Eating Disorder

1. See Also
   1. Anorexia Nervosa
   2. Bulimia Nervosa
   3. Binge-Eating Disorder (or Compulsive Overeating)
2. Epidemiology
   1. Age
      1. Eating Disorders are most common in teen age and early adulthood
   2. Gender
      1. Most common in girls and women
      2. However, more common in males in certain activities (e.g. figure skating, dance) as well as with "bulk and cut" (see below)
   3. Eating Disorder lifetime Prevalence
      1. Females: 8%
      2. Males: 2%
3. Types: Weight loss or fluctuation (Restrictive Eating Disorders)
   1. Anorexia Nervosa
      1. Restricted food intake resulting in significantly low body weight
      2. Intense fear of weight gain or fatness
      3. Distorted body image
   2. Bulimia Nervosa
      1. Recurrent Binge Eating with a sense of loss of control
      2. Weekly behaviors (>=3 months) to prevent weight gain (e.g. induced Vomiting, Laxatives, Diuretics, excess Exercise)
      3. Self worth is overly dependent on weight and body shape
   3. Avoidant-Restrictive Food Intake Disorder (ARFID)
      1. Avoidance of Food Intake (e.g. lack of interest, altered food Sensation)
      2. Inadequate nutrition (e.g. significant weight loss or inadequate weight gain during growth, nutritional deficiency)
      3. No disturbance in body weight or shape Perception (contrast with Anorexia Nervosa and Bulimia Nervosa)
      4. Not due to other condition (e.g. food availability, religious practice, medical condition, other mental health disorder)
4. Types: Weight gain
   1. Binge-Eating Disorder
      1. Recurrent Binge Eating with a sense of loss of control
      2. No behaviors to prevent weight gain
         1. Contrast with Bulimia Nervosa
      3. Weekly behaviors (>=3 months)
         1. Fast eating, uncomfortable after eating, eating large quantities when not hungry
         2. Embarrassed about Overeating
   2. Compulsive Overeating
      1. Compulsive behavior around food, eating, and body image
      2. Interferes with daily functioning
5. Types: Other Disordered Eating Patterns
   1. Rumination Disorder
      1. Repeated regurgitation of food for at least one month
      2. Patient purposely regurgitates and spits out or rechews and reswallows food
      3. Not due to gastrointestinal, other medical condition or other Eating Disorder
   2. Pica
      1. Non-nutritive, non-food substance ingestions for >1 month
      2. Not due to developmental or cognitive deficit, and not due to cultural practices
   3. Bulk and Cut (typically males)
      1. Males with body dissatisfaction, focusing on lean muscularity
      2. Use performance enhancing substances to increase muscularity, followed by inducing weight loss
      3. Lavender (2017) Curr Psychiatry Rep 19(6): 32 [PubMed]
6. Associated Conditions
   1. Anxiety Disorder
   2. Major Depression
   3. Substance Abuse
   4. Personality Disorder (esp. Obsessive Compulsive Disorder)
   5. Somatization
   6. Self-Injury (e.g. cutting)
   7. Suicidality
      1. Suicidal Ideation is present in up to half of adolescents with Eating Disorders
      2. Suicide accounts for more than 20% of Eating Disorder related deaths
      3. Swanson (2011) Arch Gen Psychiatry 68(7): 714-23 [PubMed]
7. History: Eating and Weight
   1. See Anorexia Nervosa
   2. See Bulimia Nervosa
   3. Extremes of weight gain or weight loss or fluctuating weight
   4. Food related behaviors (Picky Eating or specific eating-related rules, calorie counting)
   5. Marked increased or decreased calorie intake
   6. Binge Eating
   7. Purging (e.g. induced Vomiting, Laxatives, Diuretics)
   8. Use of supplements to impact Muscle mass (e.g. performance enhancing drugs, esp. males)
   9. Excessive Exercise
   10. Frequently checking body weight or measurements, or looking at body shape in mirror
   11. Fear of gaining weight
   12. Self-esteem hinges on body weight and shape, and impacts eating behaviors
   13. Dissatisfaction or preoccupation with body weight or shape
   14. Family History of Eating Disorder
8. History: Associated Conditions
   1. Amenorrhea
   2. General
      1. Fatigue
      2. Generalized Weakness
   3. Cardiovascular Effects
      1. Syncope
      2. Exercise intolerance
      3. Palpitations
   4. Gastrointestinal Effects
      1. Constipation
      2. Delayed Gastric Emptying
      3. Pancreatitis
   5. Mental Health
      1. Anxiety Disorder
      2. Major Depression
      3. Substance Abuse
      4. Suicidality
9. Exam
   1. See Anorexia Nervosa
   2. See Bulimia Nervosa
   3. Vital Signs
      1. Record a full set of Vital Signs
      2. Be alert for Hypotension, Bradycardia, Hypothermia (esp. in Anorexia Nervosa)
   4. Constitutional
      1. Record today's measured weight and height, and calculate Body Mass Index (BMI)
      2. Plot measurements on growth curve in teenage patients still growing
   5. Head and Neck (induced Vomiting changes)
      1. Dental Erosions
      2. Parotid hypertrophy
   6. Cardiovascular
      1. Mitral Valve Prolapse
   7. Skin
      1. Alopecia
      2. Lanugo Hair
      3. Cutting, burns or other self harm
      4. Skin dryness
      5. Calluses on the dorsal hands related to induced Vomiting maneuvers
   8. Musculoskeletal Exam
      1. Muscle Wasting
      2. Edema (hypoalbuminemia related)
   9. Genitourinary
      1. Delayed Sexual Development
   10. Psychiatric
       1. Flat affect
       2. Evasive
10. Labs
    1. See Anorexia Nervosa
    2. See Bulimia Nervosa
    3. Complete Blood Count
       1. Leukopenia, Anemia and Thrombocytopenia may be seen with Bone Marrow hypoplasia (severe Anorexia)
    4. Serum Electrolytes
       1. Includes basic metabolic panel, Serum Calcium, Serum Phosphorus and Serum Magnesium
       2. Evaluate for Electrolyte abnormality
          1. Hyponatremia (Vomiting, Diuretic Abuse, water Intoxication)
          2. Hypokalemia (Vomiting, Diuretic Abuse)
          3. Hypocalcemia, Hypophosphatemia and Hypomagnesemia
       3. Evaluate for acid base disorder
          1. Metabolic Acidosis (Laxative abuse)
          2. Hypochloremic Metabolic Alkalosis (Vomiting, Diuretic Abuse)
    5. Liver Function Tests
       1. Liver Transaminases increase with purging
    6. Thyroid Stimulating Hormone (TSH with reflex to T4)
    7. Serum Amylase and Serum Lipase
       1. Amylase increased with purging behavior
    8. Cholesterol Level
       1. Increased Cholesterol
    9. Serum Prealbumin or Serum Albumin
       1. See Lab Markers of Malnutrition
       2. Decreased Serum Prealbumin and Serum Albumin in Malnutrition
    10. Urinalysis
        1. Increased Urine Specific Gravity, Ketones (Dehydration)
11. Diagnostics
    1. Electrocardiogram (EKG)
12. Differential Diagnosis
    1. Malignancy
    2. Hypothyroidism or Hyperthyroidism
    3. Celiac Sprue
    4. Diabetes Mellitus
    5. Inflammatory Bowel Disease
    6. Adrenal Insufficiency
    7. Tuberculosis
    8. HIV Infection
13. Screening
    1. SCOFF Questionnaire
    2. HEADSS Psychosocial Interview (Adolescent History)
    3. Height, Weight and Body Mass Index (BMI) monitoring at clinic visits (plotted on growth curve)
14. Evaluation: Motivational Interviewing (Five Rs Technique)
    1. Relevance
       1. Encourage the patient to identify why Eating Disorder effects are relevant to them
       2. How would your life be different if you spent less time thinking about eating?
    2. Risks
       1. Discuss the consequences of disordered eating (decreased concentration, Fatigue, weakness)
    3. Rewards
       1. Ask the patient what benefits they would foresee from overcoming disordered eating habits
       2. Examples: Improved energy, clothes fit, not hiding intentional weight loss behaviors
    4. Roadblocks
       1. What would be the downside of changing the way you eat?
       2. Lack of motivation to change
          1. Malnutrition and decreased decision making capacity
          2. Lack of self awareness and body image distortion
          3. Fear of regaining weight
       3. Disordered thoughts and behaviors
          1. Reinforced by prior praise at initial weight loss
          2. Coping strategy for negative thoughts and excessive stress
    5. Repeat
       1. Readdress at each visit with an unmotivated patient
15. Management: Indications for Hospitalization and Stabilization
    1. See specific conditions
    2. Acute food refusal
    3. Uncontrolled binging and purging
    4. Failed outpatient management
    5. Malnutrition complicated by acute medical complication
       1. Syncope
       2. Seizure
       3. Acute Heart Failure
       4. Acute Pancreatitis
       5. Hematemesis
       6. Electrocardiogram abnormalities (e.g. prolonged QTc Interval)
       7. Severe Bradycardia (<40 bpm in adults, <50 bpm in children)
       8. Hypotension (<90/50 mmHg)
       9. Hypothermia (<96 F or 35.6 C)
    6. Fluid and Electrolyte derangements
       1. Dehydration
       2. Hypokalemia
       3. Hyponatremia
    7. Uncontrolled comorbidity
       1. Major Depression with Suicidality
       2. Type 1 Diabetes Mellitus
16. Management: General
    1. Referral to multi-specialty team skilled in Eating Disorders
       1. Eating Disorder program or provider
       2. Mental Health Therapis
       3. Nutritionist
    2. Treatment settings
       1. Outpatient management is ideal if possible and this serves most patients
       2. Stabilization hospitalization for correction of significant abnormalities or for Suicidality may be needed first
       3. Residential, Partial hospitalization or intensive day treament may be needed (e.g. failed outpatient management)
    3. Nutrition Management (as counseled by nutritionist)
       1. Goal weight gain is typically 1-2 kg (2.2 to 4.4 lb) per week to stabilize cardiovascular status
    4. Management is specific for each condition
       1. See Anorexia Nervosa
       2. See Bulimia Nervosa
       3. See Binge-Eating Disorder (or Compulsive Overeating)
17. Complications
    1. Superior Mesenteric Artery Syndrome
       1. Third duodenal segment compression by superior Mesenteric Artery
       2. Presents with Abdominal Pain, early satiety and persistent Emesis
    2. Refeeding Syndrome
       1. See Anorexia Nervosa
    3. Osteoporosis (Anorexia)
    4. Electrolyte abnormalities
       1. Hypokalemia
       2. Hypophosphatemia
       3. Hypomagnesemia
    5. Gastrointestinal injury (forced Vomiting)
       1. Mallory Weiss Tear
       2. Esophageal Rupture (Boerhaave Syndrome)
       3. Peptic Ulcer Disease
    6. Lung Injury (forced Vomiting)
       1. Pneumothorax
       2. Pneumomediastinum
    7. Stimulant Laxative related injury (risk of severe Constipation)
       1. Mesenteric Nerve Plexus injury
       2. Cathartic Colon Syndrome
    8. Mental Health Comorbidities
       1. See Associated Conditions above
18. Prognosis
    1. Disordered eating persists >20 years after diagnosis in one third of patients
       1. Early intervention is key to preventing prolonged course and complications
    2. Anorexia or Bulimia
       1. Eating Disorders are among the deadliest psychiatric illnesses
       2. Age adjusted mortality due to complications and Suicidality: 2-6 fold over peers
       3. Suicide completion rates 18 fold higher than peers
19. Resources
    1. Academy for Eating Disorders
       1. http://www.aedweb.org/web/index.php
    2. National Eating Disorders Association
       1. http://www.nationaleatingdisorders.org/
    3. National Asssociation of Anorexia Nervosa and Related Disorders
       1. http://www.anad.org/
    4. National Institute of Mental health (NIMH) - Eating Disorders
       1. https://www.nimh.nih.gov/health/publications/eating-disorders-new-trifold/index.shtml
    5. American Psychiatric Association - Eating Disorders
       1. http://www.psychiatry.org/eating-disorders
    6. American Psychological Association - Eating Disorders
       1. http://apa.org/topics/eating/index.aspx
    7. Families Empowered and Supporting Treatment of Eating Disorders
       1. http://members.feast-ed.org/
20. References
    1. Renbarger and Pearson (2021) Crit Dec Emerg Med 35(8): 17-23
    2. Klein (2021) Am Fam Physician 103(1): 22-32 [PubMed]
    3. Trent (2013) Am J Emerg Med 31:859-65 [PubMed]