Update on the Medical Management of Eating Disorders

1. Dr. Richard L. Levine Professor of Pediatrics and Psychiatry Chief, Division of Adolescent Medicine and Eating Disorders Penn State Hershey Children’s Hospital Update on the Medical Management of Eating Disorders

2. Case Example • K is a 22 y.o. female college student, track star at a local university. • Asked to leave track team this semester because of malnutrition, referred to student health center for evaluation. • Transferred to HMC for severe malnutrition and medical instability. • Evaluated and admitted to MIMC.

3. Case Example • History of severe restriction of food intake and more than 50 lbs.weight loss over 6-9 months. Seen by Internist during summer and cleared for return to school. Asked to “eat better.” • Significant exercise with running, even the day of admission. • No vomiting or laxative use, but history of diet pill use. • Amenorrhea, and fatigue.

4. Case Example • On examination: Ht. 5’11’’, Wt. 109 lbs. • Vital Signs: pulse 32 bpm, BP 88/56. • Laboratories demonstrated hyponatremia, hypokalemia, hypophosphatemia, abnormal LFT and abnormal renal function tests. • Abnormal EKG with heart block and prolonged QTc. • Abnormal echo with dilated RV, LV, low systolic function, MVP and mitral regurgitation.

5. Case Example • Patient did well in MIMC. • Treated with IV fluids, electrolyte replacement including phosphate replacement. • Nutrition slowly improved. However- found exercising in bed- which was discouraged. • Transferred to medical floor bed and then to inpatient eating disorder facility close to family’s home.

6. Diagnostic Criteria • Established in DSM IV • Useful in setting the diagnostic standard • But should not be applied too strictly in determining who is to be treated, especially in adolescents

7. Diagnostic Criteria • Anorexia Nervosa • Refusal to maintain a normal weight for height, leading to a weight which is less than 85% expected • This may include weight loss or failure to make expected weight gains during a period of growth

8. Diagnostic Criteria • Anorexia Nervosa • An intense fear of gaining weight or becoming fat • A disturbance in the perception of body weight or shape • In post-menarchal females- the presence of secondary amenorrhea for three consecutive menstrual cycles

9. Diagnostic Criteria • Anorexia Nervosa • Two subtypes described: Restricting and Binge eating/Purging • Many adolescents with eating disorders do not fulfill all of these criteria • One should not deny treatment to these “sub-clinical” patients

10. Case 2-Bulimia Nervosa • A.M. was a 16 year old female seen on the GI inpatient service with a history of chronic intractable vomiting. Negative w/u. Symptoms did not improve after cholocystectomy. • Eventually admitted to bulimic symptoms • History of sexual activity without contraception • Positive testing for chlamydia and herpes • History of substance use,depression and cutting behavior

11. Diagnostic Criteria • Bulimia Nervosa • Recurrent episodes of binge eating followed by some recurrent inappropriate compensatory behavior • Binges characterized by eating a very large amount of food over a short period of time and feeling a lack of control over eating

12. Diagnostic Criteria • Bulimia Nervosa • The compensatory behavior can include self-induced vomiting, laxatives, enemas, diuretics or compulsive exercise • This behavior must occur on average twice a week for three months • Also demonstrate over-concern with weight and body shape

13. Diagnostic Criteria • Bulimia Nervosa • Two subtypes described:Purging and Non-purging who use fasting and exercise as the compensatory behavior • Also category of Eating Disorder-Not Otherwise Specified

14. Diagnostic Criteria • Significant controversies regarding the diagnostic criteria and possible modifications for DSM V. • Cutoff weight for AN • Amenorrhea for AN • BED • Role of EDNOS • ED in children

15. Epidemiology • Incidence increased 2-5x in past 30 years • Prevalence of AN is about 1/120 adolescent females • Female to male ratio is 10-1 • AN demonstrates a bimodal age range with peaks at 14,18 • Bulimia nervosa has prevalence of 1-5% • Increased in older teens • Female to male ratio of 5-1 to 20-1 • Must consider Dx of AN, BN in males • All social, economic, cultural classes

16. Epidemiology • Statistics underestimate prevalence of disturbed body image and eating behavior in teens • 50%-67% of adolescent females are dissatisfied with wt, body shape • Majority of female teens have dieted • Many use unhealthy wt control methods such as fasting, diet pills and vomiting • Studies correlate abnormal eating attitudes and behavior with other risk-taking behavior

17. Etiology • Etiology is multifactorial • Biological vulnerability and genetic role • Psychological factors • Cultural influences

18. Etiology • Neuroendocrine dysfunction • Serotonin dysregulation • According to family studies the risk of AN or BN is 7- 20 times more common among a female relative of a patient with an ED than the general population. • Most likely not related, however, to one particular gene or chromosome but rather a “multi- hit” process.

19. Etiology • Psychological factors • Individual problems and family dynamics • Patients with AN demonstrate low self esteem and pervasive sense of ineffectiveness • Depressed, anxious, obsessive, perfectionistic. • BN- problems with impulse control

20. Etiology • Cultural Influences are important • Emphasis on thinness in society • Exacerbated by media • Increase in nutrition and fitness articles • Female body shape of models • Role of excessive exercise • Females in gymnastics and ballet • Males in wrestling

21. Differential Diagnosis • Diagnosis usually self-evident • Must consider other conditions • Eating Disorders can present in patients with another chronic disease • Endocrine • Gastroenterlogical • Neurological • Malignancies • Chronic Infection • Connective Tissue Diseases • Other Psychological Conditions

22. Evaluation • Screen yearly • Assess with complete H/P • Assess eating behavior, weight history, body image, bingeing/purging, exercise, etc. • Complete PE with vital signs, accurate ht. and wt. • Examine looking for physical sequelae of disease and other diagnoses. • Limited laboratory evaluation.

23. In the office • “Red Flags” on Physical Exam • Bradycardia • Hypotension • BMI • Hypothermia • Parotid enlargement • Enamel Erosion • Acrocyanosis • Russel’s sign- abrasions of knuckles of the hand

24. Medical Complications • Serious medical conditions that require early and aggressive treatment • Affect every organ of the body • Some are reversible, but concerns about long-term, irreversible complications • 4% mortality associated with anorexia • Causes of death include suicide, severe electrolyte disturbances, and arrhythmias

25. Metabolism • Patients with Anorexia have an abnormal metabolism with reduced energy expenditures- demonstrated by indirect calorimetry. • Fat and lean body mass are reduced and extra cellular water volume is expanded. • Physiological adaptation to severe malnutrition. • Concept of “Autocannibalization.”

26. Case - Fluids and Electrolytes • CH is 18 year old female with Anorexia Nervosa with purging features. • Long history of eating disorder behavior with restricting and purging via vomiting. • Presents to the emergency room with syncope. • Ht. 65”, Wt. 76 lbs., BP- 93/65, P-60 • Labs included Na 132, CL 84, K 1.4, CO2 36

27. Fluids and Electrolytes • Patients with Bulimia or Anorexia with purging features can present with significant abnormalities in fluids and electrolytes. • With vomiting this takes the form of a hypokalemic, hypochloremic metabolic alkalosis.

28. Fluids and Electrolytes • Patients with laxative abuse develop metabolic acidosis due to bicarbonate losses in the stool. • Patients with anorexia can present with dehydration if fluid restricting. • Patients can also demonstrate symptomatic hypoglycemia.

29. Case One - GI Complications • J is a 19 year old female presenting with a restricting/bingeing/purging cycle. Diagnosis- Bulimia Nervosa. • History of depression, self-mutilation treated with medication. History of substance abuse including “huffing”. • History of abdominal pain, hematemesis, involuntary vomiting.

30. Case One -GI Complications • On PE- Ht. 5’4’’, Wt. 139 lbs., epigastic tenderness • Endoscopy revealed esophagitis. • Patient treated with PPI, sucralfate, and metoclopramide. • Poor compliance with medications- symptoms persist at the present time. • Currently in ED-PHP

31. Case Two-GI Complications • MM is 16 year old female who presented with restricting and weight loss, and amemorrhea. Significant family problems. • On PE- Ht. 5’9’, wt. 94.5 lbs.- emaciated appearance. • Started to eat with treatment but began bingeing. Developed abdominal pain and constipation with laxative abuse.

32. Case Two- GI Complications • Gained a large amount of weight quickly- now up to 150 lbs. • Abdominal pain increased. Saw local GI specialist. Had normal barium enema. • Required colace, lactulose, mineral oil for bowel movements. • Condition has currently stabilized but continues to over eat

33. Gastrointestinal Complications • Depend on the nature of the eating disorder. • With Anorexia Nervosa- complications of decreased gastric and small intestinal motility • Early satiety • Gastroparesis • Chronic constipation

34. Gastrointestinal Complications • With Bulimia Nervosa- complications from the purging behavior. • Can develop chronic constipation from laxative abuse. • Cathartic colon syndrome

35. Gastrointestinal Complications • With Bulimia Nervosa significant complications from chronic vomiting • Complications include involuntary regurgitation from weakening of the gastroesophageal sphincter. • Peptic ulcer disease, gastroesophageal reflux with resulting esophagitis, Mallory-Weiss esophageal tears and even esophageal rupture. • Dental caries and loss of enamel- lingual surfaces

36. Gastrointestinal Complications • Medications options- Proton pump inhibitors, Histamine Blockers • Prokinetic agents such as metoclopramide. • Polyethylene Glycol for chronic constipation.

37. Case One- Cardiac Complications • J is a 12 year old female with a history of weight loss for several months. • Ht. 64” and wt. 72 lbs. Her pulse rate was 38 bpm in clinic (18 bpm on the ward) and BP was 74/40 with orthostatic changes. • Her EKG demonstrated borderline QTc abnormality. • Echocardiogram demonstrated a pericardial effusion.

38. Case Two- Cardiac Complications • E is a 18 year old female also with at history of significant weight loss and eating disorder symptoms for 2 years. • History of food restriction and purging. • Ht. 65”and Wt. 83 lbs. • Echocardiogram revealed abnormal thinning of anterior and lateral left ventricular walls.

39. Cardiac Complications • Patients with Anorexia demonstrate significant bradycardia and hypotension. • Demonstrate EKG abnormalities and arrhythmias. • Right axis deviations, ST-T wave abnormalities, concerns regarding prolonged QT interval.

40. Cardiac Complications • Changes in myocardial function have been shown including decrease in myocardial tissue mass. • Risk of CHF with too rapid hydration and refeeding.

41. Case Three- Cardiac Complications • KK is a 16 year old female admitted for muscle weakness and dyspnea. • Significant muscle weakness on exam. • QTc abnormality on EKG. • Dilated left ventricle and poor cardiac contractility on echocardiogram

42. Cardiac Complications • Admitted to daily purging with self-induced vomiting via ipecac use for several months. • Significant risk of cardiac damage from abuse of Ipecac. Contains toxic alkaloid- emetine. • Rate of excretion is slow and ingestion of regular doses can accumulate. • Leads to a reversible myopathy. • Significant cardiac toxicity including arrhythmias and cardiomyopathy.

43. Cardiac Complications • Significant risk from OTC diet pill use and abuse. • Most compounds contain stimulants- ephedra-like compounds • Herbal stimulants • These drugs can cause cardiac arrhythmias, cardiac ischemia, myocardial infarctions and strokes.

44. Neurological Complications • Alterations in neurotransmitter levels including serotonin and others. • Significant role in the etiology and persistence of the condition. • Associated with psychiatric co-morbidities. • Neuropsychiatric abnormalities include impaired attention, concentration, learning and behavior.- Could be associated with resistance seen in treatment

45. Neurological Complications • In severe Anorexia, CT scans have demonstrated cortical atrophy and ventricular dilatation. • These changes have been shown to reversible on CT with refeeding and improved nutrition. • However, abnormalities have been shown to persist on MRI scans even after treatment and weight recovery.

46. Neurological Complications • The most recent study is by Wagner et al in Biological Psychiatry in 2006. • This study looked at MRI scans in 40 recovered patients with AN, AN B/P and BN. • Average length of recovery ranged from 29.8-39.5 months

47. Case One- Endocrine Complications • A is a 24 year old female who presented at age 12 with malnutrition and lack of weight gain. +preoccupation with food and wt and distorted body image. • Ht 59.5” and wt. 76.2 lbs. • Patient diagnosed with AN and treated in outpatient program. She lost more wt. and required 3 inpatient hospitalizations. • Now recovered. Ht. 61” and wt. 120 lbs.

48. Case One- Endocrine Complications • Patient has not reached and will not reach her genetic potential for height. • Patient has had primary amenorrhea and demonstrates osteopenia on DEXA scan. • Patient has had 5 stress fractures associated with running.

49. Endocrine Complications • This case demonstrates several of the potential complications- short stature, amenorrhea, and the risk of osteoporosis.

50. Endocrine Complications • Risk of irreversible short stature in patients that develop AN and malnutrition during their adolescent growth spurt. • A recent study demonstrated that the longer the duration of illness at this time, the more disturbance in growth and increased risk of short stature.