1. Medical Aspects of Eating Disorders Richard Kreipe, M.D. Professor of Pediatrics, Division of Adolescent Medicine, Golisano Children’s Hospital Medical Director, Eating Disorders Recovery Center of Western New York February 29, 2008

2. The role of the physicians on the eating disorder treatment team is to 1. Identify the disorder. 2. Rule out other causes. 3. Monitor for consequences. 4. Treat the disorder.

3. Identification of patients with eating disorders

4. Determination of normal weight for height in adults Predicted body weight method (PBW): Predict body weight based on height. Divide actual weight by predicted weight Example: PBW for 5'6" woman is 130 lb. If actual weight is 110 lb., then patient is 85% of predicted weight.

5. Determination of normal weight for height in children and adolescents Growth chart Height Weight Body mass index for age

6. Age in years Weight Height Growth chart: height and weight for age

7. Age in years body mass index = weight/height 2 Growth chart: body mass index for age

8. Symptoms of patients with anorexia nervosa Dizziness, weakness, fainting, fatigue Cold intolerance Hair loss Bloating, abdominal pain, heartburn, constipation, diarrhea Lack of menstrual periods Bone pain from stress fractures in athletes

9. Physical examination: anorexia nervosa Appearance of malnutrition: Thin, loss of subcutaneous tissue, muscle wasting Skin pale, poor circulation, dry Hair dry, brittle, thinning Lanugo: fine body hair as in newborns

10. Physical examination: anorexia nervosa (continued) Low blood pressure Slow heart rate Orthostatic “positional” changes in heart rate and blood pressure Low body temperature

11. Symptoms of patients with bulimia nervosa Feeling faint or fainting Depression and anxiety Bloody vomiting (unusual) Throat or upper abdominal pain Fatigue, weakness, difficulty concentrating Facial swelling around jaw

12. Physical exam: bulimia nervosa Signs of vomiting: Enlargement of salivary glands Throat irritation Subconjunctival hemorrhages Upper abdominal tenderness Dental erosions

13. Diagnosis Complete history and physical exam Screening lab work: blood count, chemistry panel, thyroid-stimulating hormone, urinalysis Targeted lab work: done based on findings

14. Differential diagnosis of eating disorders

15. Differentiation of eating disorders from other diseases Gastrointestinal disease Crohn’s disease, ulcerative colitis Celiac disease Endocrine disease Diabetes mellitus Hyperthyroidism

16. Differentiation of eating disorders from other diseases (continued) Pulmonary diseases Malignancy Chronic infection Central nervous system tumors

17. Differentiation of eating disorders from other diseases (continued) Psychiatric disorders Depression Obsessive compulsive disorder General anxiety disorder Panic disorder

18. Monitoring for consequences of eating disorders

19. Metabolic consequences of eating disorders Lowered basal metabolic rate—suppressed metabolism Increased catabolism—breakdown of tissue— muscle, brain, bone  70% of weight loss is lean tissue, 30% is fat Decreased anabolism—building of tissue Electrolyte abnormalities  Potassium, sodium, phosphorous Hypercholesterolemia early and hypocholesterolemia late

20. Endocrine system consequences of eating disorders Lack of menstrual periods, estrogen deficiency Irregular menstrual periods Lowered testosterone levels Elevated cortisol levels Thyroid adaptation

21. Bone consequences of eating disorders: osteoporosis Lack of normal bone density gains in adolescence and early adulthood Midlife osteoporosis if peak bone density is low Stress fractures Suppressed bone formation related to hormonal changes that affect calcium uptake into bone.

22. Normal bone density growth

23. Osteoporosis

24. Gastrointestinal system consequences of eating disorders Reduced intestinal movement and delayed stomach emptying Gastroesophageal reflux Gastric tears Dental erosions Elevated liver enzymes

25. Cardiovascular consequences of eating disorders Decreased heart size Abnormal heart rhythms

26. Hematologic consequences of eating disorders Bone marrow depression Anemia: low red blood cell count Leukopenia: low white blood cell count Thrombocytopenia: low platelet count

27. Behavioral and psychological consequences of eating disorders Ancel Keys’ study of the effects of starvation on healthy young men showed that many psychological and behavioral symptoms of eating disorders were the result of the biology of starvation. Weight and caloric intake must be returned to normal in treatment process while psychological issues are also addressed. Binge eating is in part a physiologically based reaction to starvation.

28. Treatment of patients with eating disorders

29. Improve nutritional status A subnormal weight cannot be healthfully maintained. Malnutrition cannot be corrected without adequate intake of carbohydrates, proteins, fats, and total calories.

30. Improve nutritional status (continued) Malnutrition can be seen in patients who are normal or overweight and have restrictive eating, bulimia, or binge eating disorder.

31. Coordinating with the treatment team Physician and medical staff have ongoing consultation with: Dietitian Social worker/case manager (if separate from psychotherapist or other team member) Psychotherapist Psychiatrist Regular—weekly or biweekly—appointments until weight gain is well established or symptoms have decreased.

32. Management: education Educate on: Effect of malnutrition on the body: metabolic, gastrointestinal, psychological. Normal body weight/acceptance of current body weight. Risks of purging behaviors. Long-term risks of being underweight. Use of “blind” weights, if applicable.

33. Pharmacologic treatment Psychotropic medications SSRI medications decrease purging behaviors, address co-morbid conditions such as depression or anxiety. SSRI medications are not effective for promoting weight gain in anorexia nervosa. SSRI, tricyclics, and anticonvulsant medications being tried with binge eating disorder. Reference: Devlin, M. J. (2005) “Binge Eating Disorder 2005,” 15 th Annual Conference, Renfrew Center Foundation, Nov. 12.

34. Pharmacologic treatment (continued) No evidence of effectiveness: Appetite stimulants for weight gain Estrogen replacement

35. Treatment plan Establish a relationship. Address the patient’s and family’s concerns, even if different from our own. Set nutritional intake to support nutritionist’s recommendations. Monitor weight and medical status. Set treatment plan for  expected rate of gain.  weight or medical criteria for which hospitalization may be required.

36. Treatment: Adults Adults age 18 and over must agree to treatment. Health care for patients 18 and over is confidential.  Signed release required for medical provider to discuss specifics with family.  Confidentiality does not include a situation that is life-threatening.

37. Management: Anorexia Nervosa (continued) Osteoporosis: Weight gain. Calcium 1,500 mg with Vitamin D 400 IU per day or four servings of calcium-rich food per day. Dexa scan if no menstrual period for six months to one year or prolonged malnutrition. Estrogen replacement does not treat osteoporosis in young women. Drugs like Fosamax used to increase bone density are not currently used in women before or during childbearing years because the safety profile is not known.

38. Treatment: Anorexia Nervosa Refeeding syndrome—fluid and electrolyte abnormalities that occur when a patient who is malnourished suddenly eats large amounts: Occurs in patients less than 75% PBW. Usually occurs in first few days of a high-calorie diet. Prevent by starting with low caloric intake and increase slowly. Check electrolytes, especially phosphorous, frequently.

39. Management: Bulimia Nervosa Monitor for electrolyte abnormalities. Help patients stop laxative abuse. Discuss dental care. Discourage dieting in conjunction with treatment team members:  Eat three meals a day plus two snacks.  Increase protein in diet.

40. Indications for hospitalization in patients with eating disorders Less than 75% of predicted body weight. Inability to eat. Changes in blood pressure, pulse, and temperature indicative of seriously compromised circulation and organ perfusion. Cardiac arrhythmias.

41. Indications for hospitalization in patients with eating disorders (continued) Serious serum electrolyte abnormalities: potassium, phosphorous, sodium Esophageal tears Intractable vomiting Failure to improve despite intensive out-patient treatment Psychiatric instability: Danger to self or others, e.g., suicide risk

42. “The road to success is always under construction.”

43. References Garner, D. M., and Garfinkel, P. E. (1997) Handbook of Treatment for Eating Disorders, 2nd ed. New York: Guilford Press. Kreipe, R. E., and Yussman, S. M. (2003) “The Role of the Primary Care Practitioner in the Treatment of Eating Disorders.” Adolescent Medicine 14(1). Levine, R. L. (2002) “Endocrine Aspects of Eating Disorders in Adolescents.” Adolescent Medicine 13(1). Mitchell, J. E. et al. (2001) “Combining Pharmacotherapy and Psychotherapy in Treatment of Patients with Eating Disorders.” Psychiatric Clinics of North America 24(2).