I do not have any conflict of interest or will be discussing any off-label product use.

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1 Disclosure Statement I do not have any conflict of interest or will be discussing any off-label product use. This class has no commercial support or sponsorship, nor is it co-sponsored.

2 Overview Eating disorders Case DSM IV vs DSM 5 Signs and symptoms Complications Treatment Approaches Obesity Case Complications Treatment Approaches Resources

3 Age of Consent in Alaska In AK youth of certain ages can seek care for various things without a parent Sexually transmitted disease/hiv testing: no age limit STD or HIV treatment: providers can legally tell parents Reproductive health: no age limit on contraception Abortion: if under 18, parental notification or judicial bypass except in the case of rape, incest, abuse. There is no mandatory waiting period Mental Health treatment:??? Alcohol and drug treatment: not specified

4 Case 13 y/o female with secondary amenorrhea Her current BMI is within normal at 23 You review her past growth charts with clinic notes and notice that she was seen 6 months ago for a well child visit. At that time she was told her weight was too high and she was at risk for diabetes. Her BMI was then 29.

5 What questions do you want to ask? Body Image? Physical Changes? Eating Disorder Eating Behaviors? Activities?

6 Eating Disorders: DSM IV Old Criteria: Anorexia Nervosa Refusal to maintain body weight greater than normal (e.g.<85%) Intense fear of gaining weight even though underweight Disturbance in the way one s shape is experienced Postmenarchal-absence of 3 consecutive cycles Bulimia Nervosa Recurrent episodes of binge eating Recurrent inappropriate compensatory behavior to lose weight Episodes average at least twice per week for 3 months Self-evaluation unduly influenced by body shape and weight Eating d/o NOS Distorted body image Restrictive eating and refusal to maintain body weight May have episodes of binge/purge

7 NEW DSM 5 Anorexia Nervosa (ICD 10 subtypes for coding) Restriction of energy intake, leading to significantly low body weight Significantly low weight = weight less than minimally expected for children/adolescents Intense fear of gaining weight or becoming fat Distorted body image Restricting type (F50.01): during the last 3 months, weight loss through dieting, fasting, or excessive exercise Binge-eating/purging type (F50.02): during the last 3 months, recurrent episodes of binge eating or purging Severity: Mild: BMI 17 kg/m2 Moderate: BMI Severe: BMI Extreme: BMI <15

8 Bulimia Nervosa (F50.2) Recurrent episodes of binge eating. An episode is both: 1) eating more food in a discrete period than most individuals would eat in a similar period under similar circumstances 2) a sense of lack of control over eating during the episode Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting laxative misuse, diuretics, or other meds fasting or excessive exercise The binge eating & compensatory behavior both at least once a week for 3 months Self-evaluation is unduly influenced by body shape & weight Severity: Mild: avg 1-3 episodes per week Moderate: avg 4-7/wk Severe: avg 8-13/wk Extreme: avg 14+/wk

9 *Binge Eating disorder (F50.8) Recurrent episodes of binge eating. An episode is 1) eating a large amount in a discrete time period 2) a sense of lack of control over eating during the episode Binge eating episodes are associated with 3+ of the following Eating much more rapidly than normal Eating until uncomfortably full Eating large amounts of food when not physically hungry Eating alone b/c of feeling embarrassed by the amount Feeling disgusted with oneself, depressed, or very guilty afterwards Marked distress regarding binge eating is present Binge eating occurs on average once a week over 3 mo Not associated with recurrent use of inappropriate compensatory behavior in bulimia nor exclusively during the course of bulimia or anorexia nervosa Severity Mild: 1-3 episodes/week Moderate: 4-7 Severe: 8-13 Extreme: 14+

10 Other specified feeding/eating disorder (F50.8) Atypical anorexia meets all criteria for anorexia except: despite significant weight loss, weight is within normal or above normal Bulimia nervosa (of low frequency or limited duration) Less than once a week and/or less than 3 month Binge eating (low frequency an/or limited duration) Purging disorder recurrent purging behavior to influence weight or shape in absence of binge eating

11 Avoidant/Restrictive Food Intake Disorder Avoiding/restricting may be based on lack of interest in food, sensory characteristics, or conditioned negative response (such as choking) The eating behavior leads to: Significant weight loss, poor growth, or growth failure Nutritional deficiency Supplemental or enteral feeding Impaired psychosocial function

12 Proposed New Disorders Orthorexia Extreme Obsession with healthy eating Diabulimia In insulin dependent diabetics Tendency to avoid artificial colors, flavors, processed foods, sugar, added salt, fat With holding insulin as a form of purging

13 Risk Factors Female Positive family history Perfectionistic Difficulty communicating negative emotions Difficulty resolving conflict Low self-esteem

14 Epidemiology With classic symptoms->90% are female, >95% are white and >75% are adolescents when they first develop the eating disorder Prevalence rates using the entire population underestimate the prevalence of target populations

15 Eating Disorders Occur in Boys too Jonathan

16 Prevalence of Eating Disorder Behavior The 2011 Youth Risk Behavior Surveillance survey: 12.2% of high school students did not eat for 24 hrs in order to lose weight 17.4% of females and 7.2% of males 5% of students took diet pills, powders or liquids to lose weight in the 30 days prior to the survey 6.3% of females and 3.8% of males 4% vomited or took laxatives to lose weight or keep from gaining weight in the 30 days prior to the survey 5.4% females and 2.6% of males

17 Signs and Symptoms Physical Amenorrhea Cold hands and/or feet Dry Skin/Hair loss Constipation Headaches dizziness/fainting Bloating with eating Weight loss Electrolytes: low K, Cl, & P Knuckle calluses Dental erosion Swollen parotid glands Mental Poor concentration Social withdrawal/isolation Obsessive thoughts (especially around food) Compulsions (exercise, rituals) Depression/anxiety Irritability Guilt Depression anxiety

18 Red Flags you may hear I ve been trying to eat healthy Red flag if the teen is thin or lost a significant amount If I eat I HAVE to exercise or work it off I ve tried diet pills/laxatives/vomiting to lose weight I have a friend/family member who has an eating disorder Reported weight loss of extreme amounts so friends/family have commented For obesity we expect weight loss of 1-2lbs/week

19 Irreversible Complications Eating disorders are complex, but malnutrition can have irreversible consequences: Stunted growth if malnutrition occurs before epiphyses close Tooth enamel damage Pubertal delay Osteoporosis and increased fracture risk Possible constitutional brain changes on MRI and PET scan Golden, et. al. Eating Disorders: Position Paper. Journal of Adolescent Health. Vol 33, No 6, 2003

20 Other Complications Bone health and amenorrhea Poor nutrition leads to hypothalamic pituitary dysfunction Low levels of estrogen =>amenorrhea and low bone density Supplement with oral contraceptives or other hormone replacement does not improve bone health and is not recommended Mitan, LAP. Mini Review: Menstrual Dysfunction in Anorexia. J of Ped and Adolesc Gynecology. 2004, 17: 81-85

21 Outpatient Approaches to Treatment Traditional Approach Teen has some autonomy early on Relies heavily on parent cooperation/support 3 professionals: Medical, Nutrition, Mental Health Focus on goal of intuitive eating Rarely use the word calorie Food is used to fuel the body; aim to have 3 meals and 3 snacks each day Maudsley or Family Based Treatment 3 stages Initially, teen has no autonomy; parents provide all food Focus is on refeeding initially, then move towards emotions 2 professionals: Medical, Mental Health

22 Medications for Eating Disorders Medications are not recommended for eating disorders alone However, there are often co-morbidities Depression/anxiety OCD SSRI s are often used initially, but only in conjunction with therapy Atypical antipsychotics are increasing in frequency Side effect of increased appetite risky to use without adequate knowledge of side effects

23 Different Levels of Care Outpatient Intensive Outpatient Partial Hospitalization Early stages of disease or follow up after more intensive treatment Failing outpatient, but may be medically stable Inpatient Failed outpatient, extreme ED behaviors, may be too young or have concurrent diagnoses Failed outpatient, low weight, extreme ED behaviors Residential

24 Individual Resources in Alaska Kathryn Cranor Juneau Elaine Schroeder Juneau Coleen Torence Juneau Bartlett Outpatient Psychiatry Juneau Crystal Herring Anchorage (Providence Medical) Kristin Rehmann Anchorage (Providence Medical)

25 Resources in Washington Seattle Children s (206) Seattle <18yrs Center for Discovery Edmonds (<18 yrs) and Kirkland (18+) Moore Center (425) Bellevue Emily Program <18 yrs (though <18 for residential is only in Minnesota) Opal (206) Seattle 18+

26 Criteria for Medical Stabilization Hospital admission (this is not eating disorder treatment) Bradycardia Symptomatic orthostatic changes Electrolyte abnormalities/ekg changes Extremely low weight/rapid weight loss (<75% of IBW) Suicidal ideation Syncope

27 Refeeding Syndrome Depletion of phosphorus stores with refeeding can lead to cardiac instability There is varying literature on the safest way to re-feed a malnourished patient Our inpatient Nutrition team typically recommends: Start at 1200 cal/day Increase by 200 cal/day Check electrolytes 3/week for the first week, then weekly

28 Prognosis for Patients with ED 71-86% recover Exception is in the development of osteoporosis 15-25% will develop this over time Mortality with treatment < 5%

29 Obesity

30 Case In your office is a 17 y/o female last seen 2 years ago for oligomenorrhea & PCOS You initially counseled her that weight loss would be helpful; she was morbidly obese with a BMI of 41 Since her last visit: she has increased her efforts to lose weight by restricting & taking a green tea supplement she typically skips breakfast and lunch At dinner, she ll frequently have second and third helpings At times, she feels out of control with her eating She tried going to the gym for 2 weeks but stopped Her BMI is now 42

31 Obesity Overweight in general is a BMI from and obese is a BMI >30 Morbid obesity is BMI>40 From 1980 to 2008, the percentage of teens ages who were obese increased from 5% to 18% Overweight and obesity = caloric imbalance

32 Physical Complications Hypertension Elevated cholesterol and triglycerides Insulin resistance Diabetes Hormonal imbalance/pcos Joint pain Increased risk of cardiovascular disease Stroke Sleep Apnea

33 Physical complications Overweight and obesity are associated with cancers as well: Thyroid Breast Colon prostate Endometrial Ovarian Esophageal Pancreatic Multiple myeloma Hodgkin s lymphoma

34 Emotional Complications Obese children are more likely to: Be teased or bullied To have low self-esteem To have depression To use unhealthy strategies to lose weight such as restricting, vomiting, or use of diet pills

35 Engaging teens Get to know your patients motivations Asking simple questions: What do you like to do for fun? Are you concerned about your body? Gives a world of insight Remember the stages of change: Pre-contemplation Contemplation Action Maintenance relapse

36 Stages of Change If a teen or family isn t ready, they re not going to follow through with your advice Determine which stage they re in and help them to the next stage

37 Treatment Approaches Lifestyle choices are multifactorial Housing environment Income Access to fresh foods Family/household Peers Personal choices It can be very challenging to get patients AND families to understand the health risks & be ready to change

38 Outpatient Approach to Treatment Multidisciplinary approach including: Medicine Nutrition Social Work Fitness specialist Often a Psychologist or behavioral health professional

39 Our Approach to Treatment Emphasis on lifestyle choices instead of calorie restriction Our patients are continuing to grow and develop This takes energy and often if they can maintain weight, BMI decreases as height increases Timing of eating and food choices are critical Balancing food intake and exercise are challenging Teens won t continue exercise if it isn t fun Increase the things they re already doing (walk the dog, get off the bus 2 stops earlier, engage friends, etc) Parents are extremely important (they buy the food!)

40 Tips for Change 7 Breakfast every day 0 Sugary drinks 5 Fruits and veggies 1 Hour of exercise 2 Hours of screen time

41 Treatment of Co-Morbidities Metabolic Syndrome Hypertension Impaired glucose tolerance (fasting glucose >100) Elevated cholesterol (HDL<50) and/or triglycerides Central obesity Treatment with lifestyle changes. Additional metformin with target dose of 1000mg po BID PCOS Lifestyle changes Combined oral contraceptive pills (Ortho Cyclen or Lo Ovral have less androgenic progestins [norgestimate & norgestrel]) +/-Spironolactone for hirsutism (25mg po daily or 25mg po BID) Metformin if metabolic syndrome is present

42 National Programs USDA launched ChooseMyPlate.gov Eliminating the food pyramid

43 Summary Eating disorders and obesity are both related to energy intake We focus on healthy lifestyle changes for treatment Listen to body hunger cues Eat regularly to fuel growth and development Return to exercise is gradual, typically after 90% of IBW is reached or return of menses for restrictive eating disorders Families are expected to play a role in recovery

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