Medical Medical ParametersParametersfor Healthfor Health
Or Or “What does the “What does the doctor do, anyway, doctor do, anyway, and why does she do and why does she do it that way?”it that way?”
Laura Koenigs, MDDirector, Adolescent MedicineBaystate Children’s Hospital
Springfield, MA
ObjectivesObjectives
Describe differential diagnoses Describe differential diagnoses of weight loss and vomitingof weight loss and vomiting
Describe techniques for Describe techniques for determining ideal body weightdetermining ideal body weight
Describe common medical Describe common medical complications of eating complications of eating disordersdisorders
Tasks for ProviderTasks for Provider
Establish diagnosisEstablish diagnosis Set parameters for normal Set parameters for normal
weightweight Set guidelines for activitySet guidelines for activity Clarify need for Clarify need for
hospitalizationhospitalization Organize a team Organize a team
Irreversible Medical Irreversible Medical ConsequencesConsequences
Growth retardationGrowth retardation Structural brain changesStructural brain changes Decreased peak bone Decreased peak bone
massmass Loss of dental enamelLoss of dental enamel
Establish Establish DiagnosisDiagnosis
HistoryHistory PhysicalPhysical Laboratory testsLaboratory tests ECGECG
Differential Differential DiagnosisDiagnosis
Endocrine diseasesEndocrine diseases Gastrointestinal diseasesGastrointestinal diseases Neurologic diseasesNeurologic diseases MalignanciesMalignancies Connective tissue diseasesConnective tissue diseases Chronic infectionChronic infection Other psychiatric illnessesOther psychiatric illnesses
Symptoms of Symptoms of StarvationStarvation
Cold all the timeCold all the time TiredTired Full easilyFull easily ConstipatedConstipated Sad/ IrritableSad/ Irritable Hair changesHair changes
Signs of StarvationSigns of Starvation
BradycardiaBradycardia HypotensionHypotension HypothermiaHypothermia Lanugo / BaldingLanugo / Balding Yellow discoloration – handsYellow discoloration – hands AcrocyanosisAcrocyanosis KetosisKetosis
Signs of VomitingSigns of Vomiting
OrthostasisOrthostasis Parotid SwellingParotid Swelling Subconjunctival Subconjunctival
hemorrhageshemorrhages Facial petechiaeFacial petechiae Tooth enamel erosionTooth enamel erosion Russell’s signRussell’s sign Extremity edemaExtremity edema
Medically Stable?Medically Stable?
Severe malnutrition (≤ 75% av.)Severe malnutrition (≤ 75% av.) Heart rate (<45)Heart rate (<45) Temperature (<96)Temperature (<96) Heart dysrthymiaHeart dysrthymia HypoglycemiaHypoglycemia Electrolyte or divalent Electrolyte or divalent
abnormalitiesabnormalities Orthostasis/ HypotensionOrthostasis/ Hypotension
Criteria for Criteria for AdmissionAdmission
Medical instabilityMedical instability Medical complications of Medical complications of
malnutritionmalnutrition Arrested growth/developmentArrested growth/development Uncontrolled binging / purgingUncontrolled binging / purging Acute psychiatric emergenciesAcute psychiatric emergencies Failure of outpatient treatmentFailure of outpatient treatment
Society Adol Med Position Paper J Adol Health 2003; 33:496-503
What Should a What Should a Person Weigh?Person Weigh?
Preadolescent: 11-14% body fatPreadolescent: 11-14% body fat
Adult woman’s body: 20-25% Adult woman’s body: 20-25% fatfat
Adult male’s body 8- 11% fatAdult male’s body 8- 11% fat
Determining WeightDetermining Weight
Adult woman (≥18 y/o)Adult woman (≥18 y/o)
100 lbs for first 5 feet100 lbs for first 5 feet
5 lbs per inch over 5 feet5 lbs per inch over 5 feet
Give/take 5-10%Give/take 5-10% Works best at normal Works best at normal
heightsheights
Height & Weight Table For WomenHeight (Feet, Inches)
Small Frame Medium Frame
Large Frame
4' 10" 102-111 109-121 118-131
4' 11" 103-113 111-123 120-134
5' 0" 104-115 113-126 122-137
5' 1" 106-118 115-129 125-140
5' 2" 108-121 118-132 128-143
5' 3" 111-124 121-135 131-147
5' 4" 114-127 124-138 134-151
5' 5" 117-130 127-141 137-155
5' 6" 120-133 130-144 140-159
5' 7" 123-136 133-147 143-163
5' 8" 126-139 136-150 146-167
5' 9" 129-142 139-153 149-170
5' 10" 132-145 142-156 152-173
5' 11" 135-148 145-159 155-176
6' 0" 138-151 148-162 158-179
ages 25-59. Weight in pounds (in indoor clothing weighing 3 lbs.; shoes with 1" heels)
Men 1" heels
Elbow Breadth
Women 1" heels
Elbow Breadth
5'2"-5'3" 21/2"-27/8"
4'10"-4'11"
21/4"-21/2"
5'4"-5'7" 25/8"-27/8"
5'0"-5'3" 21/4"-21/2"
5'8"-5'11" 23/4"-3" 5'4"-5'7" 23/8"-25/8"
6'0"-6'3" 23/4"-31/8"
5'8"-5'11" 23/8"-25/8"
6'4" 27/8"-31/4"
6'0" 21/2"-2"
Elbow Breadth for Frame Size
BMI ChartsBMI Charts
CDCCDC Weight divided by height Weight divided by height
squaredsquared Change with ageChange with age
– Adults NL: 18.5-24.9 kg/MAdults NL: 18.5-24.9 kg/M22
Elite athletes, strength Elite athletes, strength sports - 50sports - 50thth% BMI% BMI
Sample ChildSample Child
12 year old girl12 year old girl 4’10” tall 62 pounds4’10” tall 62 pounds BMI of 13 kg/MBMI of 13 kg/M22
Sample ChildSample Child
12 year old girl12 year old girl 4’10” tall, 62 pounds4’10” tall, 62 pounds BMI of 13 kg/MBMI of 13 kg/M22
Ideal BMI 16.5-20.2 kg/MIdeal BMI 16.5-20.2 kg/M22
79- 96 lbs., 87 lbs. 5079- 96 lbs., 87 lbs. 50thth % %
Sample ChildSample Child
12 year old girl12 year old girl 4’10” tall, 62 pounds4’10” tall, 62 pounds BMI of 13 kg/MBMI of 13 kg/M22
Ideal BMI 15.4-18.0 kg/MIdeal BMI 15.4-18.0 kg/M22
71-87 lbs., 87 lbs. 5071-87 lbs., 87 lbs. 50thth % %
Following PatientFollowing Patient
Make diagnosisMake diagnosis Established normal weight Established normal weight
rangerange Gather teamGather team Criteria for admissionCriteria for admission
Following PatientFollowing Patient
Orthostatic vital signsOrthostatic vital signs Same scaleSame scale Wearing only hospital gown Wearing only hospital gown Post voidPost void Check urine for specific Check urine for specific
gravitygravity Check oral temperature after Check oral temperature after
bathroombathroom
Weight Restoration Weight Restoration GoalsGoals
OutpatientOutpatient– ½ to 1 lb per week½ to 1 lb per week
InpatientInpatient– 2-3 lb per week2-3 lb per week
Caloric NeedsCaloric Needs
Basal Metabolic RateBasal Metabolic Rate– Going 24/7Going 24/7– Higher if more muscleHigher if more muscle
Normal activityNormal activity– Include growthInclude growth
ExerciseExercise
Basal Metabolic RateBasal Metabolic Rate
ChildChild– Higher than adult to include Higher than adult to include
growthgrowth AdultAdult
– 10 X weight in pounds10 X weight in pounds
BMRBMR
Goes down with starvationGoes down with starvation Goes down with Goes down with
Binge/PurgeBinge/Purge Goes up with temperature Goes up with temperature
extremesextremes Goes up with frequent Goes up with frequent
feedingsfeedings
Calorie NeedsCalorie Needs
25% of a person’s calories 25% of a person’s calories should be from fat.should be from fat.
50 - 60 grams of fat per 50 - 60 grams of fat per day = low fat diet.day = low fat diet.
Dietary GuidelinesDietary Guidelines
Not gaining weight?Not gaining weight?
Not eating enough or Not eating enough or Too much exerciseToo much exercise
Anorexia Nervosa & Anorexia Nervosa & AmenorrheaAmenorrhea
25% Precedes weight loss 25% Precedes weight loss 50% Occurs with weight loss50% Occurs with weight loss 25% Follows weight loss 25% Follows weight loss BMI < 19 kg/MBMI < 19 kg/M²² Exercise prior to menarche Exercise prior to menarche Low fat diet.Low fat diet.
Birth Control PillsBirth Control Pills
Osteopenia/Osteoporosis = Osteopenia/Osteoporosis = complication of eating complication of eating disorderdisorder
Birth Control pills have not Birth Control pills have not been shown to helpbeen shown to help
False sense of security False sense of security
ReviewReview
Diagnosis – r/o medical causes Diagnosis – r/o medical causes as well as fulfilling DSM-IVas well as fulfilling DSM-IV
Physician should give Physician should give parametersparameters– Medical stabilityMedical stability– Weight goalsWeight goals– Activity guidelinesActivity guidelines– Hospitalization guidelinesHospitalization guidelines