Eating Disorders

1. Eating Disorders Anorexia Nervosa Bulimia Nervosa Eating Disorder NOS Nichole Grier MD UNC Dept. of Psychiatry

2. What is “normal” eating? • How do you know if you are “fat” or “too thin”? • When is it a “mental illness”? • Does anyone talk about it? • How common is it? • Whose fault is it? • Who recovers? • How?

3. What is Healthy Eating? • Mindful: Know the difference between physical and emotional cues and needs. Eat when you are hungry; stop when you are full. Meet your body’s needs. • Enjoyable:Eat pleasurable foods without guilt or anxiety. • Flexible:Be able to eat needed amount in available time. No calorie counting. Eat a variety of foods. Don’t avoid any food group. Try new things without knowing all ingredients.

4. Defining “Healthy” Weight • Pediatrics • Standard: 50th Percentile BMI-for-age, CDC growth charts for US • Utilize height and weight history to plot growth on BMI-for-age chart to establish individualized goal • Adults • Standard: Medium frame, 1983 Metropolitan Height/Weight Tables, or BMI • Set minimum goal for BMI 19.5 • Individualize based on premorbid weight, resumption of menses, physical health indicators

5. What about fat . . . • The American College of Sports Medicine (ACSM) recommends that males age 16 and under with < 7% body fat and males over 16 years of age with < 5% body fat not be allowed to compete unless they have medical clearance. • The ACSM recommends 12%-14% body fat as the minimum safe percent body fat for high school girls.

6. some historical context . . . • “Anorexia Nervosa” was first described as a distinct diagnostic entity in 1873 • “Bulimia Nervosa” became a diagnostic category in 1979

7. Keyes study • Healthy males • Voluntary starvation then refeeding • Development of apathy, ritualistic behaviors, preoccupation with food • Physical symptoms cold intolerance, edema, slowed heart rate, diminished sexual interest • Increased caloric needs with refeeding • Onset binge urges

8. DSM-IV criteria:Anorexia Nervosa • Refusal to maintain body weight at or above that expected for age & height (<85%) • Intense fear of gaining weight or becoming fat • Disturbance in the way one’s body size is experienced, OR undue influence of body size on self evaluation, OR denial of seriousness of low weight. • Amenorrhea in postmenarcheal females (absence of 3 or more consecutive menstrual cycles)

9. Anorexia Nervosa: Subtypes • Restricting Type: during current episode of AN, no regular binge eating or purging behavior • Binge-Eating/Purging Type: during current episode of AN, regular binge eating or purging

10. Anorexia nervosa is not a disorder of appetite. May report decreased appetite Others FEAR appetite

11. DSM-IV criteria:Bulimia Nervosa • Recurrent episodes of binge eating • objectively a large amount of food • individual feels “out of control” • Recurrent compensatory mechanisms • self-induced vomiting • laxative use • Fasting • excessive exercise

12. DSM IV criteria: Bulimia Nervosa • Binge/Purge episodes occur, on average, at least two or more times a week for at least three months • Self-esteem unduly influenced by weight/body shape • Current weight does not meet criteria for AN (>85% IBW)

13. Bulimia Nervosa: subtypes • Purging type: self-induced vomiting, laxative abuse, diuretic abuse • Non-purging type: restricting, over-exercising

14. Eating Disorder NOS • Subsyndromal AN or BN • Current nomenclature for set of criteria under investigation as “Binge Eating Disorder”

15. DSM IV Research Criteria:Binge Eating Disorder • Recurrent episodes of binge eating: large amount with subjective loss of control • Associated with 3 or more: eating rapidly, eating until uncomfortably full, eating in private (embarrassment), eating when not physically hungry, feeling guilty about eating • Marked distress regarding binge eating • Binge eating occurs, on average, at least twice/week for six months

16. Binge Eating Disorder • Usually associated with overweight or obesity • Approximately 30% of individuals presenting to medical weight loss programs meet criteria for BED • Obesity itself is not a psychiatric illness, but 8% of overweight women and almost one third of those presenting for weight loss treatment meet criteria for BED • Often hard to diagnose – different from emotional eating /grazing

17. Eating Disorders: Epidemiology • Abnormal eating can be found in all cultures but eating disorders are far more common in industrialized countries • EDs occur in all ethnic and socioeconomic groups in the US, although they are far more prevalent in the caucasian community and seem to have lowest rates in African American community

18. Anorexia Nervosa: how common? • AN incidence around 8/100,000 per year • AN average prevalence among young females around 0.3% • About one third of AN population enters mental health care • Increasing incidence in past century until 1970’s, particularly in 15-24 year old age group; debate about increase or decrease in rates since then

19. Bulimia Nervosa: how common? • BN incidence 11-13/100,000 per year in 1980s then decreasing through 1990s to around 6.6/100,000 per year in 2000 • BN prevalence around 1% of young females • BN population enters mental health treatment at very low rate

20. ED NOS: how common? • 60% of the eating disorder cases in outpatient settings • Unknown incidence, changing definition • BED prevalence in US 2-5% and possibly occurring more frequently in AA community than in caucasian community

21. All ages at risk, but . . . • Eating disorders have onset most commonly in teen and young adult years, but may occur at other ages (BN slightly later peak onset than AN) • <10% have onset prior to puberty

22. Eating Disorders: Males • Up to 10% of AN & BN patients are male • As many as 25% of BED patients are male • Males with eating disorders are more likely to have once been overweight and more likely to have used exercise for weight control • Males may be less likely to pursue treatment for an eating disorder, but eating disorders are just as dangerous for males as they are for females

23. Survey • Dieted in the past year: 62% of high school girls, 40% of high school boys • Ever binged and purged: 13% of adolescent girls, 7% of adolescent boys • At least one third of junior high school girls admit concerns about weight • 6% of 10th grade boys have used laxatives

24. Higher rates in those with alcoholism • Higher rates when not involved in athletics Or when competing at elite level

25. Outcomes • AN: mortality 5-6% per decade of follow-up; SMR 9.6 in studies with 6-12 years of follow-up, 3.7 when 20-40 years of follow-up • Causes of death: suicide, starvation, cardiac events • Risk factors for death: BMI<13, body weight <60%, low serum albumin • Suicides do not occur exclusively during significant underweight • Purging behaviors are worse prognostic sign than restricting alone

26. Course • AN: half will have full recovery; up to 20% with chronic unremitting course • BN: 80% recovery if treated within first 5 years of illness; recovery falls to 20% by 15 years of illness • Much crossover between AN and BN • Positive indicators for recovery: early onset, early treatment, higher weight at discharge or step-down, good social support, good premorbid psychological functioning

27. Psychiatric comorbidity • More than a quarter of ED patients have a comorbid mood disorder • Comorbid anxiety disorder in up to half of AN patients, up to 75% of BN patients • Comorbid alcohol abuse, drug abuse, impulsivity common • >90% have at least one additional psychiatric diagnosis in lifetime, 50% at least one concurrent with episode of AN

28. Morbidity: Mental health • Poor sleep and Depressive symptoms secondary to starvation itself • Antidepressants generally ineffective at low weights • Cognitive impairment during underweight, changes in brain volume • Increased anxiety during weight gain secondary to changing hormonal milieu and increasing serotonin • Adverse effects of major illness episode on normal developmental trajectory

29. Morbidity: Reproduction • Reduced fertility at low weight • Higher rates of obstetric difficulties • Decreased intrauterine growth of baby

30. Morbidity: Bone health • Decrease in peak bone mineral density • Calcium supplements less effective at low weight • Weight-bearing exercise helpful but cannot offset adverse effects of underweight • Estrogen supplements alone do not preserve bone density in underweight premenopausal females • Bisphosphonates teratogenic potential unknown

31. Morbidity: Body image, Self esteem • Initial weight gain truncal. Degree of redistribution variable • Lower rates of marriage and childbearing • Decreased achievement relative to potential

32. What causes an eating disorder? • Multifactorial • Strong evidence of genetic component from twin studies BUT • Higher incidence in industrialized countries AND not everyone with a weight concern develops an eating disorder

33. Genetic factors • 58-88% of risk for developing AN, and roughly same for BN • Eating and Body-related behavioral and attitudinal factors appear to have heritable component • BMI highly heritable and independent of ED-related heritable factors • AN and Chromosome 1 • BN and self-induced vomiting and Chromosome 10

34. Other factors • Developmental events • Family dynamics • Peer milieu • Cultural influences “Genetics loads the gun . . . Environment pulls the trigger” (C. Bulik)

35. The assessment

36. Ask About: • Weight History • Highest and lowest adult weights • Recent weight changes • Perceived “ideal” weight • Eating Behaviors • Attempts to restrict intake (diet pill use, skip meals, limit amounts or types of food, counting fat/CHO grams, counting kcal) • Binge Eating (objective vs subjective)

37. Ask About: • Attempts to “compensate” for intake • Self-induced vomiting (*ask about use of Ipecac syrup) • Laxative abuse • Diuretic abuse • Driven exercise • Body Image

38. Ask About: • Menstrual history • Review of Systems (dizziness, fainting, weakness, fatigue) • Psychiatric Symptoms (depressed mood, self-harm ideations, self-harm behaviors, anxiety, neurovegetative symptoms) • Substance Use, past and current

39. Medical assessment • Physical Exam, review of systems • Medical history, weight history • Medication use, substance use • Vital signs, laboratory testing, EKG

40. Common Medical Issues • Cardiovascular • Orthostatic hypotension (starvation) • Bradycardia (starvation) • Prolonged QTc and T-wave abnormalities on EKG (purging behaviors) • Mitral valve prolapse (diminished muscle mass) • Cardiomyopathy (Ipecac)

41. Medical Issues (continued) • Cell counts • Low WBC (starvation and stress) • Anemia (starvation) • Fluid and electrolytes • Dehydration (starvation, purging) • Decreased albumin (starvation) • Peripheral edema and effusions (starvation) • Electrolyte disturbances (purging)

42. Medical issues (continued) • Renal • Acid-base disturbances (purging) • Impaired concentrating ability • Bone • Osteopenia • Osteoporosis

43. Medical Issues (continued) • Endocrine • Hypoglycemia (starvation) • Hypothermia (starvation) • Thyroid abnormalities (starvation, stress) • Amenorrhea and decreased sex hormone levels (starvation, stress)

44. Medical issues (continued) • Gastrointestinal • Bloating, nausea (starvation) • Elevated liver enzymes (starvation, refeeding) • Elevated cholesterol (starvation) • Constipation and decreased motility (starvation) • Esophageal tears (purging)

45. Medical issues (continued) • Dermatologic • Hair loss (stress, starvation) • Dull hair (decreased fat) • Lanugo hair (starvation) • Dry skin (decreased fat) • Calloused or scarred knuckles (purging) • Acrocyanosis (starvation) • Dental (purging)

46. Other causes of weight loss . . . • Thyroid disease • Adrenal disease • GI disease (motility problems, IBD, celiac disease) • Malignancies • Infection • . . . and other rare entities . . .

47. Nutrition needs • Refeeding: start with 30-35 kcal/kg, then increase by around 300 kcal every three days to achieve gain of 1-2 kg per week as inpatient, 0.5-1 kg per week as outpatient. (Diet 55-60% CHO, <30% fat, meet calculated protein needs) • Starved patients become hypermetabolic, often requiring 60-100 kcal/kg per day to gain and maintain. • Hypermetabolic state may persist for 6-12 months after weight recovery

48. Assessment done. Now what?

49. Indications for Inpatient Care

50. Other Indications for Inpatient Care • Syncope • Serum potassium < 3.2 mmol/L • Serum chloride < 88 mmol/L • Esophageal tears • Cardiac arrhythmias, including prolonged QTc interval • Intractable vomiting • Hematemesis • Failure to respond to outpatient treatment • Severity of psychiatric comorbidities (Major depression, anxiety disorders, substance abuse disorders)