8/31/ Disclosure. + Goals. Eating Disorders

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1 Eating Disorders Kelly A. Curran, MD, MA Assistant Professor Adolescent Medicine Disclosure I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Goals The learner should be able to: Recognize epidemiologic patterns of eating disorders and identify the new diagnostic criteria Describe common presenting medical signs of eating disorders Identify criteria for emergency hospitalization for patients with eating disorders 1

2 Eating Disorders on Social Media Epidemiology of EDO For all you public health junkies Lifetime Prevalence of Eating DO Anorexia Nervosa 0.9% in women 0.3% in men Bulimia Nervosa % in women % in men ED NOS, now OSFED 2.4% in women BED % in women % in men 2

3 Mortality Rates of Eating Disorders AN 0.51% per year (highest of any mental illness) 20% of deaths from suicide BN 0.17% annually 23% from suicide ED NOS 0.33% per year BED no data on annual death rate Small study 12 year follow up 2/68 patients had died (medical) Eating Disorders in Men Historically 10% of ED patients were men Newer studies men are ~25% of AN/BN and 36% of BED patients Age of Onset of Eating Disorders 10% Ages 10 and younger 14% After 20 43% Ages 16 to 20 33% Ages 11 to 15 3

4 Not Just Young Women 2012 study International Journal of Eating Disorders 1800 women age 50 and older surveyed about eating disorder symptoms 3.5% reported binge eating 8% reported purging 70% reported trying to lose weight 62% reported that their weight or shape negatively impacted their life Recovery in Anorexia and Bulimia Steinhausen, et al. 45% BN, 46% AN will have complete recovery 27% BN and 33% AN will have partial recovery Adolescents 69-85% of patients recovered in years Average duration months 23% BN and 20% AN will have chronic disease Definitions & Diagnostic Criteria 4

5 Eating Disorder vs. Disordered Eating? Both a mental and physical illness in which abnormal behaviors, beliefs around food, weight, exercise lead to the detriment of physical and emotional health Out with the Old New! Anorexia Nervosa (AN) Criteria DSM-IV TR DSM-V Body Weight Refusal to maintain body weight more than 85% of expected for height/weight Restriction of energy intake relative to requirements leading to markedly low body weight Fear of Weight Gain Body Image Although underweight, intense fear of gaining weight or becoming fat Disturbance in the way one s body weight or shape is experienced; denial of the seriousness of low body weight; undue influence of body weight or shape on self-evaluation Same OR persistent behavior to avoid gaining weight although a markedly low weight No change Menstruation Absence of three consecutive menstrual cycles No criteria 5

6 Bulimia Nervosa (BN) Criteria DSM-IV TR DSM-V Binge Eating 1) Eating an amount of food in discrete period of time (2h) that is definitely larger than most people would eat OR 2) A sense of lack of control No change Compensatory Behavior Recurrent inappropriate compensatory behavior in order to prevent weight gain (self induced vomiting, misuse of laxative, diuretics, enemas or other medications; fasting or excessive exercise) No change Frequency Self-Evaluation & Relation to AN Binge eating and compensatory behaviors occur, on average, twice weekly for previously three months Unduly influenced by body shape and weight; the disturbance doesn t occur exclusively during episodes of AN Once weekly for 3 months No change Avoidant Restrictive Food Intake Disorder (ARFID) Eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs leading to one or more of the following: Significant weight loss (or failure to achieve expected weight gain or faltering growth in children) Significant nutritional deficiency Dependence on enteral feeding or oral nutritional supplements Marked interference with psychosocial functioning ARFID Disturbance not due to: Unavailability of food, or to observation of cultural norms Anorexia nervosa or bulimia nervosa, no evidence of disturbance in experience of body shape or weight Another medical condition or mental disorder, or when occurring concurrently with another condition, the disturbance exceeds what is normally caused by that condition 6

7 Binge Eating Disorder (BED) Frequent overeating at least 1x/week for 3 months combined with lack of control and marked feelings of distress Associated with three 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, or very guilty afterward Other Specified Feeding or Eating Disorder (OSFED) AKA ED NOS Atypical Anorexia Nervosa in which all criteria for anorexia nervosa are met except that the individual s weight is within or above the normal range Subthreshold Bulimia Nervosa (low frequency or limited duration) in which all criteria for bulimia nervosa are met except the binge eating and compensatory behaviors occur on average less than once a week and for less than 3 months Subthreshold Binge Eating Disorder (low frequency or limited duration) in which all criteria for binge eating disorder are met, except the binge eating occurs on average less than once a week and for less than 3 months Purging Disorder: purge without binging; they consume a normal amount of food and typically maintain normal weight Night Eating Syndrome: nocturnal eating episodes, or eat a large proportion of their daily calorie intake after dinner Other Feeding or Eating Condition Not Elsewhere Classified which is a residual category for all other cases that are clinically significant but do not meet the criteria for formal eating disorder diagnoses People rarely come in saying, I have an eating disorder! So what exactly should I be looking for? 7

8 Growth Charts 8

9 Weight changes/failure to thrive Nausea/vomiting Fatigue Syncope Dizziness Chest pain Presenting Symptoms Decreased appetite/intake Behavior changes Constipation Amenorrhea Hair loss Cold intolerance Headaches Sore throat And the list goes on Signs on Physical Exam General Exam Abnormal body weight Hypothermia Hypo/hypertension Orthostatic blood pressure or heart rate change Bradycardia 9

10 HEENT Parotid enlargement Conjunctiva hemorrhage Temporal wasting Palate ulcerations/trauma Dental erosions Atrophic thyroid Cardiovascular & Gonads Bradycardia Medial displacement of PMI Breast atrophy Testicular atrophy Heart failure/volume overload Irregular rhythm Extremities/Skin Delayed capillary refill Cool to touch Excoriations/callouses on the back of the hands (Russell s sign) Acrocyanosis Lanugo Pallor 10

11 Neuro/Psych Psychomotor retardation Abnormal MMSE Flat, constricted affect Self-injury marks Muscular weakness Abnormal Labs CBC Leukopenia Anemia Thrombocytopenia LFTs Elevated AST, ALT BMP Electrolyte disturbance Metabolic alkalosis Elevated BUN/Cr Hypoglycemia Low estrogen/testosterone Low FSH/LH High amylase Elevated cholesterol Thyroid Function High reverse T3 Low free T4 Other Studies EKG Bradycardia QTc prolongation Arrhythmias Low voltage ST/T wave abnormalities Rightward axis Xray Osteopenia/Fractures MRI Brain Small brain volume Loss of gray matter Echocardiogram Reduced ventricular mass Pericardial effusion Mitral valve prolapse 11

12 So, I think my patient may have an eating disorder based on exam and labs? Now what do I ask? Getting the History Brought to you by the letters H, P & I The SCOFF Screening Tool Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (~14 lbs) in a 3 month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? One point for every yes ; a score of 2 indicates a likely case of anorexia nervosa or bulimia 12

13 More Questions Eating and exercise pattern Calorie or food type restriction Bingeing Skipped meals Purging Over-exercising 24 hour recall Pill/supplement use Diuretic Emetic Laxative Stimulant Diet pill Weight loss Abnormal food behaviors Avoid eating in public Cutting up food Vegetarian/vegan, gluten/dairy free Excessive gum chewing Obsession about food Body image Goal weight Pro-ana or pro-mia websites Symptoms So, besides a good history and physical, what labs and studies do I actually need? Laboratory Studies CBC, BMP, LMNOP 13

14 Recommended Evaluation CBC ESR/CRP CMP Urinalysis TSH Magnesium Phosphate Pregnancy test Stool guaiac? Gonadotropins? EKG Treatment Yes, there is hope! A multi-faceted problem needs a multidisciplinary team! Dietitian Medical Provider Therapist 14

15 Modes of EDO treatment Medical inpatient stabilization Psychiatric inpatient admission Partial hospitalization Intensive outpatient program Outpatient program Residential treatment Medical Admission Criteria Severe malnutrition (<75% of IBW) Dehydration Electrolyte abnormalities Cardiac arrhythmias Growth arrest Physiologic instability HR <50 BP <80/50 T <96 F Failure of outpatient treatment Acute food refusal (<500 calories/day) Uncontrollable bingeing & purging Medical complications Psychiatric emergency Co-morbid diagnosis that interferes with treatment Refeeding Syndrome 15

16 Ongoing Research Limited evidence-based research on approaches to treatment HOWEVER: For teens, family based treatment works Earlier treatment leads to better outcomes Those with psychiatric co-morbidities tend to have worse outcomes QUESTIONS? Questions after today? 16

17 References Steinhausen, HC; Weber, S. The outcome of Bulimia Nervosa: Findings from One-Quarter Century of Research. American Journal of Psychiatry. 2009; 166(12): Wentz, E; Gillberg, IC; Anckarsater, H; et al. Adolescent-onset anorexia nervosa: 18-year outcome. British Journal of Psychiatry. 2009; 194: Nilsson K, Hägglöf B. Long-term follow-up of adolescent onset anorexia nervosa in Northern Sweden. Eur Eat Disord Rev 2005; 13: Wentz E, Gillberg C, Gillberg IC, Rastam M. Ten-year follow-up of adolescent- onset anorexia nervosa: psychiatric disorders and overall functioning scales. J Child Psychol Psychiatry 2001; 42: Strober M, Freeman R, Morrell W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over years in a prospective study. Int J Eat Disord 1997; 22: Smink, FRE; van Hoeken, D; Hoek, HW. Epidemiology of Eating Disorders: Incidence, Prevalence and Mortality Rates. Cur Psychiatry Rep Aug; 14(4): DOI: /s y Resources Garber AK, Michihata N, Hetnal K, et al. A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol. J Adolesc Health 2012; 50: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. ed 4. Washington, DC: American Psychiatric Association; 2000; text revision. Morgan, JF; Reid, F; Lacey, JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467 Hudson, J; Hiripi, E; Pope, H; et al. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry 2007; 61, Steinhausen, HC. The Outcome of Anorexia Nervosa in the 20 th Century. American Journal of Psychiatry. 2002; 159(8): Sullivan PF. Mortality in anorexia nervosa. American Journal of Psychiatry 1995; 152: American Academy of Pediatrics, Committee on Adolescence. Identifying and treating eating disorders. Pediatrics. 2003; 111: