1. Welcome Applicants!! Morning Report: Friday, November 18 th

2. Eating Disorders

3. A Little History Lesson…  Behaviors simulating those seen in current eating disorders go back to: Binging and purging seen in ancient Rome Fasting and exercise reported among ascetics in the Middle Ages

4. A Little History Lesson…  The Island of Fiji had no people with eating disorders for 2 centuries until the appearance of American television programs!

5. Demographics  0.5% of adolescent and young adult women have anorexia nervosa Begins in adolescence  1-3% have bulimia nervosa Begins young adulthood  Much more common in women (10-20:1) Recent increase seen in men

6. Demographics  Seen more commonly in Caucasian and Asian youth Less in African American and Latino youth  More common in developed than in developing countries

7. Pathogenesis MMultifactorial Cultural factors Individual and family factors Genetic/ biochemical factors

8. Cultural Factors

9. Individual and Family Factors  Individual Factors Anorexia nervosa  Lack of control and self-confidence found in otherwise successful, although somewhat restricted, young women Bulimia nervosa  Impulsivity  Ongoing substance abuse  ?Past sexual abuse

10. Individual and Family Factors  Family Factors Over-involvement Enmeshment

11. Genetic/ Biological Factors  Cultural, psychological and family factors likely not sufficient to cause the onset of an eating disorder  Psychiatric conditions more common in individuals/ families with eating disorders Depression OCD Addictions

12. Genetic/ Biologic Factors  Several alterations are being considered Hormonal  Ghrelin  Leptin  Melanocortin Genetic  Serotonin receptor genes

13. Pathogenesis, Presentation and Prevention…

14. *Diagnosis

15. Diagnosis  Eating Disorder, NOS Those who have not missed 3 menstrual cycles or are not quite 15% below IBW Those who vomit or use laxatives regularly but do not binge Children 8-12 whose eating disorder behaviors are not driven by a fear of gaining weight

16. Evaluation  Nutrition History Weight Diet Eating disorder behaviors  Excessive exercise?  Use of diet pills, laxatives, diuretics, ipecac **Have parents confirm history**

17. Evaluation  Medical symptoms Malnutrition  Constipation  Feeling cold/faint Vomiting  Chest pain  Hematemesis Other medical causes of wt loss  HA  Polyuria/ polydipsia  Persistent Diarrhea

18. Evaluation  Psychosocial History What is the individual thinking? How is he/she functioning? Body image? Reason for wt loss? Symptoms of depression or other psych diagnoses?  Suicidality??

19. *Differential Diagnosis

20. *Complications  Medical complications Malnutrition of anorexia nervosa Bulimic behaviors Refeeding syndrome

21. *Complications  Metabolic abnormalities Electrolyte disturbances  Anorexia: hyper/hyponatremia  Bulimia (vomiting/ laxative use): hypochloremic, hypokalemic metabolic alkalosis CAN RESULT IN SUDDEN DEATH!!!  Rapid refeeding: hypophosphotemia

22. *Complications  Cardiac Abnormalities Anorexia  Bradycardia  Hypotension  Orthostasis  Prolonged QT interval  Pericardial effusion Bulimia  Sudden cardiac death due to hypokalemia  Irreversible cardiomyopathy Refeeding  Cardiac failure

23. *Complications  Gastrointestinal abnormalities Anorexia  Abdominal pain  Constipation  Delayed gastric emptying with prolonged peristalsis Bulimia  Esophageal irritation Chest pain (GER symptoms)

24. *Complications  Endocrine abnormalities Decreased LH/FSH  Amenorrhea  osteopenia  osteoporosis Decreased thyroid function  Low temperature, pulse, BMR, ECG voltage  T4/TSH in low-normal range; T3 may be low (“euthyroid sick syndrome”) Decreased vasopressin  Polyuria

25. *Complications  Neurologic abnormalities Seizures Peripheral neuropathy Brain atrophy  Hematological abnormalities Mild anemia (?low WBC and plts)

26. *Management  Laboratory evaluation CBC BMP UA TFTs  ?Other hormonal values EKG

27. *When to Admit?  Mild cases Outpatient management  Pediatrician  Nutritionist  More severe cases Outpatient management  Eating disorder team Inpatient management

28. *Treatment  Watch for and intervene with complications Electrolyte abnormalities Cardiac abnormalities Refeeding syndrome Amenorrhea Osteopenia

29. *Treatment  Nutritional therapy Anorexia  Weight GAIN! Diets in the range of 1000-2000 kcal range used initially with slow increases by 200-400 kcal to a goal of 2000-4000 kcal Goal 1-1.25 lbs/wk or 4-5 lbs/mo Daily food diary Exercise restriction (if needed) Bulimia  Nutritional stabilization

30. *Treatment  Psychological Therapy Counseling  Individual (mainstay)  Family  Group (?) Medications  SSRIs Affect amount of binging and purging in bulimia Do not affect weight gain in anorexic patients (?decrease relapse)  Atypical anti-psychotics

31. *Prognosis  ALL outcomes (short and long-term) are VARIABLE No indicator provides a specific prognosis for any individual case  ??Hospital discharge wt in pts with anorexia  Long-term outcome 50% of patients do well, 30% do reasonably well but have symptoms, 20% do poorly Mortality 5-10%  Highest mortality rates of all psychiatric illnesses

32. *Prognosis  Long-term outcome (con’t) Prognosis in adolescents better??  Good motivation to maintain a high level of suspicion and have a low threshold to intervene!

33. Thanks for your attention! Noon Conference: Dr. Simon, Sinusitis