EATING DISORDERS

Nutrition departmentMedical school

University of Sumatera Utara

الرحيم الرحمن الله الرحيم بسم الرحمن الله بسم

Psychiatric condition Characterized by abnormal eating

patterns and cognitive distortions related to food and body weight, which adversely affect nutritional status and lead to medical complications and impaired health status and function

3rd most common chronic illness in adolescent females

ANOREXIA NERVOSA (AN) BULIMIA NERVOSA (BN) EATING DISORDER NOT OTHERWISE

SPECIFIED (EDNOS)

ANOREXIA NERVOSA

Voluntary self-starvation and emaciation Weight loss is viewed as a sign of

extraordinary achievement and self-discipline

Weight gain is perceived as an unacceptable loss of self-control

1-2% of young adult women 85% during adolescent Increased risk occurs with conditions in

which dietary restraint or control of body weight is considered important (e.g. athletes, DM)

American Psychiatric Association Diagnostic Criteria for ANA. Refusal to maintain body weight at or

above a minimally normal weight for age and height (e.g. weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to the body weight less than 85% of that expected

B. Intense fear of gaining weight or becoming fat, even though underweight

C. 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 denial of the seriousness of the current low body weight

D. Amenorrhea in postmenarcheal females, i.e., the absence of at least three consecutive menstrual cycles

Specific type : Restricting type : during the current of

AN, the person has not regularly engaged in binge eating or purging behavior

Binge eating/purging type : during the current episode of AN, the person has regularly engaged in binge eating and purging behavior

Body image distortion feel fat despite their often cachectic state

Symptom depression (+) due to the psychological stress of starvation

Obsessive – compulsive features (+) particularly with regard to food

Typically reject treatment

Body Image= How you see your body and the way you feel about

it.

APA recommends that in AN : 1. depressive symptoms should be

reassessed after partial or complete weight

restoration 2. patients exhibiting non-food related obsessive compulsive behaviors should

be evaluated for a co morbid diagnosis of

obs- com disorders

Characteristics Determined food avoidance Weight loss or failure to gain weight during the

period of preadolescent growth (10-14 yr) in the absence of any physical or mental illness

Any two or more of the following : - preoccupation with body weight - preoccupation with energy intake - distorted body image - fear of fatness - self induced vomiting - extensive exercising - laxative abuse

Etiology

Multifactorial, with biologic, genetic, familial, sociocultural precipitans

Typically introverted, obsessional, and perfectionistic in nature

Family pathology : overprotectiveness, rigidity Comorbid anxiety disorders, depressive

disorders, personality disorders

Physical features Weight < 85% expected BMI < 17,5 Lanugo hair on face & trunk, brittle

listless hair Cyanosis on hands & feet, dry skin CV changes bradycardia, hypotension Orthostatic hypotension GI changes delayed gastric emptying,

gut motility , severe constipation

Medical & nutritional management Goals : - nutritional rehabilitation - weight restoration - cessation of weight reduction

behavior - improvement eating behavior - improvement in psychological and emotional state Forcing weight gain without psychological

support and counseling is contraindicated

Nutrition counseling targeted helping the patients understand nutritional needs, make wise food choices by increasing variety in the diet, practice appropriate food behavior

Individualized guidance and meal plan that provides a framework for meal & snacks and food choices helpful for most patients

During early refeeding monitored closely for sign of refeeding syndrome

BULIMIA NERVOSA (BN) Characterized by recurring episodes of

binge eating followed by one or more inappropriate compensatory behaviors to prevent weight gain

Self induced vomiting, laxative abuse, diuretic abuse, excessive fasting, compulsive exercise

The binge eating behavior that is central to the diagnosis

Binge Eating

Typically within the normal weight range, some may be under or overweight

Binge : consumption of an unusually large amount of food in a discrete period (usually ≤ 2 hours)

Self-induced vomiting the most commonly used (80-90%)

Stimulate the gag reflex with a finger or instrument

Syrup ipecac cardiomyopathies & sudden death

Etiology Addictive Family Sociocultural Cognitive-behavioral psychodynamic

American Psychiatric Association Diagnostic Criteria for BNA. Recurrent episodes of binge eating. An

episodes of binge eating is characterized by both of the following :

1. Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g feeling that one cannot stop eating or control what or how much one is eating)

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months

D. Self-evaluation is unduly influenced by body shape and weight

E. The disturbance does not occur exclusively during episode of AN

Specific type : 1. Purging type : during the current episode of BN, the person has regularly engaged in self-

induced vomiting or the misuse of laxatives, diuretics or enemas 2. Nonpurging type : during the current episode of BN, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas

Complication BNVomiting scarring of the dorsum of the hand used to stimulate the gag reflex Russell’s sign parotid gland enlargement erotion of dental enamel with increased

dental caries resulting from the frequent presence of gastric acid in the mouth

dehydration, alkalosis, hypokalemia Mallory-Weiss esophageal tears

Laxative abuse Dehydration Elevation of serum aldosterone &

vasopressin Rectal bleeding Intestinal atony Abdominal cramps

Diuretics abuse Dehydration & hypokalemia

Ipecac irreversible myocardial damage & sudden death

Medical & nutritional management Interdisciplinary team management Main goal help the patients develop

normal eating habits Patients often believe that controlled

intake is healthy and is the only way to lose/maintain weight need to met with clear guidelines

EDNOS 50% of ED Do not meet the diagnostic criteria for

either AN or BN If the disordered behaviors continue, they

may progress to frank BN or AN Treatment modality depend on the

severity of impairment & symptoms

1. For females, all of the criteria for AN are met except that the individual has regular menses

2. All of the criteria for AN are met except that, despite significant weight loss, the individual’s current weight is in the normal range

3. All of the criteria for BN are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months

American Psychiatric Association Diagnostic Criteria for EDNOS

4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amount of food

5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food

6. Binge Eating Disorder (BED) : recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of BN

BINGE EATING DISORDER Bingeing behavior without the compensatory

purging seen in BN 1-2% of the population, late adolescent or early

twenties Binge episodes must occur at least twice a week

and have occurred for at least 6 months Most patients are overweight & suffer the same

medical problems by obese population Significant emotional distress (+) feeling

disgust, guilt, depression

The binge eating episodes are associated with three or more of following :

1. Eating much more rapidly than normal 2. Eating until feeling uncomfortably full 3. Eating large amounts of food when not feeling physically hungry 4. Eating alone because of embarrassment over how much one is eating 5. Feeling disgusted with oneself, depressed, or very guilty after overeating

Malnutrition PEM results when the body’s need for protein

and energy fuels are not satisfied by the diet Its clinical manifestations depends on : - Duration and degree of shortfall in dietary intake - The quality of the diet - Host factors such as age - Interplay with infection

Origin Primary inadequate food intake

Secondary other diseases that lead to : - low food ingestion - inadequate nutrient absorbtion or utilization - increased nutritional requirements - increased nutrient losses

What are the Causes of Malnutrition?

Economists•Slow GDP growth•Low incomes

Nutritionists•Not enough calories or protein• Poor nutrition knowledge• Micronutrient deficiencies• Infections

Two Views

The problems of PEM The main health problem ‘primadonna’ of nutritional diseases Influencing morbidity and mortality

among underfives Early detection and proper management

are very important Severe malnutrition should be

hospitalized Poor quality of life

MARASMUS

Result from prolonged starvation Predominant energy deficit Because of chronic or recurring infections

with marginal food inatake (secondary marasmus)

most common form of PEM before 1 yr of age

KWASHIORKOR Usually affect children after 18 mo of age Predominant protein deficiency and

varying degrees of energy deficit Main sign is oedema so children look ‘fat’ Others : - hair changes : loss of pigmentation,

easy pluckability - skin lesions and depigmentation - apathetic

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