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Medical Aspects of Eating Disorders Richard Kreipe, M.D. Professor of Pediatrics, Division of Adolescent Medicine, Golisano Children’s Hospital Medical Director, Eating Disorders Recovery Center of Western New York February 29, 2008

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Medical Aspects of Eating Disorders

Richard Kreipe, M.D.Professor of Pediatrics, Division of Adolescent Medicine,

Golisano Children’s HospitalMedical Director, Eating Disorders

Recovery Center of Western New York

February 29, 2008

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The role of the physicians on the eating disorder treatment team is

to

1. Identify the disorder.

2. Rule out other causes.

3. Monitor for consequences.

4. Treat the disorder .

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Identification of patients with eating disorders

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Determination of normal weight for height in adults

Predicted body weight method (PBW):• Predict body weight based on height.

• Divide actual weight by predicted weight

Example: PBW for 5'6" woman is 130 lb. If actual weight is 110 lb., then patient is 85% of predicted weight.

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Determination of normal weight for height in children and

adolescents

Growth chart• Height

• Weight

• Body mass index for age

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Age in years

Weight

Height

Growth chart: height and weight for age

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Age in years

body mass index= weight/height2

Growth chart: body mass index for age

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Symptoms of patients with anorexia nervosa

• Dizziness, weakness, fainting, fatigue

• Cold intolerance

• Hair loss

• Bloating, abdominal pain, heartburn, constipation,

diarrhea

• Lack of menstrual periods

• Bone pain from stress fractures in athletes

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Physical examination: anorexia nervosa

Appearance of malnutrition:• Thin, loss of subcutaneous tissue,

muscle wasting• Skin pale, poor circulation, dry• Hair dry, brittle, thinning• Lanugo: fine body hair as in newborns

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Physical examination: anorexia nervosa

(continued)

• Low blood pressure• Slow heart rate• Orthostatic “positional” changes in heart

rate and blood pressure• Low body temperature

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Symptoms of patients with bulimia nervosa

• Feeling faint or fainting• Depression and anxiety• Bloody vomiting (unusual) • Throat or upper abdominal pain• Fatigue, weakness, difficulty concentrating• Facial swelling around jaw

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Physical exam: bulimia nervosa

Signs of vomiting:• Enlargement of salivary glands• Throat irritation• Subconjunctival hemorrhages• Upper abdominal tenderness• Dental erosions

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Diagnosis

• Complete history and physical exam• Screening lab work: blood count,

chemistry panel, thyroid-stimulating hormone, urinalysis

• Targeted lab work: done based on findings

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Differential diagnosis of eating disorders

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Differentiation of eating disorders from other diseases

Gastrointestinal disease• Crohn’s disease, ulcerative colitis• Celiac disease

Endocrine disease• Diabetes mellitus• Hyperthyroidism

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Differentiation of eating disorders from other diseases (continued)

• Pulmonary diseases• Malignancy• Chronic infection• Central nervous system tumors

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Differentiation of eating disorders from other diseases (continued)

Psychiatric disorders• Depression• Obsessive compulsive disorder• General anxiety disorder • Panic disorder

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Monitoring for

consequences of

eating disorders

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Metabolic consequences of eating disorders

• Lowered basal metabolic rate—suppressed metabolism

• Increased catabolism—breakdown of tissue—muscle, brain, bone

70% of weight loss is lean tissue, 30% is fat

• Decreased anabolism—building of tissue

• Electrolyte abnormalities Potassium, sodium, phosphorous

• Hypercholesterolemia early and hypocholesterolemia late

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Endocrine system consequences of eating disorders

• Lack of menstrual periods, estrogen deficiency

• Irregular menstrual periods• Lowered testosterone levels • Elevated cortisol levels• Thyroid adaptation

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Bone consequences of eating disorders: osteoporosis

• Lack of normal bone density gains in adolescence and early adulthood

• Midlife osteoporosis if peak bone density is low

• Stress fractures• Suppressed bone formation related to hormonal

changes that affect calcium uptake into bone.

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Normal bone density growth

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Osteoporosis

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Gastrointestinal system consequences of eating disorders

• Reduced intestinal movement and delayed stomach emptying

• Gastroesophageal reflux• Gastric tears • Dental erosions• Elevated liver enzymes

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Cardiovascular consequences of eating disorders

• Decreased heart size

• Abnormal heart rhythms

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Hematologic consequences of eating disorders

Bone marrow depression • Anemia: low red blood cell count• Leukopenia: low white blood cell count• Thrombocytopenia: low platelet count

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Behavioral and psychological consequences of eating disorders

• Ancel Keys’ study of the effects of starvation on healthy young men showed that many psychological and behavioral symptoms of eating disorders were the result of the biology of starvation.

• Weight and caloric intake must be returned to normal in treatment process while psychological issues are also addressed.

• Binge eating is in part a physiologically based reaction to starvation.

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Treatment of patients

with

eating disorders

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Improve nutritional status

• A subnormal weight cannot be healthfully maintained.

• Malnutrition cannot be corrected without adequate intake of carbohydrates, proteins, fats, and total calories.

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Improve nutritional status (continued)

• Malnutrition can be seen in patients who are normal or overweight and have restrictive eating, bulimia, or binge eating disorder.

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Coordinating with the treatment team

Physician and medical staff have ongoing consultation with:

• Dietitian• Social worker/case manager (if separate from

psychotherapist or other team member)• Psychotherapist• Psychiatrist

Regular—weekly or biweekly—appointments until weight gain is well established or symptoms have decreased.

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Management: education

Educate on: • Effect of malnutrition on the body: metabolic,

gastrointestinal, psychological.• Normal body weight/acceptance of current body

weight.• Risks of purging behaviors.• Long-term risks of being underweight.• Use of “blind” weights, if applicable.

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Pharmacologic treatment

Psychotropic medications• SSRI medications decrease purging behaviors,

address co-morbid conditions such as depression or anxiety.

• SSRI medications are not effective for promoting weight gain in anorexia nervosa.

• SSRI, tricyclics, and anticonvulsant medications being tried with binge eating disorder.

Reference: Devlin, M. J. (2005) “Binge Eating Disorder 2005,” 15th Annual

Conference, Renfrew Center Foundation, Nov. 12.

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Pharmacologic treatment (continued)

No evidence of effectiveness:• Appetite stimulants for weight gain• Estrogen replacement

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Treatment plan

• Establish a relationship.• Address the patient’s and family’s concerns, even

if different from our own.• Set nutritional intake to support nutritionist’s

recommendations.• Monitor weight and medical status.• Set treatment plan for

expected rate of gain. weight or medical criteria for which hospitalization

may be required.

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Treatment: Adults

• Adults age 18 and over must agree to treatment.

• Health care for patients 18 and over is confidential. Signed release required for medical

provider to discuss specifics with family. Confidentiality does not include a situation

that is life-threatening.

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Management:Anorexia Nervosa

(continued)Osteoporosis:

• Weight gain.• Calcium 1,500 mg with Vitamin D 400 IU per day

or four servings of calcium-rich food per day.• Dexa scan if no menstrual period for six months to

one year or prolonged malnutrition.• Estrogen replacement does not treat osteoporosis

in young women.• Drugs like Fosamax used to increase bone density

are not currently used in women before or during childbearing years because the safety profile is not known.

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Treatment: Anorexia Nervosa

Refeeding syndrome—fluid and electrolyte abnormalities that occur when a patient who is malnourished suddenly eats large amounts:

• Occurs in patients less than 75% PBW.• Usually occurs in first few days of a high-calorie diet.• Prevent by starting with low caloric intake and increase

slowly. • Check electrolytes, especially phosphorous, frequently.

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Management: Bulimia Nervosa

• Monitor for electrolyte abnormalities.• Help patients stop laxative abuse.• Discuss dental care.• Discourage dieting in conjunction with

treatment team members: Eat three meals a day plus two snacks. Increase protein in diet.

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Indications for hospitalization in patients with eating disorders

• Less than 75% of predicted body weight.

• Inability to eat.• Changes in blood pressure, pulse, and

temperature indicative of seriously compromised circulation and organ perfusion.

• Cardiac arrhythmias.

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Indications for hospitalization in patients with eating disorders

(continued)• Serious serum electrolyte abnormalities:

potassium, phosphorous, sodium• Esophageal tears• Intractable vomiting• Failure to improve despite intensive

out-patient treatment• Psychiatric instability: Danger to self or

others, e.g., suicide risk

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“The road to success is always

under construction.”

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References

• Garner, D. M., and Garfinkel, P. E. (1997) Handbook of Treatment for Eating Disorders, 2nd ed. New York: Guilford Press.

• Kreipe, R. E., and Yussman, S. M. (2003) “The Role of the Primary Care Practitioner in the Treatment of Eating Disorders.” Adolescent Medicine 14(1).

• Levine, R. L. (2002) “Endocrine Aspects of Eating Disorders in Adolescents.” Adolescent Medicine 13(1).

• Mitchell, J. E. et al. (2001) “Combining Pharmacotherapy and Psychotherapy in Treatment of Patients with Eating Disorders.” Psychiatric Clinics of North America 24(2).