Diagnosis and Management of Eating Disorders

Stephanie Bui MD FAAPAssistant Clinical Professor of Medicine and PediatricsUCLA Health System – Brentwood

Case Study #1

K.P. is a 17 year old female presenting to your office for “irregular periods”.

Had been seen 8 months prior for a well visit. At that time height was 65 inches, weight 140 lbs (BMI 22.6). Menarche age 13, having normal menstrual cycles every 28-32 days

Today height is 65 inches, weight 115 lbs (BMI 18.6). Last period was 3 months previously

What Questions should you ask?

Case Study #1 (continued)

Patient denies sexual activity Patient says that she has just been

“getting healthy” by cutting out snacks

Patient says she started exercising as well to “get healthy”

Is very evasive and defensive when asked how much she eats/how much exercises

Case Study #1 (continued)

Mom asks to see you outside of the room Has noticed that K.P. is eating less meals

with the family Has noticed a weight loss (unsure how

much) Scale is now moved from bathroom to

K.Ps room Mom has not been able to discuss this

with K.P. as patient gets defensive Worried that K.P. has an eating disorder

Physical Exam

As stated – weight 115 lbs. Blood pressure 100/60. Heart rate 50. Temp 96.7

HEENT – Lanugo noted on face Neck – Thyroid – normal size, no masses CV: Bradycardia Breasts: Tanner 4, Pubic Hair Tanner 4 Abdomen: Soft/non tender/no masses Extremities: Cool fingertips and Toes

Case Study #1 (continued)

What labs do you want?

Case Study #1

Urine Pregnancy test – negative CBC – WBC 3.1 otherwise normal Chem 10 – Normal Prolactin – Normal TSH – Normal FSH – 2.0 LH – 2.0 Estradiol <30 EKG – Sinus bradycardia at 50 BPM

otherwise normal

Case Study #1 (continued)

You tell K.P that her lack of periods is likely due to her weight loss

You begin to discuss healthy ways of gaining weight, she storms out of the room and says “No Way I’m doing that – I’m fine the way I am”

What’s your Diagnosis?

Anorexia Nervosa

• DSM IV-TR Criteria • A. Refusal to maintain body weight at or above

a minimally normal weight for age and height• B. Intense fear of gaining weight or becoming

fat, even though underweight• Disturbance in the way in which one’s body

weight of shape is experienced• Amennorhea (in post menarchal females) –

absence of at least 3 menstrual periods• Type – Restricting Type or Binge-Eating/purging

Type

Anorexia Nervosa: Etiology Genetic: First degree relative 3x risk Biologic: neurotransmitter abnormalities Sociocultural: obsession with thinness Psychological

Low self esteem Conflict about identity, sexuality Obsessive-compulsive 40% history of abuse, being teased

Family: enmeshed, overprotective Sports: gymnastics, ice skating ballet

Anorexia Nervosa: Epidemiology• Prevalence – Estimated at 1%• 90-95% are female• Bimodal peaks of onset at ages 13-

14 and 17-18• Prepubertal may be associated with

more severe profile• Adolescent onset associated with

better prognosis that prepubertal and adult onset

• 30% of patients were obese

What to do now?

Anorexia Nervosa:Management

Determine Level of Care: Medically Unstable: medical hospital▪ Heart rate <40, glucose < 60 mg/dl,

potassium <3 mEq/l, orthostatic hypotension Psych Unstable: psych hospital Med/Psych stable:▪ <70% IBW: Inpatient▪ 70-85% IBW: Partial/Day treatment▪ >85%: Outpatient

Anorexia Nervosa:Management

Create treatment team Therapist: individual and family Nutritionist Medical provider Psychiatrist

Coordination between all providers is KEY

Start with therapeutic alliance

Anorexia Nervosa:Management

School – Consider reduced schedule Exercise: limit activities, team

sports, gym Amennorhea: consider OCP >6-12

months Calcium 1200-1500 mg Vitamin D 400-800 IU Dexa Scan if no menses > 6 months

Anorexia Nervosa:Target Weights

Standardized tables Premorbid weight Weight at which patient had last

period Progressive weight goals Weight at which patient feels safe

and healthy May need to postpone discussion

Anorexia Nervosa:Management Close monitoring: every 1-2 weeks Standardized weights: gown, empty

bladder Weight gain: ½-1 lb per week

If faster risk refeeding syndrome Ask patient if they want to know weight Avoid comments about weight During treatment constantly assess:

Resistance, denial, non-compliance, deception Depression, anxiety Purging activities

Treat psychiatric co-morbities

Anorexia Nervosa: Complications

Cardiac: Arrhythmias, prolonged QT, heart failure, pericardial effusions

Neurologic: cerebral atrophy Endocrine:Osteoporosis Renal: renal failure, nephrolithiasis GI: gastric dysmotility Dental: enamel erosions

Back to K.P.

Initial visit – after coaxing back into room, you explain your concerns about health

She reluctantly agrees to see a nutritionist, refuses to see a therapist

Follow-up one week later, weight is down 2 pounds – refused to implement changes suggested by nutritionist

Admitted to day treatment program

Anorexia Nervosa: Course and Outcome

< 50% achieve full recovery Predictors of recovery: higher body weight at

intake, shorter duration of intake episode, and atypical features

1/3 improve with lingering symptoms 1/5 remain chronically ill Mortality

Mortality rate is 12x higher than that for age matched women

24% of deaths due to suicide

Case Study – 5 years later

K.P. presents to your office 5 years since initial diagnosis of anorexia nervosa – since that time, she has had one inpatient admission and 3 partial hospitalizations – last at age 19.

Her weight has been stable at 135 for the past 2 years

On exam, you noticed parotid enlargement, and scars on her knuckles

What happened?

Bulimia Nervosa

Bulimia Nervosa: Diagnostic Criteria

Recurrent episodes of binge eating Recurrent inappropriate compensatory

behaviors in order to prevent weight gain (self induced vomiting, misuse of laxatives, diuretics, enemas or other medications, fasting, excessive exercise)

At least 2 episodes of binge eating per week for 3 months

Two types: Purging Non purging

Bulimia Nervosa: Etiology

Similar to anorexia nervosa Borderline personality disorder Impulse Control Perfectionism Disturbances in family function History of sexual abuse

Bulimia Nervosa: Epidemiology

Lifetime Prevalence 1%-4.2% 90-95% femaile Onset later than in anorexia nervosa Less common in African Americans 50% of patients with anorexia

nervosa will migrate to Bulimia Nervosa

Bulimia Nervosa: History

Eating and Body image questions Questions about binge eating

Frequency, amounts Triggers – specific foods, situations, feeling Facillitators

Questions about purging Frequency, techniques After purge, how do you feel? Dental Care Vomited Blood, reflux symptoms

Bulimia Nervosa: Management Determine Level of Care Create treatment team Focus on the binge, not the purge Dental Care

Rinse teeth immediately, don’t brush for 30 minutes

Sensitive toothpaste Medications

SSRIs – most studied is fluoxetine 60 mgs/day Bupropion – black box warning re: seizures

Bulimia Nervosa: Complications

Related to purging activity Dental: erosion, false teeth GI: esophageal tears, cathartic colon,

GERD Metabolic: electrolye imbalance,

dehydration

Bulimia Nervosa – Prognosis

Mortality – low 50% will achieve full recovery at 5 –

12 years 1/3 of these will go on to relapse

And then there is everything else…..

Eating Disorder “not otherwise specified”Binge eating Disorder

Disordered Eating

Case Study #2 – J.J

21 year old female, no past medical history

Height 5 ft 8 lb, weight 140 lbs On routine history – exercises 7

days/week for 60 minutes – because “if I don’t I feel fat”

Counts calories Eats same foods every day Weighs herself daily Physical exam normal, Labs normal

Eating Disordered Thinking

When thoughts about your body and/or eating interfere with your life “If I were just 5 lbs thinner I would be

happy” “If I were thinner, then people would like

me more” “ I feel so fat; I am so fat; I will eat today

and start my diet tomorrow”

Eating Disordered Behavior

Eating rituals – same food, same schedule

Cutting out fat, favorite foods Weighing self a lot Excessive exercising Eating only if “good”

SCOFF Questionnaire

Do you make yourself Sick “purge” because you feel uncomfortalby full?

Do you worry that you have lost Control

Have you recently lost more than 14 lbs (One Stone) in a 3 month period

Do you think you are too Fat Would you say that Food dominates

your life

Remember Anorexia Anorexia Nervosa

Case Study #3 – M.B.

15 year old male new patient presented to office for “anorexia nervosa”

Recently discharged from inpatient eating disorder facility

Previous to his admission there, had lost 15 pounds with decreased intake. Vague complaints of abdominal pain

On review of labwork, had microcytic anemia prior to admission to eating disorder facility

Case Study #3

Gained weight only with tube feeds in hospital (was refusing po)

Repeat labs after hospitalization – persistent microcytic anemia, low Fe levels, elevated ESR

Dad with “colitis”

Case Study #3

Bottom line – severe Crohn’s disease Ultimately required ileocecal

resection.

Take Home Messages

If your patient says “I feel fat”, it is code for I feel sad I feel angry I feel stupid

Don’t dismiss the feeling, normalize it Emphasize health and fitness for patient

and family People are different shapes and sizes Everyone can try to be healthy, fit and heave

healthy body image

Take Home Messages

Routinely ask about body image Set follow up appointments For families

Be Direct: “I am worried about you” Be prepared: show direct evidence Be Firm Don’t bribe or monitor Get help – Earlier the diagnosis, better

the prognosis