Eating Disorders
Joan R. Griffith, MD, MHA, MPH
Associate Professor
Department of Pediatrics
University of Toledo
Objectives
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Review eating disorders categories
Discuss salient research studies
Case Presentation
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15 yo female with history restricted food intake and
poor weight gain over past 6-9 months
Active in school, friends have noticed her decreased
food intake
Significant family dynamics
BMI 16
Introduction 1
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“Understanding the complexities of eating
disorders, such as influencing factors,
comorbid illness, medical and psychological
complications, and boundary issues, is
critical in the effective treatment of eating
disorders”
-- American Dietetic Association Position Statement, J Am Diet
Assoc.2006 Dec;106(12):2073-2082
Introduction 2
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News media’s role in shaping public perception of
eating disorders
-- Simplifies and sensationalizes versus view as
complex medical phenomena
-- Impact on insurance coverage: “serious or
biologically based”
-- Stigma: “fear, hostility, disapproval versus
compassion, support, understanding”
-- O’Hara & Smith. Patient Education and Counseling.2007;68:43-51
Introduction 3
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British polls:
-- 35% feel patients should “pull themselves together”
-- 33% blame the individual
--- View AN as “extreme form of dieting, often for narcissistic
motives”
2005 National Eating Disorders Association sponsored poll of
American adults for primary causes of eating disorders:
-- Dieting (66%)
-- Media (64%)
-- Families (52%)
-- Genetics (33%)
-- O’Hara & Smith. Patient Education and Counseling.2007;68:43-51
Dieting Data
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Prevalence of eating disorders in teens
increased during past 50 years
40% to 60% of high school girls in US diet to
lose weight
13% induce vomiting or use diet pills,
laxatives or diuretics
30% - 40% of junior high girls admit concern
about weight
Eating Disorder Categories
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Anorexia nervosa (AN)
Bulimia nervosa (BN)
Eat disorder not otherwise specified
(EDNOS)
Binge-eating disorder (rarely seen in
adolescents)
Anorexia Nervosa:
Diagnostic and Statistical Manual of
Mental Disorders (DSM) IV Criteria
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Refusal to maintain body weight at or above
minimally normal for age & height
Intense fear of gaining weight or becoming
fat, even though underweight
Disturbance in the way in which one’s body
weight or shape is experienced, or shape on
self evaluation, or denial of the seriousness
of the current low weight
DSM IV Criteria--continued
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In post-menarcheal females, amenorrhea,
i.e., absence of at least 3 consecutive
menstrual cycles
Type:
a. Restricting type
b. Binge-eating/purging type
Anorexia Nervosa
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90% to 95% are females
90% diagnosed before age 25 years
Two peaks for symptoms begin:
- 13 to 14 years
- 17 to 18 years
Diagnosis may be delayed 1 to 2 years
Anorexia Nervosa
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Prevalence in US and Great Britain: 0.5% of
adolescent females
Middle & upper socioeconomic classes
- 1 in 300 of 15-19 yr girls in elite private
schools
Increasing in other ethnic/racial groups and
SES
Etiology/Pathogenesis
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Biologic/genetic evidence
-- Biomedical framework: genetic and environmental*
-- Genetic factors explain more than 50% of risk for
developing eating disorder*
Increased in monozygotic twins
Increased incidence in sisters
Increased prevalence of affective disorders in
families
Psychological
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Personality traits: negative emotionality,
perfectionism, drive for thinness, poor interoceptive
awareness, ineffectiveness, obsessive-compulsive*
Family characteristics: enmeshment, overprotectiveness, rigidity, lack of conflict resolution and
history of early separation stress and sexual abuse
-- Lilenfeld et al. Clinical Psychology Review.2006;26:299-230.
Socio-cultural stressors
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Affluence in industrial countries
Social standard: thinness = beauty
Media bombardment: thinness = success
Media: women as sex objects
Some sport requirements for thinness:
gymnastics, distance running & ballet
Presenting Symptoms
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Excessive weight loss
-- Female: 100 lbs at 5 feet plus 5 lbs for each
additional inch
-- Male: 106 lbs at 5 feet plus 5 lbs for each
additional inch
Primary or secondary amenorrhea
GI symptoms: abdominal pain, vomiting, or bloating
Growth failure or pubertal delay
Differential Diagnosis
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Thyroid disease
Diabetes mellitus
Addison disease
Inflammatory bowel disease
Brain tumors
Malignancy
HIV
DDx--continued
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Drug/alcohol abuse
Depression
Schizophrenia
Personality disorders
Obsessive/compulsive disorders
Diagnosis: Detailed History
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Weight
Diet
Exercise
Body image
Self-induced binging; purging
Self-medication with laxatives, diuretics, or
diet pills
Diagnosis— Detailed Hx continued
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Menstrual/puberty
Sexual/physical abuse history
Family history of psychiatric illness,
alcoholism, and eating disorders
Substance abuse, sexual behaviors,
compulsive/impulsive behaviors
Physical Exam
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Significant weight loss or failure to make
expected gain
Bradycardia, hypotension, orthostatic
hypotension, hypothermia
Acrocyanosis, edema, cool mottled
discoloration of extremities
Skin: lanugo, loss of scalp hair, jaundice, dry
skin
Physical Exam--continued
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Musculoskeletal weakness, loss of muscle
mass
Cardiac arrhythmias
Lab Findings
Results of following are usually normal:
 CBC: rare to find anemia
 Lytes: unless associated with vomiting
 BUN: low to normal even with dehydration
 LFTs: increased with severe starvation due
to fatty liver
Labs--continued
Results of following sometimes abnormal
 UA: alkaline with ketones and protein
 Cholesterol: elevated
 Amylase: elevated
 ECG: bradycardia, low voltage & nonspecific
ST and T wave changes, prolonged QT
 Bone densitometry: may show osteopenia
Labs--continued
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Results usually abnormal
LH & FSH: low
TFTs: low
Cortisol: high
Treatment
Role of Primary Care Provider (PCP)
 Diagnosing the eating disorder
 Setting weight goals
 Planning with patient how to meet goal
 Negotiating consequences if goal not met
 Makes referrals and coordinates care:
psychotherapist, nutritionist
Treatment--continued
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Manages complications of the eating
disorder
Provides care for inter-current illnesses
Establishes clear criteria for hospitalization if
treatment started as outpatient
Treatment--continued
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Outline plans for changing unhealthy
behaviors, e.g., binging, vomiting, dieting,
excessive exercise
Psychotherapy
Close relationship with PCP
 Individual, family and/or group therapy
 Antidepressants as needed
Nutrition
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Patient & family education
Weight gain goal of 1 pound per week for outpatient
and 3 pounds per week for inpatient
Normal active female adolescent requires about
1500 kcal/day to maintain weight;
-- AN may consume only 600 to 1000 kcal/day
AN patients may require 2000 – 3000 calories/day
for sustained weight gain as 3 meals and 2-4 snacks
per day
Indications for Hospitalization 1
Physiologic
 Weight 30% or more below ideal body weight
 Severe metabolic/cardiovascular problems
 Unusual presentation
Indications for Hospitalization 2
Psychiatric
 Severe depression or suicide risk
 Acute psychosis
 Uncontrollable binging & purging
 Acute food refusal
 Severe family dysfunction or family crisis
Outcome
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50% of patients recover fully
30% recover partially, i.e., continue to have
dysfunctional eating, body image distortion, and
impaired social relationships but do well in school/job
Approximately 20% remain chronically ill
AN has the highest rate of mortality of any
psychiatric disorder*
-- O’Hara & Smith. Patient Education and Counseling.2007;68:43-51.
*-- Franko & Keel. Clinical Psychology Review.2006;26:769-782.
Refeeding Syndrome
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Severely malnourished patients (at least 30% below average body
weight for height)
Risk of developing severe complications if refed too rapidly:
-- Edema
-- Fatty liver
-- Hypophosphatemia
--- Cardiac failure, CNS depression, hemolytic anemia
Can occur with oral, enteral or parental feeding
Prevention: use prophylactic phosphorus and refeed slowly (800-1000
calories/day and increase by 100-200 calories/day)
-- C Holland-Hall & RT Brown. Adolescent Medicine Secrets.2002. Hanley & Belfus,
Inc, Philadelphia.
Case Presentation
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15 yo female with history of recurrent vomiting and
diarrhea since Feb 2007
Weight in 90th percentile for age and height
PE: Flat affect, marked erosion of dental enamel
10-26-08: admitted for full work-up including GI
evaluation; WNL
10-30-08: Psychology referral. Mother asks, “Does
she look like she has an eating disorder?”
Bulimia Nervosa
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College age: 1% to 5% women; 1% men
Secondary school: 1.1% girls; 0.2% boys
Incidence is increasing
Partial syndrome of vomiting and/or laxative
use without binge-eating may be more
common, especially in college students
Do not have adequate knowledge of the
etiology & maintenance of the syndrome
DSM-IV Diagnostic Criteria
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Recurrent episodes of binge eating
-- Binge characterized by both:
1. Eating in a discrete period of time, an
amount of food larger than most people
would eat during a similar period of time &
under similar circumstances
2. A sense of lack of control over eating
DSM-IV Continued
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Recurrent inappropriate compensatory
behavior to prevent weight gain, e.g., selfinduced vomiting, laxatives, diuretics,
enemas, fasting, excessive exercise
Binging and inappropriate compensatory
behaviors both occur at least twice a week
for 3 months
DSM-IV Continued
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Self evaluation is unduly influenced by body
shape and weight
The disturbance does not occur exclusively
during episodes of anorexia nervosa
2 Types:
-- Purging
-- Non-purging
Etiology & Pathogenesis
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Biologic factors:
1. Dysregulation of serotonin metabolism
resulting in binge eating of high-carbohydrate
foods
2. Family history of alcoholism and affective
disorders, e.g. depression
Etiology Continued
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Psychological factors:
1. History of incest, rape or sexual abuse
2. Dysfunctional family interactions
-- parental enmeshment to absence
-- chaotic, conflicted & critical
Lead to feelings of being out of control, poor
self-esteem, and needing comfort
Etiology-- Psychological Continued
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Personality differences in AN and BN
-- AN: anxious, inhibited, controlled
-- BN: affectively labile, under controlled,
active
Etiology Continued
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Socio-cultural factors:
1. Strong pressures for thinness lead to
dissatisfaction with normal or overweight
-- physically attractive/socially acceptable
2. May begin after unsuccessful dieting
3. “Contagion” factors in college dorms for
binging and purging “parties”
Differential Diagnosis
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Thyroid disease
Diabetes mellitus
Addison disease
Inflammatory bowel disease
Brain tumors
Malignancy
HIV
DDX Continued
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Drug/alcohol abuse
Depression
Schizophrenia
Personality disorders
Obsessive/compulsive disorders
Diagnosis--History
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Weight history
Detailed diet history
Detailed exercise history
Body image history
History of self-induced binging; purging; selfmedication with laxatives, diuretics, or diet
pills
Diagnosis--HX Continued
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Detailed menstrual/puberty history
Sexual/physical abuse history
Family history of psychiatric illness,
alcoholism, and eating disorders
History of substance abuse, sexual
behaviors, compulsive/impulsive behaviors
Physical Examination
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Head & neck: bilateral parotid gland
swelling, loss of tooth enamel (from acidic
stomach contents), dental caries,
subconjunctival hemorrhage (from forced
vomiting)
Skin: scarring or hyperpigmentated calluses
on knuckles (Russell’s sign); petechiae on
face (from forced vomiting)
Physical Exam Continued
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GI: abdominal distention, ileus, constipation,
rectal bleeding, gastritis, esophagitis,
esophageal tears
Pulmonary: aspiration pneumonia,
pneumomediastinum
Cardiac: arrhythmias
Outcome
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Variable course; majority chronic fluctuation of
binge/purge behavior
Pts with history of sexual abuse, conflicting family
environments, comorbid medical or psychiatric
states, or inability to seek or accept Rx have more
severe course
BN tend to be more responsive than AN
-- 60% BN vs. 50% AN recover in first 5 years
Outcome Continued
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Potential lethal complications:
-- Esophageal tears from severe repetitive
vomiting
-- Cardiac arrhythmias from hypokalemia due
to vomiting and diuretic abuse
-- Cardiomyopathy and death from ipecac
use
Outcome Continued
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Antidepressants are somewhat effective in
controlled short-term Rx of binge eating
Twelve-month follow-up studies show
recovery rates up to 70% but frequent
relapses occur
Lower recovery rates in patients requiring
inpatient treatment or those with concurrent
alcohol abuse
Outcome Continued
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Cognitive-behavioral interventions reduce
bingeing and vomiting as well as associated
psychopathology
-- individual and group therapy effective
-- not uniquely effective as other nonbehavioral psychotherapy seems effective
-- more effective than pharmacotherapy
Literature Review: Medication Use in
Children and Adolescents with Eating
Disorders 1
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2 major classes of drugs: antidepressants (SSRIs)
and atypical antipsychotics
Limited evidence-based: limited studies in children
-- One retrospective study on the use of SSRIs
-- Some case reports on atypical antipsychotics for
children and adolescents with AN,
-- One small open trail on SSRIs for adolescent BN
-- Couturier & Lock, J CAN Acad Child Adolesc Psychiatry. Nov
2007;16(4):173-176.
Literature Review: Medication Use in
Children and Adolescents with Eating
Disorders 2
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Olanzapine (Zyrexa) and other atypical antipsychotics may prove
useful for AN at low body weight
-- Decrease eating-related anxiety
-- Uncertain whether SSRIs prevent relapse in AN
Fluoxetine (Prozac): first line drug option in children and adolescents
with BN
-- Open trial: 10 adolescent, 12-18, 60 mg for 8 weeks
-- Binging decreased from 4 to 0
-- Purging decreased from 6 to 0
-- Couturier & Lock, J CAN Acad Child Adolesc Psychiatry. Nov
2007;16(4):173-176
Suicidality in Eating Disorders
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High rates of completed suicide in patients with AN
-- 50-fold increased risk
-- Rate is 200 times greater than in general population
-- Crude Mortality Rate = 0% to 5.3%
-- 2nd most common cause of death in meta-analysis of 42 studies
Rates of completed suicide do not appear elevated in BN
-- Crude Mortality Rate = 0.1%
Rates of suicide attempts:
-- 3 to 20% of patients with AN
-- 25% to 35% of patients with BN
-- Franko DL, Keel PK. Clinicaly Psychology Review.2006;26:769-782
Role of Parenting
Experiences in Development of Anxiety and
agoraphobia in Eating Disorders
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Social anxiety: fear of social situations in which the individual may be
exposed to unfamiliar people or the scrutiny of others
-- Associated with abandonment and emotional inhibition beliefs
-- Associated with inhibiting parenting by fathers (parenting that
reflects a lack of ability to share feelings with the child)
Agoraphobia: anxiety about being in places or situations from which
escape might be difficult
-- Associated with vulnerability to harm beliefs
-- Associated with pessimistic/fearful parenting by mothers (parenting
that reflects anxious, fearful traits in the mother and a pessimistic
outlook on life)
-- Hinrichsen, Sheffield, Waller. Eating Behaviors.2007;8:285-290
Eating Disorders: Younger Girls vs.
Older Teenagers
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Girls presenting before menarche may have a long history of
poor weight gain and growth retardation before the onset of
weight loss
Older adolescents start weight loss at an above-average weight
without prior poor weight gain
Psychopathology in young girls may be different and less
evident compared to older teenagers
Important to be aware that poor weight gain and growth
retardation may be associated with early-onset eating disorder
-- Swenne I, Thurfjell B. Acta Paediatr.2003 Oct;92(10):1133-1137.
Summary
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Major roles of Primary Care Provider:
-- Making the diagnosis
-- Forming a bond of trust with patient
-- Involving family
-- Establishing therapeutic team
- Managing patients health over the course
It will require trust and time.
Exercise caution with vegetarians
-- May mask and eating disorder
References
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Stoylen IJ, Laberg JC. Anorexia nervosa and
bulimia nervosa. Perspectives on etiology
and cognitive behavior therapy. Acta
Psychiatr Scand Suppl 1990;361:52-58.
References Continued
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Steiner H, Lock J. Anorexia nervosa and
bulimia nervosa in children and adolescents:
A review of the past 10 years. J Am Acad
Child Adolesc Psychiatry 1998;37(4):352359.