Understanding Eating Disorders

• Eating disorders are complex, chronic psychiatric illnesses
• Eating disorders are characterized by abnormal eating habits and/or weight control behaviors
• Anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), pica, avoidant-restrictive food intake disorder (ARFID), and rumination disorder are types of eating disorders.
• Eating disorders have a significant impact on physical and mental health and social functioning
• Eating disorders have high rates of suicide
• Anxiety disorders, mood disorders, and substance-use disorders are often reported as co-occurring psychiatric illnesses
• Eating disorders have an increased risk for death by suicide and medical complications

Incidence

• Eating disorders affect females more than males
• AN and BN begin in adolescence and young adulthood.
• Peak incidence of AN and BN is between 15-20 years old
• ARFID is commonly diagnosed in younger children and early adolescence
• BED typically begins in early adulthood with a mean age of onset of 25 years
• Individuals can be diagnosed with more than one eating disorder in their lifetime, but they do not occur concurrently

Eating Disorder Signs

• Rapid weight loss may indicate an eating disorder
• Failure to gain weight or difficulty gaining weight can indicate an eating disorder
• Body image disturbance may indicate an eating disorder
• Abnormal food practices or thoughts about weight or shape can indicate an eating disorder
• Growth stunting or pubertal delay in children and adolescents can indicate an eating disorder
• Sudden changes in eating or exercise patterns can indicate an eating disorder

Screening

• Any individual may be affected by an eating disorder, regardless of race, gender, socioeconomic status, or body size
• Preteens, adolescents , sexual minority individuals, transgender individuals, and gender diverse youth should be screened
• People with a history of trauma and abuse, childhood adversity or those with chronic diseases should be screened
• Screening individuals with a psychiatric disorder, or those undergoing an initial psychiatric evaluation is important
• Screening tools screen for potential cases but are not meant for diagnostic purposes.
• SCOFF Questionnaire is a screening tool that is widely used to test for eating disorders
• A score greater or equal to 2 on the SCOFF Questionnaire indicates that anorexia nervosa or bulimia nervosa is likely
• Other screening tools include: Eating Attitudes Test-26 (EAT-26), Eating Disorder Screen for Primary Care (EDS-PC), and Eating Disorder Inventory (EDI-2).

Clinical Presentation

• Symptoms of eating disorders are due to malnutrition or disordered eating
• Syncope or fainting may be a signs of an eating disorder
• Abdominal pain may be a sign of an eating disorder
• Amenorrhea or menstrual irregularities may be a signs of an eating disorder
• Cold intolerance may be a signs of an eating disorder
• Russell's sign, which is abrasions on knuckles may occur because of self-induced vomiting
• Lanugo is a sign
• Vital sign changes such as bradycardia, hypotension, and temperature changes

Anorexia Nervosa (AN)

• It is a restrictive illness where individuals fail to maintain expected body weight and struggle with significant body shape or weight disturbance

Anorexia Nervosa (AN) Categories

• Anorexia nervosa, restricting type includes: no binge eating or purging and weight loss through excessive dieting, exercise, and/or fasting
• Anorexia nervosa, binge eating/purging type includes: restrictive eating and one or both of the following: Recurrent binge eating and purging (e.g., vomiting; diuretic, laxative, and/or enema misuse)
• Complications can occur secondary to sustained malnutrition

Anorexia Nervosa Diagnostic Criteria

• Reduction in energy intake (restrictive eating) leading to significantly low body weight
• BMI < 18.5 kg/m² for people >20 years of age indicating underweight
• BMI < 5th percentile for sex and age indicates underweight for those ≤ 20 years of age
• A fear of weight gain is one of the following: profound fear of weight gain or persistent behaviors that prevent weight gain (e.g., excessive exercise, purging)
• Body image distortion is one of the following: Body image distortion or disproportionate impact of weight or body shape on self-worth
• Lack of acceptance of the seriousness of current low weight

Bulimia Nervosa (BN) - Overview

• Characterized by recurrent binge eating followed by ways to prevent associated weight gain, known as compensatory mechanisms, as well as body image disturbances
• Binge eating often occurs in secrecy and individuals may experience feelings of shame afterward
• Binge eating is eating more than what most people would eat in the same time period
• A person experiencing an eating disorder has loss of control, or the feeling that eating cannot be stopped or controlled
• Healthy weight or slightly elevated may indicate BN
• BMI ≥ 18.5 kg/m2 for people >20 years of age indicates healthy weight or slightly elevated
• BMI ≥ 5th percentile for sex and age indicates healthy weight or slightly elevated for people ≤ 20 years of age

Bulimia Nervosa Diagnostic Criteria

• Recurrent binge eating episodes
• Recurrent inappropriate weight compensatory behaviors to counteract weight gain such as: Self-induced vomiting after binge eating (most common), Laxative misuse, diuretic misuse, Transient starvation periods, Excessive exercise, and prescription drug misuse (e.g., levothyroxine misuse, insulin omission in pts with diabetes)
• Binge eating and inappropriate weight compensatory behaviors both occur at least once a week over a 3-month period on average
• Sense of self-worth disproportionately influenced by the perception of one’s weight and/or body shape
• Binge eating and inappropriate weight compensatory behaviors do not occur only during episodes of anorexia nervosa

Bulimia Nervosa (BN) - Severity

• Severity is based on the number of episodes of inappropriate weight compensatory behaviors per week
• Mild: 1-3 episodes/week
• Moderate: 4-7 episodes/week
• Severe: 8-13 episodes/week
• Extreme: ≥ 14 episodes/week

Binge-Eating Disorder (BED) - Overview

• Most common eating disorder in adults in the U.S.
• Associated with high levels of distress related to binge eating
• Recurrent binge eating episodes that are not associated with inappropriate weight compensatory behaviors
• Pronounced dieting at a young age is common
• Can be associated with ASCVD risk factors and psychological conditions
• Course: typically chronic, relapsing disease

BED Diagnostic Criteria

• Recurrent binge eating episodes, which are characterized by both of the following: Consumption of an excessive amount of food within a given period of time (usually ≤ 2 hours) and lack of control in relation to what and/or how much food is consumed
• Episodes of binge eating are associated with ≥ 3 of the following: Eating faster than normal, Eating until uncomfortably full, Eating large amounts when not hungry, Eating alone because of embarrassment over the amount of food eaten, and feeling of disgust, depression, and/or guilt after eating
• Significant distress over binge eating
• Binge eating occurs at least once a week over a 3-month period on average
• No purging behavior, and binge eating does not occur only during episodes of anorexia nervosa or bulimia nervosa

BED Severity

• Severity is based on the number of binge eating episodes per week
• Mild: 1-3 episodes/week
• Moderate: 4-7 episodes/week
• Severe: 8-13 episodes/week
• Extreme: ≥ 14 episodes/week

Avoidant Restrictive Food Intake Disorder (ARFID) - Overview

• Characterized by the inability to maintain adequate nutrition unrelated to body image disturbance
• May be related to pickiness in food, sensory qualities of food, fear of consequences of eating (e.g., vomiting, choking)
• Commonly occurring in young children and adolescents
• Clinical key features are not explained by body image disturbance, cultural practice, food insecurity, or another medical (e.g., GI disease) or psychiatric (e.g., anorexia nervosa) condition
• Avoidance or restriction of food

ARFID Features

• One of the following must also be present: Significant weight loss; slow growth trajectory (in children), Malnutrition/Nutritional deficiency, Dependence on nutrition support (e.g., enteral feedings, supplements), and Impaired psychosocial function

Management

• Confirm the diagnosis
• Evaluate for complications
• Screen for red flag features of eating disorders; determine disposition
• Initiate management specific to the disorder
• Shared decision making

Management Types

• Psychotherapy includes cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and family-based therapy (FBT)
• Pharmacotherapy include these facts: SSRIs are often used to help manage comorbid psychiatric conditions, fluoxetine is the only drug FDA approved for treatment of BN as it can reduce binge eating episodes and purging, lisdexamfetamine is FDA approved for BED to target binge eating and help with weight reduction and Olanzapine may be used in AN to promote weight gain and can decrease obsessionality
• Management of complications (e.g., vitamin deficiencies, amenorrhea or menstrual abnormalities)
• Nutrition support aids people to support healthy eating habits, assess for food insecurity, provide nutritional education and monitor weight gain

Management: Level of Care

• Outpatient care is indicated for medically stable patients with motivation to change and good social support
• Standard outpatient care includes: intermittent psychotherapy visits (e.g., 1-2 visits/week). Meals monitored by caregivers and it does not interrupt daily living (e.g., school)
• Intensive outpatient care includes: partial day psychotherapy (e.g., ≥ 3 visits/week for ≥ 3 hours/visit). Care team may monitor meals. Minimal interruption to daily living
• Intermediate care: indicated for patients who are medically stable who require intensive guided management by a care team
• Partial Hospitalization: is when a patient lives at home but attends a clinic/hospital facility for ≥ 5 hours per day on a ≥ 5 days/week and the care team monitors most daily meals
• Residential treatment: is when a patient lives full-time at a facility with nursing on-site 24/7 (typically) and a physician on-call 24/7 and the care team monitors most daily meals
• Inpatient care is indicated for patients: with red flag features of eating disorders who require continuous monitoring and/or intensive management and/or who require treatment over objection and the care is provided in either a psychiatric or medical unit

Recovery entails

• Resolution of eating disorder behaviors (e.g., restriction, binge eating)
• Normalized eating patterns
• Improvement in health outcomes (weight gain or halted weight loss)
• Improvement in psychological components such as body image disturbance