UNDERSTANDING EATING DISORDERS

Transcription

1 ROLE OF THE PRIMARY CARE PHYSICIAN UNDERSTANDING EATING DISORDERS Judith M.E. Walsh, MD, MPH Departments of Medicine and Epidemiology and Biostatistics University of California, San Francisco ν Detection ν Coordination of care ν Management of medical complications ν Help determine when hospitalization is necessary CLINICAL QUESTIONS DEFINITIONS: ANOREXIA NERVOSA ν What signs and symptoms should lead the primary care physician to suspect an eating disorder? ν Are there high risk groups? ν What lab tests should be ordered? ν What are common medical complications? ν What is the evidence for current treatment recommendations? ν Refusal to maintain ideal body weight ν Intense fear of weight gain ν Disturbance in body image ν In females, absence of at least three consecutive menstrual cycles Primary or secondary amenorrhea ν Subtypes Restrictive: Calorie restriction ± exercise Bulimic: Binge eating followed by fasting and purging Page 1

2 DEFINITIONS: BULIMIA NERVOSA BINGE EATING DISORDER: RESEARCH DEFINITION ν Recurrent episodes of binge eating with a sense of loss of control ν Recurrent inappropriate compensatory behavior to prevent weight gain Self-induced vomiting, use of laxatives or diuretics, diet pills, strict dieting or fasting, or vigorous exercise Behaviors occur at least twice a week for three months ν Dissatisfaction with body shape and weight ν Binge eating two days per week for 6 months Eating in a discrete period of time an amount of food that is definitely larger than most people would eat under similar circumstances ν Binges must have at least 3 of the following criteria Eating much more rapidly than normal Eating until uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of embarrassment Feeling disgusted, depressed or very guilty after overeating EPIDEMIOLOGY: ANOREXIA NERVOSA EPIDEMIOLOGY: ANOREXIA NERVOSA ν Prevalence of 1% of adolescent girls May be subclinical in up to 10% of young women aged ν Risk factors Middle to upper class female Participation in activities valuing thinness Family history of eating disorder ν Precipitated by a stressful situation ν Other psychiatric diagnoses 25% lifetime prevalence of obsessive compulsive disorder 50-75% lifetime prevalence of dysthymia ν Typical course 40-45% recover completely 30% improve 25% chronic course ν Highest mortality of any psychiatric disorder 10-15% Starvation, suicide, medical complications Page 2

3 EPIDEMIOLOGY: BULIMIA NERVOSA EPIDEMIOLOGY: BULIMIA NERVOSA ν Estimated prevalence is 3-10% of adolescent and college age women ν May begin after an unsuccessful attempt at weight loss, or when the patient discovers that purging, fasting and exercise an compensate for bingeing ν Risk factors Psychoactive substance abuse or dependence History of childhood or sexual abuse Family history of alcoholism or depression ν Depression and mood disorders are common ν Prognosis generally better than anorexia More than 50% recover 30% retain nonspecified eating disorder ν Poor prognostic factors Premorbid and paternal obesity HIGH RISK GROUPS CASE 1 ν Female Athletes ν Insulin dependent diabetics ν 18 year old female, college freshman, whom you saw for a physical examination before she went to college. While she is home at Christmas, she comes to see you with the flu. She looks thin and tired, and you notice a 20 pound weight loss. What questions do you want to ask? What do you want to look for on physical examination? What laboratory tests do you want to order? Does she need to be hospitalized? Page 3

4 CASE 1: HISTORY CASE 1: HISTORY ν Previous weight and weight loss pattern ν Menstrual history ν Daytime hyperactivity and/or insomnia ν Abdominal discomfort, constipation or bloating ν Exercise habits ν Medications ν Attitude toward body weight or shape Do you think you are thin? ν Preoccupation with food ν Family history of an eating disorder ν What did you eat yesterday? ν Do you ever binge eat or use laxatives, diuretics or diet pills? CASE 1 CASE 1: LABORATORY EVALUATION ν Physical Examination: what do you want to look for? Vitals Skin Cardiac exam: MVP Extremities Signs of bingeing ν Laboratory data: what do you want to order? ν CBC ν Electrolytes, magnesium, calcium, phosphorus, BUN, creatinine, glucose, albumin ν Evaluation of amenorrhea TSH, FSH, LH, prolactin ν EKG Useful when bingeing and purging ν Bone densitometry? Page 4

5 CASE 1 CRITERIA FOR HOSPITALIZATION ν Does she need to be hospitalized? How much weight has she lost? How are things at school? Is she using laxatives, diuretics or diet pills? Is she vomiting? ν What are the criteria for hospitalization? ν Weight less than 75% of average body weight for age, sex, height ν Electrolyte disturbances ν Arrhythmia, bradycardia ν Signs of inadequate cerebral perfusion ν No response to outpatient treatment ν Uncontrollable binging and purging ν Psychiatric emergencies ANOREXIA NERVOSA: TREATMENT IS SUES ANOREXIA NERVOSA: MEDICAL COMPLICATIONS ν Immediate interventions Nutritional normalization Recovery of normal eating patterns ν Individual and family therapy Effective psychotherapy cannot occur when patient is in starvation mode ν Management of medical complications ν Cardiovascular Bradycardia and hypotension Mitral valve prolapse Refeeding syndrome» Hypophosphatemia and CHF ν Gastrointestinal Delayed gastric motility Constipation Refeeding pancreatitis Page 5

6 ANOREXIA NERVOSA: MEDICAL COMPLICATIONS ANOREXIA NERVOSA: TREATMENT ISSUES ν Amenorrhea/osteoporosis ν Fluid and electrolyte abnormalities ν Hematologic Pancytopenia ν Multidisciplinary team Primary care physician, nutritionist, mental health professional ν Goal setting Target weight Rate of weight gain ν Contract setting Indications for hospitalization or more intensive treatment Agreement to follow-up Food and exercise diary ANOREXIA NERVOSA: TREATMENT ISSUES ANOREXIA NERVOSA: TREATMENT ISSUES ν Weighing techniques Empty bladder, no shoes, one layer of clothing, same time each visit, urine specific gravity ν Food diaries Nutritional adequacy: protein, fat and calories Demonstration of portion size Intervals between eating Foods to be added Emotional and physical hunger ν MVI ν Calcium supplements ν Metoclopramide may be useful for for abdominal bloating ν Role of psychotropic medications Generally not as useful» Few controlled studies Anxiolytics around the time of eating Antidepressants?» May help maintain weight gain Page 6

7 ANOREXIA AND OSTEOPOROSIS TREATMENT ν Hypothalamic hypogonadism ν Anorexics have low bone mineral density (BMD) 50% of anorectics have BMD 2 S.D. below normal ν Physical activity has some protective effects Bone loss occurs even in areas subjected to stress Rencken, 1996; Rigotti, 1984 ν Increased risk of fracture R.R. 7.0 (95 % C.I. 3.2,18.5) ν BMD may not return to baseline after recovery Rigotti, 1991 ν Primary therapy is weight gain ν Estrogen replacement therapy OCPs or hormone therapy doses ν Bisphosphonates Not studied in this population Concerns about long term use Not currently recommended CASE 2 CASE 2 ν A 19 year old Latina student whom you have seen once previously, comes to you for advice on losing weight, so that she can return to modeling, which she did as a child. Past medical history is unremarkable except for dental problems. Her parents separated two years ago. She is a slim woman and you wonder why she wants to lose weight. What questions do you want to ask? What do you want to look for on physical examination? What lab tests do you want to order? ν Previous maximum and minimum weight ν Menstrual history ν Exercise habits ν Use of cigarettes, alcohol or other drugs ν History of rape, sexual assault, childhood abuse or depression ν Do you ever binge eat, use laxatives, diuretics or diet pills? Page 7

8 CASE 2 SCREENING QUESTIONS ν Bulimia Screening Questions ν SECRET PATTERNS Do you ever eat in secret? Are you satisfied with your eating patterns? ν Test characteristics for detecting bulimia Sensitivity 1.0 Specificity 0.9 PPV 0.36 (5% prevalence) Freund, 1993 ν SCOFF Questionnaire Do you make yourself Sick because you feel uncomfortably full? Do you worry that you have lost Control over how much you eat? Have you recently lost more than One stone (14 lb) 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? SCREENING QUESTIONS CASE 2: PHYSICAL EXAMINATION ν Positive =Score of 2 or more 100% sensitivity for detecting anorexia or bulimia 87.5% specificity ν Study was done in a select population 116 patients with known eating disorders 96 college student controls ν Needs to be validated in a broader population ν General appearance ν Vitals ν Skin Russell s sign; hand dermatitis ν Parotid gland hypertrophy ν Teeth ν Hoarse Voice ν Edema Page 8

9 CASE 2: LABORATORY EVALUATION CASE 2: CRITERIA FOR HOSPITALIZATION ν CBC ν Glucose ν Lytes, Ca, Mg, Phos, BUN, Cr Vomiting leads to metabolic alkalosis Laxatives lead to metabolic acidosis Dehydration and stool sodium losses lead to Na retention and hypokalemia ν Albumin ν TSH, LH, FSH, prolactin ν EKG ν Severe depression and suicidality ν Marked fluid and elecrolyte imbalances ν Need for withdrawal from laxatives, diuretics, emetics or diet pills ν Significant substance abuse BULIMIA: MEDICAL COMPLICATIONS BULIMIA: MEDICAL COMPLICATIONS ν Gastrointestinal Dental erosion Parotid gland swelling GE reflux Esophageal rupture Acute gastric dilatation Constipation and cathartic colon ν Pulmonary/mediastinal Aspiration Pneumomediastinum ν Cardiac Arrhythmias, Diet pill toxicity Emitene cardiomyopathy ν Endocrine/Metabolic Hypoglycemia Irregular menses Electrolyte imbalances Page 9

10 BULIMIA: TREATMENT BULIMIA: TREATMENT ν Contract Setting ν Elimination of binge/purge behaviors ν Cognitive behavioral therapy is the most effective therapy for bulimia nervosa Superior to supportive psychotherapy Reduces number of binge-purge episodes Increases percentage of individuals becoming bingepurge free ν Two RCTs of fluoxetine 60 mg of fluoxetine was significantly superior to placebo in the reduction of bulimic behaviors.» 20 mg of fluoxetine was only modestly superior to placebo FDA approved for bulimia ν Topiramate (anti-epileptic) and ondansetron (selectove serotin antagonist) may be useful ν Bright light therapy May be useful, particularly in those with seasonal bulimia nervosa EATING DISORDERS: HIGH RISK GROUPS CASE ν Female Athlete Triad ν Diabetics ν 17 year old girl is brought in to see you by her mother who is worried because she has not had her period for 6 months. She is a senior in high school and an avid gymnast. She is 5 foot 3 and weighs 88 pounds. Page 10

11 HISTORY FEMALE ATHLETE TRIAD ν Type of sport and training intensity ν Weight concerns ν Concern about body image ν Menstrual irregularities ν History of pathologic stress fractures ν Diet: Types of foods eaten and when foods eaten ν Disordered eating: spectrum of abnormal patterns of eating, including bingeing, purging, food restriction, prolonged fasting, use of diet pills, diuretics, laxatives, other abnormal eating patterns ν Menstrual disorders ν Low bone mineral density Half of all athletes with amenorrhea have bone densities at least one standard deviation below the mean Bone density decreased even in those areas subject to impact loading during exercise ν Revised criteria focus on the entire spectrum of menstrual function and bone strength» 2007 FEMALE ATHLETE TRIAD: TREATMENT CASE ν Little evidence is currently available ν Strategies used in the treatment of other eating disorders such as counseling, cognitive behavioral therapy and possibly exercise restriction may be helpful ν Communication with coach and trainers will enable common goal setting ν The desire to participate in sports and the lure of a performance-enhancing diet may motivate some patients ν 27 year old female with IDDM who you have been following for several years. She uses an insulin pump, and thus far has had no diabetic complications. Typically her HgbA1C has been , although last month her HgbA1C was 8.1 and this month it is 9.6. She denies polydipsia or polyuria or any significant change in her eating habits. ν What else do you want to know? Page 11

12 CASE : HISTORY IDDM AND DISORDERED EATING ν Does she have concerns about her weight? ν Does she ever withhold insulin as a means of purging? ν Up to 1/3 of young women with IDDM have eating disturbances Rodin, 1986; Steel, 1987; Rodin, 1991 ν Eating disorders are more common in adolescent females with eating disorders than their non-diabetic peers» 10% vs 4%; p,0.001 Jones, 2000 ν Mortality is particularly high in individuals with both DM and anorexia nervosa DISORDERED EATING IN DIABETICS DIABETES AND DISORDERED EATING ν Binge eating ν Purging with laxatives or vomiting ν Insulin omission Important cause of recurrent DKA in adolescents ν Taking less insulin than prescribed to lose weight ν Dietary regimen emphasizes intense meal timing and consistency ν Hunger associated with hypoglycemia encourages binge eating ν Weight gain often associated with good glycemic control In DCCT adolescents on intensive control more likely to be overweight Page 12

13 IDDM AND DISORDERED EATING IDDM AND DISORDERED EATING ν Diabetics with eating disorders Noncompliance with treatments Omission or underdosing of insulin to induce glycosuria and weight loss Impaired metabolic control ν Up to 40% of young patients with IDDM will have microvascular complications Krowlewski et al, 1985 ν Does disordered eating have an impact on diabetic complications? ν 91 women with IDDM were followed for 4-5 years ν Definition of disordered eating Binge eating Omission or underdosing insulin to promote weight loss, Self-induced vomiting or use of laxatives ν Classifed as nondisordered, moderately or highly disordered 29% had disordered eating at baseline Of those with nondisordered eating at baseline, 22% had disordered eating at follow-up Rydall, 1997 IDDM AND DISORDERED EATING IDDM AND DISORDERED EATING ν Disordered eating was associated with elevated glycohemoglobin levels ν Retinopathy at 4 year follow-up was associated with disordered eating at baseline 86% of those with highly disordered eating 43% of those with moderately disordered eating 24% of those with nondisordered eating ν Study Limitations No baseline retinopathy measures No interim measures of glycemic control No measure of severity of retinopathy ν Despite limitations, impaired metabolic control does seem to be associated with an increased risk of diabetic retinopathy ν Physicians should remain alert for patterns of disordered eating in patients with IDDM Page 13

14 TREATMENT STRATEGIES TREATMENT STRATEGIES ν Proposed strategies for at risk diabetics Nutritional counseling to promote healthy eating instead of dietary restraint Regular (vs fixed) meal and snack times Less intensive insulin therapy to reduce weight gain Family counseling to improve communication ν No evidence as yet that any of these strategies reduces the risk of developing eating disorders ν No studies have evaluated optimal treatment of diabetics with established eating disorders ν Presumably strategies that are effective for non-diabetics will be effective Cognitive Behavioral Therapy Medications ν Diabetic management strategies that do not require the patient to constantly think about food may be beneficial Less tight control? CASE CASE ν 62 year old woman who moved to California about a year ago and came in to establish primary care. She has hypertension which is borderline controlled and she is obese (5 foot 7 inches and 293 pounds). She has a history of mildly elevated glucose but has not been treated with medications. She moved here to be closer to her daughter and is currently living with her and her family. She belongs to the YMCA and goes to water exercise classes three times a week. ν She would really prefer not to have to take medications for diabetes. She says she wants to lose weight and you and she have talked about Weight Watchers several times. Each time you see her there is another reason she has not gone to Weight Watchers. This time she states that the meetings in her area are at night and she does not want to go out at night. Page 14

15 CASE CASE ν On further questioning, she admits that she likes to stay in her room alone at night watching TV. She keeps a stash of food in her room and she know she would have to get rid of it if she was to start going to Weight Watchers. ν She has mild depression and sees a therapist regularly but is not on medication. ν In the midst of all this, she goes for lab testing and her fasting glucose is now 207, up from 125 about 6 months ago. BINGE EATING DISORDER BINGE EATING DISORDER ν Currently a research diagnosis ν Strong association with obesity 25-30% of adults presenting for weight loss treatment» Self report ν General population prevalence estimate 2-3% More common in females ν Although many obese patients report binge eating, not all have binge eating disorder ν Obesity related complications are likely to occur ν May be more common in weight cycling patients ν Preliminary studies suggest that cognitive behavioral therapy, SSRIs, antiepileptics and appetite suppressants may be useful in treatment Page 15

16 SUMMARY AND CONCLUSIONS SUMMARY AND CONCLUSIONS ν Eating disorders are common in young women and clinicians must maintain a high index of suspicion ν Primary care physicians must be able to detect eating disorders, determine the need for hospitalization and manage the medical complications of eating disorders Team includes nutritionist and mental health professional ν Nutritional management Food diaries Supplementation with iron, calcium, MVI ν Amenorrheic patients with eating disorders should receive estrogen therapy ν Psychotherapy is imperative Patient must be out of starvation mode ν SSRIs are useful in the treatment of bulimia but should not substitute for therapy SUMMARY AND CONCLUSIONS ν Diabetics are at high risk for disordered eating and disordered eating increases the risk of microvascular complications ν Treatment strategies which emphasize healthy eating and require less focus on food may be beneficial ν Binge eating disorder is often associated with obesity related complications CBT and medications may be useful Page 16