Weiss syndrome
• Ipecac-induced myopathy
• Symptoms and physical findings may direct labs such as Serum electrolytes, blood urea nitrogen, Serum creatinine, complete blood count, and Liver function tests
• Severely ill patients may warrant additional tests can include ​​Serum calcium, magnesium, and phosphorous as well Electrocardiograms
• Electrolyte abnormalities like hypokalemia and hypomagnesemia should be addressed, as well as monitoring hyperamylasemia
• Outpatient care is the goal unless medical problems need treatment
• Supraventricular and ventricular ectopic rhythms need to be examined, as well as Torsade de pointes

Bulimia Nervosa: Treatment

• Psychotherapy, starting with CBT: first line of treatment proven to be effective
• Nutritional Counseling: designed to control binge eating and compensatory behavior
• Medication may include fluoxetine, sertraline, escitalopram or fluvoxamine - Bupropion is contraindicated due to the increased risk of seizures
• Support Groups: with motivational interviewing

Bulimia Nervosa: Course and Prognosis

• Onset before puberty or after age 40 is uncommon
• Eating frequently begins during or after an episode of dieting to lose weight
• Experiencing multiple stressful life events also can precipitate the onset of bulimia nervosa
• Diagnostic crossover from initial bulimia nervosa to anorexia nervosa occurs in a minority of cases (10%–15%)
• Percentile for chronic bulimia nervosa is 20%, fluctuating course is 30% and recover is 50%
• Signficantly elevated risk for mortality resulting from all causes and suicide

Binge Eating Disorder

• Characterized by recurrent episodes: eating within any 2-hour period, a large amount of food and a sense of lack of control
• Binge-eating episodes are associated with eating more rapidly than normal, eating until feeling uncomfortably full, large amounts of food when not hungry, and alone
• Binge Eating Disorder: Feeling disgusted, depressed, or guilty afterward
• Marked distress is present as well as these episodes occurring at least once a week for 3 months.
• Is not associated with inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia or anorexia nervosa

Binge Eating Disorder: Epidemiology and Treatment

• 12-month prevalence is 0.44% to 1.2% and lifetime prevalence ranges from 0.85% to 2.8% overall
• Higher rates in women
• Treatment includes reducing binge eating episodes and excess weight and reducing excessive concerns with body image.
• Can include treatment for psychiatric comorbidity, monitoring obesity effects and bariatric surgery.
• Therapies include psychotherapy (CBT) and support groups with medication like fluoxetine and lisdexamfetamine
• Binge eating disorder occurs in normal-weight, overweight and obese individuals as is associated with increased risk for weight gain and development of obesity has also shown a potential for suicidal ideation