Eating Disorders in Teens

1. Eating Disorders in Teens Maj Anisha Abraham, MD, MPH

2. Objectives • To identify the risk factors for eating disorders • To perform an evaluation of the physical, emotional and nutritional status of a teen • To establish the diagnosis of anorexia or bulimia • To manage a patient with an eating disorder using a multi-disciplinary team

3. The Drive for Thinness • 63% of women feel that body weight determines how they feel • Americans spend 33 billion dollars on dieting and diet-related products • The average female starts dieting at age 9yrs

4. The Drive for Thinness • Started when Twiggy replaced Marilyn Monroe in the 60’s • The average woman is 5’4 and 140 lbs • The average model is 5”11 and 117 lbs

5. Scope of the Problem • The incidence of eating disorders has increased five times since 1955 • More than 1/2 of high school girls have dieted • Anorexia is the third most common chronic disease in teens

6. Scope of the Problem • 10-50% of teens engage in binge eating or vomiting • 1-5% have bulimia .5-1% develop anorexia • 1 in 5 females 19-25yrs have an eating dx

7. Culture and Eating Disorders • One anthropological study found: • when women are more financially dependent and marital ties are paramount, the standard is to be curvaceous • When independence for women is possible, the standard for female attractiveness is towards thinness

8. Culture and Eating Disorders • There is an increase in eating disorders among Black, Hispanic and Asians • Linked to the pressure to integrate and be a ‘smart,beautiful and thin career woman” • In Argentina, China, and Japan similar pressures have developed

9. Eating Disorders in the Military Study by Mayo researchers at Madigan Army Medical Center: 8% of active duty women were reported to have eating dxs compared to 1-3% in general population Study conducted among active duty males in the Navy: 2.5% of male doctors were anorexic and 11% were bulimic (Mcnulty, 1994)

10. Eating Disorders in the Military • Anorexia-1.3%(Army), 1.1%(Navy), and 0.8%(AF) • Bulimia-4.3%(Army), 5.2%(Navy), 9.3% (AF) • Diet pill usage in the Army-8.6%(year-round) • Increased by 3.9% at PT time • Vomiting,laxative use and diurectic use showed similar patterns

11. Ethnic and socioeconomic status Cultural influence Low self-esteem/perfectionistic Difficulties with communication, separation and conflict resolution w/ family Anxiety or depressive disorder Family history A drive to excel in sports Early puberty Winter season Sexual Abuse Risk Factors for Eating Disorders

12. Case1-Eating Disorders • Ellen is a 14 yo Caucasian female w/ a 6 mo hx of wt loss who is referred to you by her primary care provider. Her last visit to the physician’s office was over 6 mo’s ago for a camp physical at which time she was doing well. • Her wt was 53kgs and her ht was 160cm. Her mother brought her into the doctor’s last month because she was losing weight and becoming isolated and withdrawn. The primary care provider was surprised at her appearance.

13. Case1-Eating Disorders • She appeared cachetic and pale. Her wt was 40kgs and her height was 160 cm. He followed her over the next four weeks and she continued to lose weight. The family physician did a preliminary work up and refers her to you.

14. Case1-Eating Disorders • Ellen was angry about having to come into the hospital for an evaluation as she did not feel that anything was wrong with her. The patient tells you that she was in good health till 6 mo’s ago when following a move with her family to a different city, she voluntarily restricted her intake and began a regular strenuous exercise program.

15. Case1-Eating Disorders • Her mother was concerned because she was no longer eating breakfast and only eating a small salad and a cup of tea for dinner. As she lost increasing amounts of weight, her appetite diminished and she found it easier to diet. She seems neither surprised nor concerned when she is told that has lost over 25% of her body weight.

16. Case1-Eating Disorders • What further information do you need to help understand Ellen’s problem? • What further evaluation would help you to make the diagnosis? • How will you manage Ellen?

17. The Interview • Perception of illness • History of Illness • Weight and height • Body image • Means of weight control

18. The Interview • Menstrual Function • Past Medical History • Family History • Psychosocial History

19. Differential Diagnosis Depression,OCD • CNS tumors • Endocrinologic disorders-IDDM, Hyperthyroidism, Addison’s • GI disorders-IBD,malabsorption • Chronic infections,SLE,Malignancy

20. Diagnostic Criteria-Anorexia • Refusal or inability to maintain body weight over a minimum normal weight • Intense fear of gaining weight despite being underweight • Disturbance in perception of body shape • Absence of three consecutive menstrual cycles

21. Diagnostic Criteria-Bulimia • Minimum of 2 binge-eating episodes weekly for 3 months/recurrent binge eating • A feeling of lack of control over binge-eating behavior • Regular use of self-induced vomiting, laxatives,diuretics,strict dieting,fasting,or vigorous exercise to prevent weight gain • Disturbance of body shape perception

22. Diagnostic Criteria-Eating Disorder Not Otherwise Specified • All of the criteria for Anorexia Nervosa are met except the individual has regular menses or weight is in the normal range. • All of the criteria for Bulimia Nervosa are met except binges less than twice a week or less than 3 months. 3. Binge eating disorder- recurrent episodes of binge eating in the absence of the regular use of purging,etc

23. Physical examination • Vital signs • Weight and height percentiles, BMI and weight percentile for ht • HEENT-dental erosion,parotid swelling • Thyroid • Cardiovascular-poor cap refill,bradycardia • Breasts-loss of fat

24. Physical examination • Genitourinary-tanner stage • Abdominal-organomegaly • Skin-color,loss of fat,edema,lanugo,bruises on mcp joint • Mental state-apathy, depression, anxiety,obsessive-compulsive

25. Laboratory evaluation • CBC • Urine dip • Electrolytes,BUN,creatine, Ca,Mg,Phos • T4 and TSH,serum protein and albumin • EKG • ?Stool for occult blood, ESR • ?FSH,LH,Prolactin

26. Management-Mild Stage • Set goal weight-usually BMI>18 • Refer to nutritionist • Aim for wt gain of .5-1 kg weekly • Check weights with gown,pt facing away from scale and empty bladder. • Check hr,temp,and urine PH. If ph>7=metabolic alkalosis • Consider calcium and iron supplementation • Reevaluate regularly

27. Question whether there is one ideal body shape Cultivate the ability to appreciate uniqueness Take care of your body Surround yourself with people who feel good about their body Learn to respect internal cues Value body movement and competence Cultivate role models with appearances that are not the ideal Bond with friends on issues other than dieting Ways to Develop a Good Body Image

28. Management-Moderate Stage • Set goal weight • Refer to psychology/ psychiatry and nutrition • Provide structure to daily activities and meals. • Consider restriction of excercise • Increase calories by 200 every 2-3 days • Follow up frequently • Stress medical markers of starvation, consequence of failure to gain wt to patient

29. Indications for Hospitalization • Electrolyte abnormalities • hypokalemia,hypophosphatemia • Physiologic decompensation • Temp <36 degrees • Pulse < 45 • Altered mental status • Acute medical complications • arrhythmias,syncope,seizures

30. Indications for Hospitalization • Inability to break cycle as outpatient (>3-6mo’s) • Acute psychiatric emergency- ie.suicidal • Rapid or excessive weight loss • >10% in 2mos’s • weight <75% for IBW

31. Medical Therapy • Bulimia • Fluoxetine is the only drug which is approved-60mg/day. Use w/ CBT • Anorexia- • TCA’s may improve wt gain/has side effects • SSRI’s showed no change vs placebo on hospitalized AN patients Did improve weight for outpt wt recovered patients

32. Medical Concerns in Eating Disorders • Cardiac-,bradycardia, arrythmias • Pulmonary-pneumomediastinum • GI-Delayed emptying, constipation,SMA syndrome,Mallory-Weiss tear,dental erosion • Metabolic-Osteoporosis (consider OCP’s, bone density), increased cholesterol, low bg, hypercarotenemia

33. Medical Concerns in Eating Disorders • Hematologic-Leukopenia, anemia, thrombocytopenia, decreased ESR, low wbc’s • Dermatologic-Lanugo,dry skin,brittle nails,acrocynanosis • Other-ammenorhea-need 90% of IBW to reestablish menses

34. Prognosis • Associated with length of illness • Worsening occurs in 15-25% of patients • Mortality is 5% for anorexia • Poorer prognosis for bulimia with hx of sexual abuse,coexistent personality disorder or depression,substance abuse

35. Summary • Eating disorders are common in teens • Screen for eating disorder risk factors • Check physical exam for evidence of abnormalities,consider routine labs • Rule out organic disease, use criteria to diagnose anorexia/bulimia • Use a team approach in treating eating disorders!

36. QUESTIONS?