Eating Disorders in Adolescents

1. Eating Disorders in Adolescents Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College

2. Anorexia Nervosa (DSM-IV) • Body weight less than 85% of expected • Intense fear of gaining weight even though underweight • Disturbance in body image • In post-menarchal females absence of at least three consecutive menstrual cycles • Two types are defined: • Restricting type • Binge-eating or purging type

3. Bulimia Nervosa (DSM-IV) • Recurrent episodes of binge eating • A sense of lack of control over eating during these episodes • A regular cycle of self-induced vomiting, laxatives, diuretics, exercise or dieting • Two binge-eating episodes per week for at least three months • Two types identified: • Purging type • Non-purging type

4. Epidemiology • Anorexia Nervosa • Incidence1/100,000worldwide, in white females in western countries 1/200 • Incidence in adolescent females 0.5-1% • Female predominance of 9-10:1 • Becoming more diverse • Mean age 13.75 (range 10-25 yrs)

5. Epidemiology • Bulimia Nervosa • Prevalence 1-3% in young females • Prevalence of 3-10% in college aged females • 90-95% female • Onset is usually during late adolescence, age range of 13-58 years

7. Family Risk Factors • Achievement oriented • Intrusive, enmeshed, overprotective, rigid • Unable to resolve conflicts • Frugal with support or encouragement • Maternal preoccupation with diet, weight and appearance • Positive family history of Eating Disorder

8. Individual Risk Factors • Perfectionist- “good little girls” • Feeling of low self-esteem • Obsessional style • Early puberty • Overweight • History of sexual abuse • Athletes

9. Eating Behaviors • 40-60% girls in high school have dieted • 18% reported fasting >24 hrs to control weight • 30-40% of Jr. high school girls were concerned with wt. • 42% of college women diet, 10% purge, 7% use diet pills • 80% of girls in LI HS reported they would be happier at a lower weight

10. Comorbidity • Major depression and dysthymia in 50-75% AN/BN • Bipolar 4-13% of AN/BN • OCD in 25% of AN • Substance abuse 30% of BN, 15% of AN • Personality disorders 42-75% of AN/BN • Sexual abuse 20-50% of BN • Anxiety disorders high in AN/BN

11. History –Eating Disorder Symptoms • Pinpoint exact time • Reinforcement of behavior • Food faddism, rituals and para-eating behaviors • Family characteristics • School behavior • Peer contacts • Lack of concern • Food as a battleground

12. History • Parental concern or patient concern? • Weight loss- highest wt, lowest wt, patients personal goal wt. • Menstrual history • Exercise • Binging, purging, laxatives, diet pills or diuretics • Body image • Family conflicts over food • 24 hour food recall

13. History • HEADS assessment • Home • Education • Activity • Drugs/Depression • Suicide/Sexual Activity • ROS- dizziness, syncope, cold intolerance, constipation and abd pain, dry skin and hair, fatigue

14. Physical Exam- Vital Signs • Bradycardia • Hypothermia • Orthostatic hypotension- HR inc. 20, BP dec. 20 • Weight and height

15. Physical Exam • General-cachectic, depressed, dehydrated • HEENT- dental enamel erosion, parotid hypertrophy • Breasts- atrophic • Abdomen- scaphoid, palpable stool • Extremities- acrocyanosis, Russell’s sign, peripheral edema • Skin- lanugo hair, yellow skin discoloration, bruising

16. Laboratory Evaluation • CBC- leukopenia, anemia, thrombocytopenia • ESR- low • UA- specific gravity, ketones • Chemistries- hypokalemia, hyponatremia, BUN high, low Ca, Mg, Phos, LFT’s and chol high, carotene elevated • TFT’s- TSH nl, T4 low or nl, T3 low • Hormones- estradiol low in females, testosterone low in males, prolactin nl, LH and FSH low or low nl

17. Complications • Cardiac • EKG- bradycardia, low voltage, t wave changes, prolonged QTc • Echocardiography- decreased cardiac size, reduced myocardial contractibility, increased prevalence of MVP, Ipecac CM, pericardial effusion

18. Complications • Gastrointestinal • Delayed gastric emptying- abdominal bloating/pain • Hypomotility- constipation • Fatty infiltration of the liver • Superior mesenteric artery syndrome • Esophagitis • Mallory-Weiss tear

19. Complications • Neurologic • Poor attention and concentration • Poor problem solving skills • Cerebral atrophy • Cerebral ventricular enlargement • Atrophy correlates with degree of malnutrition and is reversible with weight gain

20. Complications • Osteoporosis • Related to amenorrhea and hypoestrogenism • Can lead to increased fracture risk • DEXA (Dual Energy X-ray Absorptometry) if amenorrheic >6months • Exercise not protective • Adequate Ca intake necessary • NOT completely reversible even with weight gain and resumption of menses

21. Treatment • Multidisciplinary approach • Physician • Psychiatrist • Therapist- individual, group, family • Nutritionist • Family involvement a must!!!!

22. Out-Patient Management • Multidisciplinary approach • Weekly visits- UA, Wt in gown, Food records • No exercise until Wt gain • Behavioral contract can be used • Medications-SSRI’s • Weight gain- expect about 1-2lbs per week until goal weight-90% of IBW-resumption of menses • Parents and family need to avoid food conflicts • Bulimia- focus on binging not purging

23. Indications for Admission • Weight <75% of IBW • Dehydration or Electrolyte disturbances • EKG abnormalities • HR<40, SBP<70, T<35C, Orthostatic • Failure of outpatient management • Acute food refusal • Uncontrollable binging and purging • Medical/ Psychiatric emergencies

24. In-Patient Management • Multidisciplinary approach • Daily weights after voiding and in hospital gown • Behavioral Modification Protocol: Privileges- phone, TV, visitors • Start at 1400 Kcal and increase calories slowly, 200Kcal/day • Follow electrolytes carefully for the first week • If food refusal use supplements or NGT • Day treatment program as a transition

25. The Refeeding Syndrome • Starved state- catabolic breakdown of fat and muscle- Inc. nutrients in blood • Refeeding- Carbohydrates inc Insulin leading to anabolic protein synthesis and inc uptake of glucose, phosphorous, and water into cells • Combo of TBD of phosphorous during catabolic phase and intracellular influx during anabolic phase leads to severe extracellular phosphorous depletion

26. Refeeding • Severe phosphorous depletion leads to decrease in ATP production • Leads to muscle problems- cardiac, hepatic, neuromuscular, respiratory • Most lethal- altered myocardial function/arrhythmia

27. Recommendations to Avoid the Refeeding Syndrome • Be aware of the syndrome • Recognize the patient at risk • Cardiac monitoring during refeeding • Increase caloric delivery slowly • Administer multivitamins routinely and neutrophos if phosphorous drops <3.0 • Carefully monitor electrolytes daily for the first week and then biweekly

28. Prognosis • 50% good outcome, 25% intermediate outcome, 25% poor outcome • Mortality less than 4% • Of those that recover- 1/3 recover over 3yrs, 1/3 by 6yrs, 1/3 by 12yrs • Adolescents better prognosis than adults

29. Prognosis • Poor prognosis • Early Onset • Longer duration of illness • Lower weight • Failed previous treatment • Personality disorder/ depression • Difficult family relationships • Social Isolation