Laura Tomaselli, MD

Medical Student B Year 4

SUNY Downstate Medical Center

Brooklyn, NY

Mary Ciccarelli, M.D.

Departments of Medicine and Pediatrics

Indiana University School of Medicine

Indianapolis, In

Pre-test

Q1. True or False. Eating disorders can present as menstrual irregularities, infertility, pathological fractures, or ankle edema.

Q2. True or False. A body mass index below 22 kg/m2 is considered significantly underweight in adolescence and young adult life.

Q3. Best answer. Which of the following diagnoses is least likely to be included in the differential diagnosis of an underweight teen female?

A. Crohn's disease

B. Hypothyroidism

C. New onset diabetes mellitus

D. CNS tumor

Q4. Best answer. Which of the following laboratory results would be associated with a diagnosis of anorexia nervosa?

A. Metabolic acidosis

B. Hyperglycemia

C. Elevated amylase

D. Leukocytosis

Q5. True or False. Patients who have a history of recovery from an eating disorder are at increased risk for recurrence of symptoms during periods of increased life stress.

Q6. True or False. Bulimia nervosa has a significantly higher mortality rate than other forms of eating disorders.

Q7. True or False. The selective serotonin reuptake inhibitors have been used with some success in the treatment of eating disorders.

Objectives:

On completion of this module, the resident will be able to:

1. Perform a routine screening for eating disorders.

2. Recognize the signs, symptoms, and varied presentations of anorexia nervosa.

3. Appreciate the definition of and diagnostic criteria for anorexia.

4. Recognize the range of medical complications that are associated with eating disorders.

5. Appreciate the importance of multidisciplinary management and treatment options for anorexia.

6. Have competent skills in the primary care aspects involved in caring for patients with eating disorders.

Facilitator's Preparation

In order to prepare for this presentation, the following articles are suggested:

Mehler PS. Diagnosis and care of patients with anorexia nervosa in primary care settings. Annals of Internal Medicine. 134(11):1048-59, 2001 Jun.

Walsh JME, Wheat ME, and Freund K. Detection, evaluation, and treatment of eating disorders: the role of the primary care physician. Journal of General Internal Medicine. 15(8):577-90, 2000 Aug.

Committee on Adolescence, American Academy of Pediatrics. Identifying and treating eating disorders. Pediatrics. 111(1): 204-211. 2003 Jan.

Ressel, GW. Practice guidelines: AAP release policy statement on identifying and treating eating disorders. American Family Physician. 57(10):2224-2227, 2000 May.

The classic work in this field is Hilda Bruch's 1978 The golden cage: the enigma of anorexia nervosa. Harvard University Press, Cambridge MA. Reissued in 2001.

For more detailed information the presenter is directed to the references at the end of the module.

Background

Over the last few decades, as society and the media have placed much emphasis on being thin, the prevalence of eating disorders has grown so that they now rank among the most common causes of chronic disease in the adolescent age group, especially in females. Current research shows that between 0.5 to 3.7% of females in the United States will suffer from anorexia nervosa (AN) in their lifetime, while anywhere from 1.1 to 4.2 % of females will suffer from bulimia nervosa (BN). However, the true prevalence of eating disorders in the adolescent population is difficult to determine since these diseases are often kept secret. Also, individuals with disordered eating do not always meet the full diagnostic criteria for anorexia or bulimia, so, the prevalence is likely much higher than what is reported.

Eating disorders tend to be diseases of young women. Recent data shows that greater than 90 % of individuals suffering from an eating disorder are women between the ages of 12 and 25, with a bimodal peak age of onset occurring at 13 B 14 years of age and again at 17 B 18 years of age. In the US, Caucasian and Hispanic females are most commonly affected, the next most affected group is Native American females, while the least affected groups are African and Asian females. In addition, guidelines laid out by the American Academy of Pediatrics (AAP) report that 5 to 10% of eating disorders occur in males; a percentage that is higher than was previously thought.

Anorexia nervosa is a psychiatric disorder with medical consequences. Adolescents suffering from AN rigorously restrict their caloric intake because they are intensely afraid of gaining weight. They have a disturbed body image and see themselves as fat even though in reality they are below what would be viewed as normal weight. Anorexia is an "ego-syntonic" disease - e.g., they have no recognition that either their ideation or behavior is dysfunctional. Individuals suffering from AN do not believe that they have a problem or are doing anything harmful to their bodies.

There is no one clear cut cause of AN; however, many behaviors or personality traits are known to be associated with people who suffer from this and other eating disorders. Common associations are listed below.

TABLE 1. Common associations with anorexia nervosa and other eating disorders

· Rigid personality

· Low self-esteem

· Feeling helpless

· A strong need to control one=s environment

· Social phobia

· Anxiety and irritability

· History of weight fluctuations

· Changes in appetite regulation

· Shifts in food preferences

· Counting calories

· Hoarding food

· Collecting recipes

TEACHING CAPTION: These associations are maintained without recognition of their dysfunctional nature.

An individual=s family and social environment influences one's eating behaviors and beliefs about food. For example, children who are surrounded by friends or relatives who focus on being thin, stress dieting, and are never satisfied with their own body, are likely to develop similar beliefs and also have issues with eating and weight.

Currently, a biopsychosocial model is used to understand and explain anorexia. This model suggests that psychological, social, environmental, and biological factors interact and are involved in the development of the disease. Not all patients that have disordered eating will fulfill the DSM-IV diagnostic criteria for either anorexia or bulimia, however, they may still suffer both physically and mentally from their disordered eating behaviors.

Pediatricians serving as primary care providers for adolescent patients need to possess an understanding of and carry a high index of suspicion for eating disorders so that they will be prepared to identify disease when present and get the patient appropriate care. Eating disorders can lead to serious medical conditions and have significant morbidity and mortality associated with them. The sooner the problem is recognized, addressed, and treated, the better the chances of preventing complications and providing the patient with the best probability for a healthy future.

A Case History -- Part 1

Debbie is a 15-year-old white female who comes to the office with her mother for a routine physical exam before starting the school year. You have seen Debbie once before, a little over a year ago, and at that time everything was fine. She is a sophomore in high school with "straight A" grades, and has no significant past medical history.

Debbie's menarche was at age 13. Over the last year, her menses have gone from regular monthly periods which lasted 5-6 days to irregular episodes of 1-2 days of spotting and now about 3 months of amenorrhea.

Debbie, the 4th and youngest child in the family, participates in cheerleading (as did her two sisters) and is a member of the school theater group. Debbie denies any recent or significant emotional stressors; however, she is a little worried about having any health problems that would interfere with attending the sectional cheerleading championships.

At this point, set up a role playing exercise to work through the concerns of the various persons involved. Assign members of the group to play the patient, the parent accompanying the child, the pediatrician, the psychologist, and the nutritionist.

Scenario: The pediatrician is working in clinic one afternoon when one of his/her patient's, whom he/she hasn't seen in a while, is brought in by a parent. The parent states that he/she is concerned about his/her daughter. The parent (for now we'll just say it is the mother) is starting to become concerned by her daughter's behavior. The daughter has started exercising "too much" and the mother can not remember the last time the daughter sat down and had a full meal with the family. At first the mother didn't think anything of the daughter's behavior; she was actually pleased that her daughter had lost some weight (she used to think that her daughter was a little plump, and had actually told her so). However, the mother now feels that this weight loss has gone too far. The reason the mother brought her daughter in now is because she was cleaning her daughter's room the other day and she found several empty packages of laxatives. This finding has greatly concerned the mother.

Some suggestions on what you should try to get out of the roles:

Patient - The patient is not concerned about her health, she does not think she should be at the doctor. Play this role how you think an adolescent with an eating disorder might respond when being questioned about her behavior. What do you think her response would be to someone suggesting that she is treating her body in an unhealthy way and that she is not fat, but in fact too thin?

Parent - The parent is very concerned for her child. Play this role how you think a parent might react to seeing her own child voluntarily hurt herself and damage her health due to an unrealistic belief that she is fat.

Pediatrician - The pediatrician should make sure to obtain as much history as possible from the patient and the parent in order to determine what is going on with patient. Think about the types of questions you should be asking when you are concerned about an eating disorder. Also, what are the important aspects of the physical exam that should always be included when concerned about eating disorders. You can call in other health professionals (i.e. the psychologist and nutritionist) to help you elicit a good history and to help you come up with the best plan of action for your patient.

Psychologist - The psychologist can help to fully elicit the patient=s history. The psychologist may be able to come up with some questions the pediatrician missed. Also, the psychologist can be involved in getting the patient to talk more about her feelings and why she thinks she is behaving this way.

Nutritionist - The nutritionist can help with obtaining a dietary history. Also, the nutritionist can be involved in counseling/educating the patient on healthy eating and coming up with a treatment plan.

Throughout the rest of this module you will find information that will provide you with a solid background on how to approach patients with eating disorders. As a learning tool, as you go through the module, go back to the ideas you came up with during your role play and compare what you did with what the research and leading experts in the field tell us to do. This will help to show you the strengths and weaknesses you have when it comes to dealing with a patient with a possible eating disorder.

Q1. From the history elicited so far, is there anything in particular that makes you concerned about an eating disorder? (See appendix for listing of common hidden presentations of eating disorders.)

A1. First and foremost, amenorrhea is a common presenting symptom for anorexia nervosa. As you will see later, it is included as part of the diagnostic criteria for Anorexia Nervosa (AN). Second, Debbie participates in cheerleading. As stated in guidelines laid out by the AAP, female athletes tend to be at an increased risk for disordered eating. Athletes at greatest risk are those involved in activities that emphasize appearance and leanness in order to optimize performance, including: gymnastics; ballet dancing; long distance running; and cheerleading. Abnormal eating behaviors and the resultant health consequences, which include amenorrhea and osteoporosis, are unfortunately quite common in female athletes and together have been termed the female athlete triad.

The female athlete triad:

Anorexia nervosa, amenorrhea, and osteoporosis

It is also important to note that Debbie says she has not experienced any recent or significant emotional stressors. It is always important to ask patients about stress or difficult experiences they may have recently gone through because eating disorders are often triggered by a stressful event.

Q2. How should you screen for eating disorders?

A2. Since eating disorders are common in adolescence, screening should be done in all adolescent patients.

First: Obtain the weight and height and plot on appropriate curves for age and sex. Then calculate the BMI and put it on the CDC percentile curve for age and sex.

The Body Mass Index in Anorexia Nervosa

The BMI is weight divide by the square of the height (in kg/m2)

For older girls and adults, a BMI < 17.5 kg/m2 suggests anorexia nervosa.

20 to 25 kg/m2 is a healthy weight

25 to 30 kg/m2 increases health risk (Overweight)

>30 kg/m2 is at a high health risk (Obese)

Second:

Table 2. The SCOFF Questionnaire:

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 pounds) in a 3 month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say Food dominates your life?

* Each yes = 1 point: a score of 2 points indicates a likely diagnosis of anorexia nervosa.

[From Mehler. Annals of Internal Medicine]

TEACHING CAPTION: The "S.C.O.F.F." is a highly sensitive screening instrument that should be used on all patients and takes about 20 seconds to perform. It is likely to capture all or almost all affected teen-agers with eating disorders. [Hyperlink to Nutritional Assessment] A more comprehensive screening instrument, developed from material provided by the AAP, is shown below.

TABLE 3. A more detailed questionnaire for AN

What is the most you ever weighed? ____

When was that? _____ How tall were you then? ___

What is the least you ever weighed in the past year?

When was that? ____How tall were you then? ___

Are you comfortable with your body weight? ____

What do you think you ought to weigh? ____

Are you dieting now? ____

Do you go on diets often? ____

Do you think about food and choice of foods often? ____

Do you wish you could think about it less? _____

Do you feel in control of the way that you are eating? ____

Do you feel that you know how to eat? ___

Do you exercise? ___

How much?____

How often? ____

At what level of intensity? ____

How stressed are you if you miss a workout?____

If female, what is the menstrual history:

age at menarche? ____

Regularity of cycles? ____

Last menstrual period? ____

TEACHING CAPTION: This questionnaire provides more detail and can be used as a follow-up for patients with an initial positive screen. This took less than 4 minutes in a mock patient. A real anorectic patient would (and should) take longer. Derived from American Academy of Pediatrics(1) and Sigman, GS. Pediatric Clinics of North America (2)

For the full set of questions provided by the AAP see appendix.

The Case History Continues -- Part 2

Before she leaves the room so you can talk to and examine Debbie privately, Debbie's mother comments that her daughter has been on a weight reduction diet for the past 7 months. Debbie has lost about 40 pounds, but still wants to lose another 10 pounds. She has cheerleading for 2 hours 3 times a week and does calisthenics in her room each evening. Her mother is worried that this dieting and exercise are getting out of hand.

Further history elicited from Debbie reveals that she currently purchases and prepares her own food. She tells you her maximum weight was 150 pounds about six months ago and her current goal weight is 100 pounds. Debbie insists she has never been on a significant weight loss diet in the past. For exercise, she says she does 30-40 minutes of sit-ups and jumping jacks each evening. Debbie does not have to eat dinner with her family most nights because of after school activities. When she does eat with others, Debbie often excuses herself from the table. Debbie also tells you that she has never been sexually active and uses no tobacco, alcohol or illegal drugs.

After eliciting this history, you are becoming quite concerned about Debbie.

Q3. Debbie's history illustrates some of the characteristics of AN. What are they?

A3. The characteristics of AN portrayed by Debbie include:

Menstrual irregularities - amenorrhea
Large weight loss with a goal to still lose more weight B she lost about 40 pounds, but still wants to lose another 10 pounds.
Exercise - practice for 2 hours 3 times a week and calisthenics in her room each evening
Family concern - Her mother is worried that this dieting and exercise are getting out of hand

Q4. Now that you are concerned about AN are there any additional questions you should ask Debbie to get a more complete picture of her situation?

A4. Begin by taking a 24 hour diet history and looking for any of the following:

Let the resident attempt taking a history from the "patient." Have the "parents' there.

* Calorie counting, fat gram counting? Taboo foods (foods you avoid)?

*Any binge eating? Frequency, amount, triggers?

* Purging history?

* Use of diuretics, laxatives, diet pills, ipecac? Ask about elimination pattern, constipation, and diarrhea.

* Any vomiting? Frequency, how long after meals?

Now have the psychologist enter the role play

Next, a psychosocial assessment is needed since AN is a psychological disorder. In order to fully assess the patient, one needs to determine the patient=s, as well as the family=s, beliefs about food and body and the readiness for treatment.

· ask if there was any previous therapy including "what kind?", "how long?", and whether or not it was helpful.

· check the family history carefully for signs of eating disorders or altered perceptions of leanness.

For a more detailed list of questions to ask during the psychosocial assessment see appendix.

The Case History Continues -- Part 3

After asking these additional questions, you find out that Debbie uses a scale to weigh portions, counts calories, and is currently eating 500-550 calories per day in her effort to lose the "last" 10 pounds she wants to lose before the cheerleading championship. While she denies purging behaviors, Debbie does admit that she sometimes spits out mouthfuls of food into her napkin and then excuses herself to flush the contents. She has occasionally taken a laxative when she feels bloated (about once every week or so). She does not take diet pills, vitamins, herbal remedies or diuretics.

You decide to move on to the physical exam. On exam, Debbie is dressed in oversized clothes and is very thin. Debbie's vital signs are as follows: blood pressure 90/60, heart rate 50, respiratory rate 12, and temperature 97.4. Her weight is 110 pounds, her height is 65 inches, and her BMI is 18.2. Debbie has patches of lanugo on the lateral cheeks, but her parotids are not enlarged. She has had dental work for caries in the past, but has had no recent problems. The lung, heart and abdominal exam are normal. The external genital exam notes sparse pubic hair, tanner stage 5. Debbie's extremities are thin but have well defined muscles, and her strength is normal.

After completing the physical exam you are extremely concerned that you are dealing with AN.

Q5. What are signs of anorexia that you should look for on physical exam?

A5. The first impression you will have is likely to be of a child who is at an older age than stated and is affected by a chronic debilitating disease. You may get a sense of clinical depression, also. Cachexia in cancer or HIV disease might come to mind. Here are physical findings:

Table 4. Physical exam findings associated with AN

Vital signs

Hypothermia
Hypo tension
Bradycardia

Cardiac

Heart murmur

Dermatological

Lanugo
Dull, thin hair

Musculoskelatal

Sunken cheeks
Pitting edema of extremities

Gastrointestinal

Epigastric pain
Constipation

Neurological

Fatigue
Flat affect

Gynecological

Atrophic breasts (post pubertal)
Atrophic vaginitis (post pubertal)

TEACHING CAPTION: This table provides a list of physical findings commonly found when examining patients with eating disorders. There is much overlap between findings associated with AN and Bulimia Nervosa (BN); physical symptoms alone will not allow you to differentiate between the two diseases. As a clinician, it is important, however, to be aware of these common findings so that when detected on physical exam, they bring eating disorders into your mind and differential diagnosis. (Derived from American Academy of Pediatrics)

See appendix for a more detailed list of physical findings.

Q6. What findings on Debbie=s physical exam are suggestive of AN?

A6. You found the following elements of AN in your examination:

Blood pressure of 90/60
Heart rate of 50
Temperature of 97.4
Weight of 110 pounds while height is 65 inches
Patches of lanugo on the lateral cheeks
Genital exam notes sparse pubic hair

The Case History Continues -- Part 4

You decide to move on to do some tests so that you can more fully assess the state of Debbie=s health and also so you can have a baseline for comparison later on as you work with Debbie.

Q7. What lab abnormalities might you see in patients with eating disorders? What are they?

A7. In order to diagnose a patient with an eating disorder, he or she does not have to possess any abnormal lab values, but when present, certain abnormalities are more commonly associated with eating disorders. These include:

hypophosphatemia
hypoglycemia
hyperamylasemia
high muscle enzymes
metabolic alkalosis

(See appendix for a more detailed list.)

Q8. What laboratory tests should be done for Debbie?

A8. The initial laboratory work up includes tests to identify disordered acid-base balance, abnormal glucose and protein metabolism, and organ dysfunction; abnormalities afflicting individuals with eating disorders.

Table 5a. Laboratory Tests used in to identify children with eating disorders

· Electrolyte profile

· Glucose

· CBC

· Protein/albumin

· Phosphorus

· Liver and renal function

· TSH, free thyroid index

· EKG

TEACHING CAPTION: The table above lists laboratory tests commonly performed when trying to determine the presence and severity of an eating disorder. The table below lists tests that should be done when a patient is amenorrheic. These tests rule out pregnancy, prolactinoma, and ovarian failure. See appendix for a listing of additional tests to perform for a more complete assessment of the patient's health.

Table 5b.

· Pregnancy test

· LH, FSH, and estradiol

· PRL

The Case History Continues -- Part 5

Debbie has come back from the lab and you look up her results on the computer.

Laboratory results:

Sodium 138, potassium 3.8, chloride 104, bicarb 26, albumin 3.6, glucose 102
Hemoglobin 11.1, MCV 82, WBC 7,600, platelets and differential normal
TSH 3.7, T3 - 110, total T4 B 8.3
E2 - 24, FSH 4.3, LH 1.2
Pregnancy test B negative
Zinc normal
Amylase normal
Urinalysis reveals a specific gravity of 1.025 and trace ketones.

Q9. How would you interpret her test results? What do they suggest about the diagnosis?

Let the residents try

A9. As suspected, most of Debbie's lab results are within normal limits, except for her hemoglobin and estrogen, which are both low. The low estrogen provides an explanation for Debbie's amenorrhea. Due to the low hemoglobin, it would be worthwhile to also check Debbie=s iron levels.

Most test results will be normal even when a patient has an eating disorder. Normal results do not rule out disease, they simply serve as a baseline for comparison for tests that may need to be done again later.

Q10.

A. According to the DSM-IV, what diagnoses can be given to a patient with disordered eating?

B. Using DSM-IV criteria, what diagnosis would you give Debbie? (See appendix for a complete listing of diagnostic criteria for eating disorders.)

A10.

A. Under the category of eating disorders, the DSM-IV includes three diagnoses: AN; BN; and eating disorder not otherwise specified (ED-NOS). It is not always easy to differentiate between AN and BN because the disorders share common dysfunctional behaviors. A main point that separates BN from AN is that in BN the person's IBW usually falls within the normal to above normal range for age and height, while by definition patients with AN are less than 85% of their IBW. Also, anorexia has a worse recovery rate and more morbidity and mortality associated with it as compared to bulimia. ED-NOS is a diagnosis that can be used for patients who do not meet all of the criteria for the other two disorders.

B. Determine Debbie=s ideal body weight (IBW):

IBW: 5 feet = 100 pounds

Add 5 pounds for each additional inch of height

Debbie's height is 65 inches, so her IBW = 125.
She currently weighs 110 pounds, which is 88% of her IBW.
Debbie is not less than 85 % of her IBW, so she does not fit all of the criteria required to give a diagnosis of AN
Debbie's BMI is 18.2 and she is amenorrheic.
At this time, Debbie could be given a diagnosis of ED-NOS

(See appendix for a listing of disorders that should be included in the differential diagnosis for eating disorders.)

Q10a. Might Debbie have trouble getting services because she does not have classic anorexia (AN) or bulimia (BN)?

As it stands currently, there are many individuals with disordered eating that do not meet the full criteria for either anorexia or bulimia, and are thus placed in the category ED-NOS. The vagueness of this category gives the impression that the individual's problem is not significant and makes it difficult for people to go through their insurance and receive the support and treatment they need. The lack of access to aid results in a continued practice of harmful behaviors and a greater risk to ones health. Not only does this vague category prevent people from gaining access to treatment, it also prevents medical personnel from getting support to research the disease and gain a better understanding of what it is and how to manage it. This is an unfortunate situation and one that psychiatrists are currently aware of and working on changing for the next revision of the DSM that is slated to come out in 2012. The hope is that if you give the diseases which currently fall into the category of ED-NOS official names, you will also give the people suffering from them more accessible help and healthier futures.

Q11. What other disorders are commonly associated with eating disorders?

A11. The two most common associated sets of problems are first, psychiatric, and second, those of chronic illness.

Table 6. - Disorders commonly linked to eating disorders

Psychiatric associations
12-18% substance abuse
25% OCD
50-75% depression
separation issues, psychosexual problems, over-achievers
history of sexual abuse
Chronic disease associations
IDDM is associated with increased incidence of eating disorders B patients may withhold insulin for weight loss
Adolescent onset scoliosis B patients tend to have increased frequency of disturbed body image and being underweight

TEACHING CAPTION: When you diagnose a patient with an eating disorder, you need to look out for these other, commonly associated, disorders.

The Case History Continues -- Part 6

With Debbie's permission, you talk with Debbie and her mother. You tell them that while at the present time Debbie appears to be physically healthy, you are concerned that she is becoming too thin and too concerned about her weight. You explain anorexia nervosa to them and tell them that you are worried that Debbie is heading down this path. You explain that you would like to work with Debbie, along with some other health care specialists, to come up with a plan to make sure that she stays healthy.

While Debbie is initially reluctant, stating that there is really nothing wrong with her, she agrees to participate in treatment.

Q12. What treatment will you propose?

A12. There are five levels of treatment for patients with eating disorders:

Table 7. Levels of Treatment

outpatient treatment -- in home
residential treatment -- in special non-hospital facility
partial/day hospitalization B a graded engagement from some hospital care to all day; but sleeps at home
inpatient hospitalization. B used when child must be observed at all times

TEACHING CAPTION: The first step in managing a patient is to determine what level of treatment is needed. Patients that are 85 to 90 % of their IBW are considered stable enough to receive outpatient treatment. In Debbie's case, outpatient treatment is best. The next step is to develop a specific treatment plan.

Table 8 -- Treatment Plan

Your role as Primary care physician is to:

Coordinate treatment, manage medical complications, and determine need for hospitalization
Aid in negotiating contracts with the patient
Perform blinded weigh-ins B the patient does not see weight

Ask patients to commit to not weighing themselves
Use same calibrated scale, gowned post-void, at least weekly during treatment
In treatment, goal to gain 2 to1 pound per week as outpatient and 2-3 pounds per week in hospital
During maintenance, 3-5 pound range are called stable

4. Monitor weight and activity

5. Exercise allowance

6. Restrict bingeing, purging

7. Goal weight B 5 pounds over weight at onset of amenorrhea

8. Recovered anorexic patients should continue to have weight checks.

9. Vulnerable for relapse especially during times of stress, such as pregnancy.

10. Women with eating disorders should be alert to increased anxiety about weight and food intake

11. Pharmacotherapy - antidepressants, estrogen, metoclopramide

Role of Nutrition specialist B The Registered Dietician (RD)

? Assess and instruct dietary intake

? Caloric recommendations

? 800-1000 initially

? Increase 200-300 q3-4 d, up to 3000-3500/d

? Normalize eating habits

? Food groups/meal frequency

? Vitamin/mineral supplement

? Zinc, calcium, multivitamin

? Food diaries

Role of Mental health provider

? Improve body image

? Improve social relationships

? Psychoanalysis

? Cognitive behavioral therapy

? Family therapy

TEACHING CAPTION: Due to the complexity of eating disorders, all treatment plans should take a multidisciplinary approach. A pediatrician, a psychiatrist, and a nutritionist (RD), all need to be involved. It is important to remember the mental health provider when making up the treatment plan. Psychological therapy is an inherent part of treatment and should not be just an afterthought.

As Hilda Bruch writes,

"[E]arly institution of meaningful psychotherapy improves the chances of recovery.[T]he outcome is entirely dependent on the therapist's capacity to understand the basic problems of the anorexic and to help him find better ways of dealing with them, and that a statistical evaluation, based on weight alone, is not only not informative but may be misleading."

(pps 381,382)

The Case History Continues -- Part 7

After a couple months of moderately successful treatment, Debbie manages to convince her mother that she is fine and can take care of herself on her own. Debbie states that she will come back to see you in a few months for a check up. Despite your attempts to reach out to the patient and her family, you lose contact.

You are working on the ward several months later when Debbie is admitted as a patient on your team. You read Debbie's chart before going in to see her and you find out that she was admitted because she passed out in school. After passing out, she was brought to the nurse's office where her blood pressure was taken and found to be 75/45. The nurse became very concerned because she thought Debbie looked very thin, an observation you are able to make for yourself as soon as you walk in the room.

Q13. When should a patient with an eating disorder be hospitalized?

A13. Full hospitalization is an alternative that must be kept in mind and insisted upon when less forceful approaches are not working. Affected teen-agers must be hospitalized before their nutritional status deteriorates to a point where they are vulnerable to sudden death from cardiac failure or over whelming infection.

Table 9. Criteria for hospitalization

· Heart rate <50 bpm during the day and <45 bpm at night

· Orthostatic changes in pulse (>20 bpm) or blood pressure (>10 mmHg)

· Cardiac dysrrhythmias

· Acute medical complications (seizures, CHF, pancreatitis)

· Severe or rapid weight loss

· Electrolyte disturbances

· Refusal to eat

· Acute psychiatric emergency (suicide risk)

(American Academy of Pediatrics)

TEACHING CAPTION: Eating disorders, especially AN, are associated with significant morbidity and mortality. It is important to be aware of and look out for critical signs and symptoms that suggest a serious problem. As a primary care provider it is your job to be aware of these criteria and get the patient into the hospital when necessary. Table 9 lists some of the more serious criteria, see the appendix for a more detailed list.

The Case History Continues -- Part 8

After talking with Debbie, her mother sees you on the floor and approaches you. She states that she has been quite concerned about Debbie for some time, but was afraid to push Debbie to get help because she did not want to make the situation worse. The mother asks you, "What can this disease do to my daughter?-"

Q14. What medical complications may arise due to anorexia nervosa?

As before, always let the resident's answer. It is interesting to have them remain in character and ask from the perspective of their roles.

A14. As noted in several places, AN has potentially lethal complications affecting multiple organ systems as well as the integrated body function as a whole as in Multiple Organ Dysfunction Syndrome (MODS).

Table 10. Common medical complications associated with AN

· Cardiac

· Dysrhythmias

· Sudden Death

· Musculoskelatal

· Osteoporosis (3 B 7 times increased risk of fracture)

· Neurologic

· Cognitive changes

· Decreased brain mass

· Seizures

· Renal

· Increased risk of renal stones

· Hematologic

· Leukopenia /Thrombocytopenia/ Anemia

· Iron deficiency

· Refeeding syndrome

TEACHING CAPTION: When taking care of patients with eating disorders, one needs to be aware of the potential complications of these diseases. Patients and their families should also be informed of these potential complications so they know what to look out for and when to bring the patient needs to the doctor. See appendix for a more complete listing of medical complications associated with AN and BN and for more information on Refeeding syndrome. (American Academy of Pediatrics)

Q15. Debbie struggles while in the hospital, but is eventually discharged. Before leaving, her parents ask you about the recovery rates for teens with eating disorders. What can you tell them?

A15. Here are the statistics: some children get better; many continue with a lingering eating disorder through life; and death is always a possibility. It=s our job to prevent this. As noted in the description of DSM IV, anorexia and bulimia nervosa syndromes have common circumstances surrounding them both. AN can shift to become BN and vice versa.

AN at 4 year follow-up:

o 40-45% recover

o 30% improve

o 25% chronic course

o 10-15% mortality

BN at 6 year follow-up:

o 60% recovered

o 29% some symptoms

o 10% persistent disease

o 1% mortality

One must be aware of those factors creating greatest risk for chronic AN/BN as well as for death from AN.

Bad Prognostic Indicators:

Lower initial and minimum weight

Late onset

Vomiter/purger

Previous failed treatment

Long duration of treatment

Married

Disturbed family dynamics

Male

Pretoria obesity

The Case History Concludes

You share the information you have found on the prognosis of anorexia nervosa with Debbie=s parents. You bring to their attention that Debbie really does not have any of the prognostic indicators for a bad outcome that makes recovery more plausible for Debbie. You remind Debbie's parents that she really needs their support and for them to be involved in her care so that they can work together to resolve her eating disorder.

References

Brewerton TD. Bulimia in children and adolescents. Child & Adolescent Psychiatric Clinics of North America. 11(2):237-56, viii, 2002 Apr.

Bruch, H. The golden cage: the enigma of anorexia nervosa. Harvard University Press, Cambridge MA. Reissued 2001.

Committee on Adolescence, American Academy of Pediatrics. Identifying and treating eating disorders. Pediatrics. 111(1):204-211. 2003 Jan.

Committee on Sports Medicine and Fitness, American Academy of Pediatrics. Medical concerns in the female athlete. Pediatrics. 106(3):610-613, 2000 Sep.

Golden NH. A review of the female athlete triad (amenorrhea, osteoporosis and disordered eating). International Journal of Adolescent Medicine & Health. 14(1):9-17, 2002 Jan-Mar.

Grace, E. Stephanie=s long walk: A facilitator=s guide. www.pedicases.org. Harvard Medial School, Children=s Hospital, Boston.

Hobart JA. Smucker DR. The female athlete triad. American Family Physician. 61(11):3357-64, 3367, 2000 Jun 1.

Kreipe RE. Birndorf SA. Eating disorders in adolescents and young adults. Medical Clinics of North America. 84(4):1027-49, viii-ix, 2000 Jul.

Mehler PS. Diagnosis and care of patients with anorexia nervosa in primary care settings. Annals of Internal Medicine. 134(11):1048-59, 2001 Jun.

Muscari ME. Thin line: managing care for adolescents with anorexia and bulimia. MCN, American Journal of Maternal Child Nursing. 23(3):130-40; quiz 141, 1998 May-Jun.

Neumark-Sztainer D. School-based programs for preventing eating disturbances. Journal of School Health. 66(2):64-71, 1996 Feb.

Otis, Carol L. et al. ACSM position stand: the female athlete triad. Medicine & Science in Sports & Exercise. 29(5):i-ix, 1997 May.

Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS). Journal of the American Dietetic Association. 101(7):810-19, 2001 Jul.

Pratt BM. Woolfenden SR. Interventions for preventing eating disorders in children and adolescents. Cochrane Database of Systematic Reviews. (2):CD002891, 2002.

Ressel, GW. Practice guidelines: AAP release policy statement on identifying and treating eating disorders. American Family Physician. 57(10):2224-2227, 2000 May.

Roerig JL. Mitchell JE. Myers TC. Glass JB. Pharmacotherapy and medical complications of eating disorders in children and adolescents. Child & Adolescent Psychiatric Clinics of North America. 11(2):365-85, xi, 2002 Apr

Rome ES. Ammerman S. Rosen DS. Keller RJ. Lock J. Mammel KA. O'Toole J. Rees JM. Sanders MJ. Sawyer SM. Schneider M. Sigel E. Silber TJ. Children and adolescents with eating disorders: the state of the art. Pediatrics. 111(1):e98-108, 2003 Jan.

Rosen DS. Neumark-Sztainer D. Review of options for primary prevention of eating disturbances among adolescents. Journal of Adolescent Health. 23(6):354-63, 1998 Dec.

Rosenblum J. Forman S. Evidence-based treatment of eating disorders. Current Opinion in Pediatrics. 14(4):379-83, 2002 Aug.

Russell GF. Involuntary treatment in anorexia nervosa. Psychiatric Clinics of North America. 24(2):337-49, 2001 Jun.

Seidenfeld ME. Rickert VI. Impact of anorexia, bulimia and obesity on the gynecologic health of adolescents. American Family Physician. 64(3):445-50, 2001 Aug 1.

Sigman, GS. Eating disorders in children and adolescents. Pediatric Clinics of North America. 50(5):1139-1179, 2003 October.

Steiner H. Lock J. Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry. 37(4):352-9, 1998 Apr

Steinhausen HC. The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry. 159(8):1284-93, 2002 Aug

Stoving RK. Hangaard J. Hagen C. Update on endocrine disturbances in anorexia nervosa. Journal of Pediatric Endocrinology & Metabolism. 14(5):459-80, 2001 May.

Su JC. Birmingham CL. Zinc supplementation in the treatment of anorexia nervosa. Eating & Weight Disorders: EWD. 7(1):20-2, 2002 Mar.

Walsh JME, Wheat ME, and Freund K. Detection, evaluation, and treatment of eating disorders: the role of the primary care physician. Journal of General Internal Medicine. 15(8):577-90, 2000 Aug.

Walsh BT. Devlin MJ. Eating disorders: progress and problems. Science. 280(5368):1387-90, 1998 May 29.

Wells LA. Sadowski CA. Bulimia nervosa: an update and treatment recommendations. Current Opinion in Pediatrics. 13(6):591-7, 2001 Dec.

Annotated Answers

A1. The answer is True. All of the pathologies could be present in eating disorders. The consequences are presented in the tire of appearance. One would hope that the history taken of a young woman with menstrual irregularities would raise a concern for an eating disorder

A2. The answer is False. A BMI of 22 kg/m2

Would put adult women at the low point in the BMI vrs morbidity/ mortality curve at all ages. A you g adult with this BMI who think they are overweight are "at risk" for an eating disorder.

A3. The answer is B. Patients with hypothyroidism are likely to be sluggish and gaining weight. The other answers are a part of the Differential Diagnosis for an underweight teen female. Check carefully for abdominal pain (Crohn's disease, polyuria, polydipsia (New onset diabetes mellitus), or neurologic signs and symptoms (CNS tumor)

A4. The answer is C. Pancreatitis is a well known consequence. As for the other answers, a metabolic alkalosis is likely; Blood sugars tend to be low, and there is malnutrition associates leucopoenia

A5. The answer is True. A statistic used is that 1/3 of eating disorders recover, 1/3 illness, and 1/3 succumb. The percentages are no longer accurate, but many children do not recover completely.

A6. The answer is False. These teens are more likely to have a chronic illness associated with dysfunctional eating. They may become obese or lean at various times in their lives.

A7. The answer is True. Depression is a common comorbidity. Effective talk and medical and behavioral therapy can help. Hilda Bruch warns of sole dependence on behavioral therapies of her time. A similar warning is made for a unitary therapy with medication. Investigation of and therapy for psychological underpinnings is an absolute necessity in treating eating disorders.

Appendix

I. Hidden presentations of eating disorders to be aware of:

" Menstrual irregularities

" Infertility

" Depression

" Pathological fractures

" Ankle edema

" Fatigue/weakness

" Esophagitis

" Electrolyte abnormalities

" Perimyolysis

II. Complete listing of screening questions from AAP guidelines.

III. Psychosocial assessment

Determine the patient's:

" Degree of obsession with food and weight

" Understanding of the diagnosis

" Willingness to receive help

" Functioning at home, in school, and with friends

" Psychiatric history - looking specifically for depression, anxiety, or obsessive compulsive disorder.

" History of physical or sexual abuse, or violence and suicidal ideation

Determine the parents':

" reaction to the illness

" understanding of treatment

" if parents are in denial or do not agree with the treatment approach and goals, a child's illness may be exacerbated and recovery delayed.

(Derived from Ressel. American Family Physician)

A primary care doctor that feels comfortable and competent with this type of assessment may take on the responsibility of the evaluation, however, if there are questions or concerns you should refer the patient to specialists.

IV. Findings on physical exam in adolescents with eating disorders

V. Optional tests to perform for patients with eating disorders

" Zinc

" Amylase

" Muscle enzymes

" Cortisol

" Cholesterol

" Urinalysis for specific gravity, ketones

" Bone density

VI. Common lab abnormalities associated with eating disorders

" metabolic alkalosis

" hypokalemia

" hypophosphatemia

" hypoglycemia

" neutropenia

" hypercortisol

" hypercarotene

" hypercholesterol

" low zinc

" hyperamylasemia

" high muscle enzymes

" high SGOT/SGPT

VII. DSM-IV Criteria for AN, BN, and ED-NOS.

VIII. Differential Diagnosis for eating disorders

" Endocrine: new diabetes, hyperthyroidism, hypopituitarism, Addison's disease

" Gastrointestinal: inflammatory bowel disease, malabsorption, celiac disease

" Psychiatric: depression, obsessive-compulsive disorder, social phobia, or other psychiatric diagnosis

" Abdominal mass

" Central nervous system lesion, malignancy

" Superior mesenteric artery syndrome (can itself be the problem or may be a consequence of an eating disorder)

(Derived from American Academy of Pediatrics)

IX. Criteria to determine when a patient needs to be admitted to the hospital.

X. Possible medical complications

XI. Complications to monitor for during refeeding:

" Gastric dilation

" CHF

" Pancreatitis

" Delirium

" Hypophosphatemia

(American Academy of Pediatrics)

If present, refeeding syndrome usually occurs during the first two to three weeks of treatment. After being malnourished for a period of time, an individual is at risk for complications when beginning to take in nutrients again. Cardiovascular collapse, due to weakened cardiac muscle and decreased cardiovascular capacity, can be a major complication.