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Eating Disorder
Aka: Eating Disorder, Restrictive Eating Disorder
- See Also
- Anorexia Nervosa
- Bulimia Nervosa
- Binge-Eating Disorder (or Compulsive Overeating)
- Epidemiology
- Age
- Eating Disorders are most common in teen age and early adulthood
- Gender
- Most common in girls and women
- However, more common in males in certain activities (e.g. figure skating, dance) as well as with "bulk and cut" (see below)
- Eating Disorder lifetime Prevalence
- Females: 8%
- Males: 2%
- Types: Weight loss or fluctuation (Restrictive Eating Disorders)
- Anorexia Nervosa
- Restricted food intake resulting in significantly low body weight
- Intense fear of weight gain or fatness
- Distorted body image
- Bulimia Nervosa
- Recurrent Binge Eating with a sense of loss of control
- Weekly behaviors (>=3 months) to prevent weight gain (e.g. induced Vomiting, Laxatives, Diuretics, excess Exercise)
- Self worth is overly dependent on weight and body shape
- Avoidant-Restrictive Food Intake Disorder
- Avoidance of Food Intake (e.g. lack of interest, altered food sensation)
- Inadequate nutrition (e.g. significant weight loss or inadequate weight gain during growth, nutritional deficiency)
- No disturbance in body weight or shape perception (contrast with Anorexia Nervosa and Bulimia Nervosa)
- Not due to other condition (e.g. food availability, religious practice, medical condition, other mental health disorder)
- Types: Weight gain
- Binge-Eating Disorder
- Recurrent Binge Eating with a sense of loss of control
- No behaviors to prevent weight gain
- Contrast with Bulimia Nervosa
- Weekly behaviors (>=3 months)
- Fast eating, uncomfortable after eating, eating large quantities when not hungry
- Embarrassed about Overeating
- Compulsive Overeating
- Compulsive behavior around food, eating, and body image
- Interferes with daily functioning
- Types: Other Disordered Eating Patterns
- Rumination Disorder
- Repeated regurgitation of food for at least one month
- Not due to gastrointestinal, other medical condition or other Eating Disorder
- Pica
- Non-nutritive, non-food substance ingestions for >1 month
- Not due to developmental or cognitive deficit, and not due to cultural practices
- Bulk and Cut (typically males)
- Males with body dissatisfaction, focusing on lean muscularity
- Use performance enhancing substances to increase muscularity, followed by inducing weight loss
- Lavender (2017) Curr Psychiatry Rep 19(6): 32 [PubMed]
- Associated Conditions
- Anxiety Disorder
- Major Depression
- Substance Abuse
- Personality Disorder
- Somatization
- Self-Injury (e.g. cutting)
- History: Eating and Weight
- See Anorexia Nervosa
- See Bulimia Nervosa
- Extremes of weight gain or weight loss or fluctuating weight
- Food related behaviors (Picky Eating or specific eating-related rules, calorie counting)
- Marked increased or decreased calorie intake
- Typical
- Binge Eating
- Purging (e.g. induced Vomiting, Laxatives, Diuretics)
- Use of supplements to impact muscle mass (e.g. performance enhancing drugs, esp. males)
- Excessive Exercise
- Frequently checking body weight or measurements, or looking at body shape in mirror
- Fear of gaining weight
- Self-esteem hinges on body weight and shape, and impacts eating behaviors
- Dissatisfaction or preoccupation with body weight or shape
- Family History of Eating Disorder
- History: Associated Conditions
- Amenorrhea
- Cardiovascular Effects
- Syncope
- Exercise intolerance
- Palpitations
- Gastrointestinal Effects
- Constipation
- Delayed Gastric Emptying
- Pancreatitis
- Mental Health
- Anxiety Disorder
- Major Depression
- Substance Abuse
- Suicidality
- Exam
- See Anorexia Nervosa
- See Bulimia Nervosa
- Vital Signs
- Record a full set of Vital Signs
- Be alert for Hypotension, Bradycardia, Hypothermia (esp. in Anorexia Nervosa)
- Constitutional
- Record today's measured weight and height, and calculate Body Mass Index (BMI)
- Plot measurements on growth curve in teenage patients still growing
- Head and Neck (induced Vomiting changes)
- Dental Erosions
- Parotid hypertrophy
- Skin
- Alopecia
- Lanugo Hair
- Cutting, burns or other self harm
- Skin dryness
- Musculoskeletal Exam
- Muscle Wasting
- Edema (hypoalbuminemia related)
- Genitourinary
- Delayed Sexual Development
- Psychiatric
- Flat affect
- Evasive
- Labs
- See Anorexia Nervosa
- See Bulimia Nervosa
- Complete Blood Count
- Leukopenia, Anemia and Thrombocytopenia may be seen with Bone Marrow hypoplasia
- Serum Electrolytes (includes basic metabolic panel, Serum Calcium, Serum Phosphorus and Serum Magnesium)
- Evaluate for Hypocalcemia, Hypophosphatemia and Hypomagnesemia
- Thyroid Stimulating Hormone (TSH with reflex to T4)
- Serum Amylase
- Amylase increased with purging behavior
- Cholesterol Level
- Increased Cholesterol
- Serum Prealbumin
- See Lab Markers of Malnutrition
- Decreased in Malnutrition
- Diagnostics
- Electrocardiogram (EKG)
- Differential Diagnosis
- Malignancy
- Hypothyroidism or Hyperthyroidism
- Celiac Sprue
- Diabetes Mellitus
- Inflammatory Bowel Disease
- Screening
- SCOFF Questionnaire
- HEADSS Psychosocial Interview (Adolescent History)
- Height, Weight and Body Mass Index (BMI) monitoring at clinic visits (plotted on growth curve)
- Evaluation: Motivational Interviewing (Five Rs Technique)
- Relevance
- Encourage the patient to identify why Eating Disorder effects are relevant to them
- How would your life be different if you spent less time thinking about eating?
- Risks
- Discuss the consequences of disordered eating (decreased concentration, Fatigue, weakness)
- Rewards
- Ask the patient what benefits they would foresee from overcoming disordered eating habits
- Examples: Improved energy, clothes fit, not hiding intentional weight loss behaviors
- Roadblocks
- What would be the downside of changing the way you eat?
- Lack of motivation to change
- Malnutrition and decreased decision making capacity
- Lack of self awareness and body image distortion
- Fear of regaining weight
- Disordered thoughts and behaviors
- Reinforced by prior praise at initial weight loss
- Coping strategy for negative thoughts and excessive stress
- Repeat
- Readdress at each visit with an unmotivated patient
- Management: Indications for Hospitalization and Stabilization
- Acute food refusal
- Uncontrolled binging and purging
- Failed outpatient management
- Malnutrition complicated by acute medical complication
- Syncope
- Seizure
- Acute Heart Failure
- Acute Pancreatitis
- Hematemesis
- Electrocardiogram abnormalities (e.g. prolonged QTc Interval)
- Severe Bradycardia (<40 bpm in adults, <50 bpm in children)
- Hypotension (<90/50 mmHg)
- Hypothermia (<96 F or 35.6 C)
- Fluid and Electrolyte derangements
- Dehydration
- Hypokalemia
- Hyponatremia
- Uncontrolled comorbidity
- Major Depression with Suicidality
- Type 1 Diabetes Mellitus
- Management: General
- Referral to multi-specialty team skilled in Eating Disorders
- Eating Disorder program or provider
- Mental Health Therapis
- Nutritionist
- Treatment settings
- Outpatient management is ideal if possible and this serves most patients
- Stabilization hospitalization for correction of significant abnormalities or for Suicidality may be needed first
- Residential, Partial hospitalization or intensive day treament may be needed (e.g. failed outpatient management)
- Nutrition Management (as counseled by nutritionist)
- Goal weight gain is typically 1-2 kg (2.2 to 4.4 lb) per week to stabilize cardiovascular status
- Management is specific for each condition
- See Anorexia Nervosa
- See Bulimia Nervosa
- See Binge-Eating Disorder (or Compulsive Overeating)
- Prognosis
- Disordered eating persists >20 years after diagnosis in one third of patients
- Early intervention is key to preventing prolonged course and complications
- Anorexia or Bulimia
- Age adjusted mortality due to complications and Suicidality: 2-6 fold over peers
- Suicide completion rates 18 fold higher than peers
- Resources
- Academy for Eating Disorders
- http://www.aedweb.org/web/index.php
- National Eating Disorders Association
- http://www.nationaleatingdisorders.org/
- National Asssociation of Anorexia Nervosa and Related Disorders
- http://www.anad.org/
- National Institute of Mental health (NIMH) - Eating Disorders
- https://www.nimh.nih.gov/health/publications/eating-disorders-new-trifold/index.shtml
- American Psychiatric Association - Eating Disorders
- http://www.psychiatry.org/eating-disorders
- American Psychological Association - Eating Disorders
- http://apa.org/topics/eating/index.aspx
- Families Empowered and Supporting Treatment of Eating Disorders
- http://members.feast-ed.org/
- References
- Klein (2021) Am Fam Physician 103(1): 22-32 [PubMed]