EATING DISORDERS: CLASSIFICATION, DIAGNOSIS, CLINICAL FEATURES, AETIOLOGY, COMPLICATIONS & TREATMENT

1. EATING DISORDERS:CLASSIFICATION, DIAGNOSIS, CLINICAL FEATURES, AETIOLOGY, COMPLICATIONS & TREATMENT Melanie Harris (RD) Julia Lovely & Associates 1 Green Point Mews 99 Main Road Green Point Tel/ fax: (o21) 439 5899 Email: eatwellwithmel@gmail.com

2. CLASSIFICATION • Anorexia nervosa • Starve/ undereat, underweight • Bulimia nervosa • Binge and purge (vomit; laxative/ diuretic abuse/ excessive exercise); also starve, binge and purge • Binge eating disorder (BED) • Overeat/ binge; no purge • Almost all are obese • Eating disorders not otherwise specified (NOS) • “Normal weight AN” • Features of both AN and BN but not enough to make a diagnosis • Orthorexia (obsessed with being very healthy) • Biggorexia/ Adonis complex/ muscle dysmorphia (obsessed with body supposedly not being lean or muscular enough)

3. DIAGNOSIS • Excessive concern with the control of body weight and shape along with an inadequate and unhealthy pattern of eating are central manifestations • To be made by a clinical psychologist or psychiatrist NOT a dietician! • Main tools used for diagnosis include: • DSM-IV criteria • ICD-10 criteria • Lask and Bryant-Waugh criteria

4. DIAGNOSIS Diagnostic CriteriaforAnorexia Nervosain DSM-IV, ICD-10 & Lask and Bryant-Waugh

5. DIAGNOSIS Diagnostic CriteriaforBulimia Nervosain DSM-IV and ICD-10

6. DIAGNOSIS The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific eating disorder. Examples include: For females, all the criteria for AN are met except that the individual has regular menses. All the criteria for AN are met except that, despite significant wt loss, the individual’s current wt is in the normal range. All the criteria for BN are met except that, the binge eating and inappropriate compensatory mechanisms occur at frequency of less than twice a week or for a duration of less than 3 months. The regular use of inappropriate compensatory behaviour by an individual of normal body wt after eating small amounts of food (e.g. self-induced vomiting after the consumption of 2 biscuits). Repeatedly chewing and spitting out, but not swallowing, large amounts of food. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of BN. Diagnostic Criteriafor Eating Disorder Not Otherwise Specified in DSM-IV

7. AETIOLOGY • PREDISPOSING FACTORS - already present in individual/ their environment – do not trigger ED • PRECIPITATING FACTORS – “triggering” factors…the final straw • PERPETUATING FACTORS – allow ED to continue

8. AETIOLOGY GENETICS PREDISPOSING FACTORS BIOLOGICAL FACTORS SOCIOCULTURAL FACTORS Trauma Stress PRECIPITATING FACTORS Life transition Vulnerability toED Lifechange Family problems/ tension Ongoingstress PERPETUATING FACTORS Ongoing trauma/ abuse Ongoing family tension EATING DISORDER

9. AETIOLOGY I feel bad about myself I can’t believe it; I’ve put on 3kg I’d feel better if I was thinner I’ll go on a diet Binge I’ve lost 3kg; I’m feeling hungry but really good I’ve ruined it now, what the hell! I’m getting fed up because I’m not losing much weight and now I can’t stop thinking about food One piece of cake won’t hurt It’s her birthday, everybody’s happy but me The Vicious Cycle of Dieting Perpetuating Bingeing – The Binge/ Starve Cycle (Trotter 1997)

10. CLINICAL FEATURES

11. COMPLICATIONS ANOREXIA • Neurological • Psuedo-atrophy of brain • Sleep disturbances • Neural damage • Neurotransmitter disturbances (CCK; serotonin – happy hormone in brain & gut) • Dermatological • Lanugo • Alopecia • Acrocyanosis • Xerosis • Brittle fingernails • Yellow-coloured skin (hypervitaminosis A/ hypercarotaemia) • Endocrine •  thyroxine level with normal TSH level •  production of ACTH leads to  production of stress hormone cortisol by adrenal cortex, resulting in release of protein from muscle (wasting) • production of FSH and LH; this leads to production of oestrogen & progesterone in females;  production of testosterone in males

12. COMPLICATIONS HYPOTHALAMUS Changes in the production of specific hormone-releasing factors PITUATARY Reduced production of TSH Increased production of ACTH Reduced production of FSH and LH THYROID GLAND Reduced production of thyroxine, resulting in slowed heart rate, low blood pressure, poor thermal response and cold extremities ADRENAL CORTEX Increased production of cortisol as a normal stress response, resulting in release of protein from muscle and muscle wasting GONADS Reduced production of oestrogen and progesterone in females, resulting in loss of ovulation and menstruation Reduced production of testosterone in males resulting in impotence Endocrine effects of starvation (Trotter 1997)

13. COMPLICATIONS ANOREXIA contd • Cardiovascular • Sinus bradycardia (as low as 30 bpm) • Hypotension •  in myocardium • NB cause of mortality – sudden death in AN • Heamatological • Anaemia; leucopaenia (impaired cell-mediated immune func) – however not more prone to infectious diseases; thrombocytopaenia • GIT •  concentration of serum liver enzymes and sometimes hepatomegaly •  serum cholesterol (inverse to weight) •  gastric emptying &  gut motility • Constipation • Renal • Dehydration & possible irreversible renal tubule damage • Partial diabetes insipidus may occur secondary to abnormal vasopressin release with  renal concentrating capacity • Renal calculi

14. COMPLICATIONS ANOREXIA contd • Skeletal •  oestrogen and  cortisol levels are largely implicated • If menstruation interrupted for a prolonged period of time, bone loss results. •  risk of fractures and osteoporosis • Refeeding syndrome • Syndrome characterised by +++ fluid & electrolyte shifts • Hypokalemia • Hyponatremia • Hypophosphatemia • Hypomagnesemia • Oedema • Also: hyperglycaemia, rebound hypoglycaemia, possible nausea and vomiting, possible diarrhoea, possible cardiopulmonary failure….. death

15. COMPLICATIONS BULIMIA • Neurological • Disturbances in serotonin levels • Blunting of postprandial CCK release – decreased satiety • Dermatological • Dry skin • Russell’s sign • Endocrine • Usually continue to menstruate; dysmenorrhea is common • Blunting of TSH and GH in response to thyroid-releasing hormone • Hyper-and hypoglycaemia • Cardiovascular • Idiopathic oedema may be present; often attributable to laxative/ diuretic abuse

16. COMPLICATIONS BULIMIA contd • GIT • Salivary gland hypertrophy (parotid gland) (“chipmonk cheeks”) • Occasionally pancreatitis • Oesophagitis & oesophageal perforation • Gastric dilatation – poses risk of gastric rupture • Loss of bowel control • Constipation • Steatorrhoea • Pulmonary • Aspiration pneumonia; recurrent chest infections • Dental • Erosion of dental enamel • Projection of fillings above the surface of the teeth

17. COMPLICATIONS BULIMIA contd • Electrolyte disturbances (Refeeding syndrome) • Due to vomiting and laxative abuse, as well as binge episodes • Metabolic alkalosis (elevated serum bicarbonate levels) due to dehydration • Hypokalaemia, hypochloraemia • Metabolic acidosis in laxative abusers (loss of bicarb-rich fluid in stool) • Seldom hyponatraemia, -calcaemia, -magnesemia, and hypophosphataemia. BINGE EATING DISORDER • Obesity • CVD (include: dyslipidaemia; HT) • Diabetes • Insulin resistance • Skeletal (knees)

18. TREATMENT ASSESSMENT • Full physical examination & appropriate medical investigations (FBC, iron studies, serum electrolytes) • Assess pts height & wt (dry wt & blind weighing) • If any of the following features are present, then inpatient treatment is indicated: • Wt < 70% of that expected Or BMI < 15 • Acute rapid wt loss (> 25 % premorbid wt < 6mo) • Marked dehydration • Electrolyte imbalance • Convulsions (10% ANs) • Ciculatory failure • Uncontrolled vomiting • GIT bleeding • Acute pancreatitis • Self-injurous behaviour/ self-mutilation • Severe depression, suicide risk • Lack of response to outpatient treatment • Intolerable family situation • Family & individual interviews covering social situation, medical conditions, personal situation, family dynamics, dietary history, and food frequency, food dislikes, scary foods, binge foods, smoking, drug use, amount of exercise, bingeing/ purging frequency • Assessment by a clinical psychologist AND a psychiatrist (medication?). Various psychometric tools are available (Eating Disorders Inventory)

19. TREATMENT NUTRITIONAL INTERVENTION • Goals of Nutrition Intervention • To normalise the relationship with food • To gain an understanding of nutrient needs for growth, development, tissue maintenance, wt control, appropriate body wt • To provide an increased/ adequate energy intake (macronutrient) to promote weight gain (initially 800-1200kcal/ d and gradually increased to achieve goal weight gain of 0.5 to 1 kg/ wk) OR weight stabilisation • Introduction of fear foods • Adequate vit & min intake (Ca, Mg, K, Zn, Fe, B-vits) • Avoidance of strategies to reduce energy intake & manage hunger (e.g. excessive caffeine intake, chewing gum, and modified food products) or promote energy expenditure (e.g. excessive exercise) • Formulation of Nutritional Plan • Nutrient requirements: • Energy • Protein • Vitamins • Minerals

20. TREATMENT Formulation of Nutritional Plan • Nutrient requirements: • Energy • Must observe energy intake with regard to wt gain • Can make use of REE and Harris-Benedict • Must be aware that refeeding in AN increases REE • Be aware of individual response • May be a period of abnormal energy requirements for wt gain and maintenance • Restrictors have greater energy requirements than BN’s • Protein • 1.2 - 1.5g/ kg IBW • Vitamins • B-complex • Vit D • Vit E • ? Vit A and B-carotene • ? Omega-3 FA’s • Minerals • Calcium • Zinc • Iron Ideally use low-dose multivit-mineral And not separate vits and mins

21. TREATMENT Implementation of Nutritional Care Plan This is done as PART of behaviour modification treatment team, NEVER in isolation by the dietitian • Outpatient Treatment • Aim to change food intake patterns, as well as food & weight related behaviour: regular meal times, food diaries, no good/ bad foods, introduce “scary” foods • Discourage or prevent home weighing • Normalise exercise habits/ patterns • Prioritise normal eating patterns over the wt, often need to de-focus from wt loss in BN • In AN, weight gain may be slow (however ideal is 0.5-1 kg/ wk) • Very high calories (> 3000-4000kcal) often required for wt maintenance of IBW • Need to be aware of possibility of hydration shifts in purgers – prepare the patient for water retention and bloating • Inpatient Treatment Nutritional concerns include: • Correcting fluid & electrolyte imbalances • Minimal, simple nutrition counselling – with low BMI’s and starvation states the individual’s capacity for psychological/ cognitive response is minimal. Even if BMI’s normal, patients are often depressed or preoccupied • Weighed 2x weekly with energy intake being increased every 4 days/ as necessary

22. TREATMENT • Inpatient Treatment contd Nutritional concerns include: • Weight gain of 0.5-1.5 kg/ wk • Caloric intakes to be increased at 200-500 kcals increments to achieve above wt gain goals • 3 meals (duration of 30mins) & 3 snacks (duration of 15mins) – if no compliance, then have consequences in form of having to catch up –meal supplement given e.g. Nutren Active and bed rest • 3 food exclusions allowed (genuine dislikes) • Meals initially planned by dietitian; patient takes over when appropriate • No toilet visits allowed within 1 hr after meal/ snack • Toilet visits supervised – no flushing • No strenuous physical exercise (only scheduled morning walks if medically stable) • Monitoring for refeeding syndrome: twice weekly FBC; monitor BP, pulse, fluid intake and output; slow calorie increase • Nutrition Education given 1-2x weekly. Following is covered: • Basic nutrition • Metabolism • Hydration • Set point theory • Key’s study • Hunger and satiety • Types of binges and binge avoidance techniques • Fad diets