1. Medical Parameters for Health Or “What does the doctor do, anyway, and why does she do it that way?” Laura Koenigs, MD Director, Adolescent Medicine Baystate Children’s Hospital Springfield, MA

2. Objectives Describe differential diagnoses of weight loss and vomiting Describe differential diagnoses of weight loss and vomiting Describe techniques for determining ideal body weight Describe techniques for determining ideal body weight Describe common medical complications of eating disorders Describe common medical complications of eating disorders

3. Tasks for Provider Establish diagnosis Establish diagnosis Set parameters for normal weight Set parameters for normal weight Set guidelines for activity Set guidelines for activity Clarify need for hospitalization Clarify need for hospitalization Organize a team Organize a team

4. Why is intervening critical?

5. Irreversible Medical Consequences Growth retardation Growth retardation Structural brain changes Structural brain changes Decreased peak bone mass Decreased peak bone mass Loss of dental enamel Loss of dental enamel

6. Establish Diagnosis

7. History History Physical Physical Laboratory tests Laboratory tests ECG ECG

8. Differential Diagnosis Endocrine diseases Endocrine diseases

10. Differential Diagnosis Endocrine diseases Endocrine diseases Gastrointestinal diseases Gastrointestinal diseases Neurologic diseases Neurologic diseases Malignancies Malignancies Connective tissue diseases Connective tissue diseases Chronic infection Chronic infection Other psychiatric illnesses Other psychiatric illnesses

11. Symptoms of Starvation Cold all the time Cold all the time Tired Tired Full easily Full easily Constipated Constipated Sad/ Irritable Sad/ Irritable Hair changes Hair changes

12. Signs of Starvation Bradycardia Bradycardia Hypotension Hypotension Hypothermia Hypothermia Lanugo / Balding Lanugo / Balding Yellow discoloration – hands Yellow discoloration – hands Acrocyanosis Acrocyanosis Ketosis Ketosis

13. Signs of Vomiting Orthostasis Orthostasis Parotid Swelling Parotid Swelling Subconjunctival hemorrhages Subconjunctival hemorrhages Facial petechiae Facial petechiae Tooth enamel erosion Tooth enamel erosion Russell’s sign Russell’s sign Extremity edema Extremity edema

14. Medically Stable? Severe malnutrition (≤ 75% av.) Severe malnutrition (≤ 75% av.) Heart rate (<45) Heart rate (<45) Temperature (<96) Temperature (<96) Heart dysrthymia Heart dysrthymia Hypoglycemia Hypoglycemia Electrolyte or divalent abnormalities Electrolyte or divalent abnormalities Orthostasis/ Hypotension Orthostasis/ Hypotension

15. Criteria for Admission Medical instability Medical instability Medical complications of malnutrition Medical complications of malnutrition Arrested growth/development Arrested growth/development Uncontrolled binging / purging Uncontrolled binging / purging Acute psychiatric emergencies Acute psychiatric emergencies Failure of outpatient treatment Failure of outpatient treatment Society Adol Med Position Paper J Adol Health 2003; 33:496-503

16. What Should a Person Weigh? Preadolescent: 11-14% body fat Preadolescent: 11-14% body fat Adult woman’s body: 20-25% fat Adult woman’s body: 20-25% fat Adult male’s body 8- 11% fat Adult male’s body 8- 11% fat

17. Determining Weight Adult woman (≥18 y/o) Adult woman (≥18 y/o) 100 lbs for first 5 feet 5 lbs per inch over 5 feet Give/take 5-10% Works best at normal heights Works best at normal heights

18. Height & Weight Table For Women Height (Feet, Inches) Small FrameMedium Frame Large Frame 4' 10"102-111109-121118-131 4' 11"103-113111-123120-134 5' 0"104-115113-126122-137 5' 1"106-118115-129125-140 5' 2"108-121118-132128-143 5' 3"111-124121-135131-147 5' 4"114-127124-138134-151 5' 5"117-130127-141137-155 5' 6"120-133130-144140-159 5' 7"123-136133-147143-163 5' 8"126-139136-150146-167 5' 9"129-142139-153149-170 5' 10"132-145142-156152-173 5' 11"135-148145-159155-176 6' 0"138-151148-162158-179 ages 25-59. Weight in pounds ( in indoor clothing weighing 3 lbs.; shoes with 1" heels)

19. Men 1" heels Elbow Breadth Women 1" heels Elbow Breadth 5'2"-5'3"21/2"-27/8"4'10"-4'11"21/4"-21/2" 5'4"-5'7"25/8"-27/8"5'0"-5'3"21/4"-21/2" 5'8"-5'11"23/4"-3"5'4"-5'7"23/8"-25/8" 6'0"-6'3"23/4"-31/8"5'8"-5'11"23/8"-25/8" 6'4"27/8"-31/4"6'0"21/2"-2" Elbow Breadth for Frame Size

20. BMI Charts CDC CDC Weight divided by height squared Weight divided by height squared Change with age Change with age –Adults NL: 18.5-24.9 kg/M 2 Elite athletes, strength sports - 50 th % BMI Elite athletes, strength sports - 50 th % BMI

21. OK135S060

22. OK135S069

23. Sample Child 12 year old girl 12 year old girl 4’10” tall 62 pounds 4’10” tall 62 pounds BMI of 13 kg/M 2 BMI of 13 kg/M 2

24. OK135S060

26. Sample Child 12 year old girl 12 year old girl 4’10” tall, 62 pounds 4’10” tall, 62 pounds BMI of 13 kg/M 2 BMI of 13 kg/M 2 Ideal BMI 16.5-20.2 kg/M 2 Ideal BMI 16.5-20.2 kg/M 2 79- 96 lbs., 87 lbs. 50 th % 79- 96 lbs., 87 lbs. 50 th %

27. OK135S060

28. Sample Child 12 year old girl 12 year old girl 4’10” tall, 62 pounds 4’10” tall, 62 pounds BMI of 13 kg/M 2 BMI of 13 kg/M 2 Ideal BMI 15.4-18.0 kg/M 2 Ideal BMI 15.4-18.0 kg/M 2 71-87 lbs., 87 lbs. 50 th % 71-87 lbs., 87 lbs. 50 th %

29. Following Patient Make diagnosis Make diagnosis Established normal weight range Established normal weight range Gather team Gather team Criteria for admission Criteria for admission

30. Following Patient Orthostatic vital signs Orthostatic vital signs Same scale Same scale Wearing only hospital gown Wearing only hospital gown Post void Post void Check urine for specific gravity Check urine for specific gravity Check oral temperature after bathroom Check oral temperature after bathroom

31. Weight Restoration Goals Outpatient Outpatient –½ to 1 lb per week Inpatient Inpatient –2-3 lb per week

32. Caloric Needs Basal Metabolic Rate Basal Metabolic Rate –Going 24/7 –Higher if more muscle Normal activity Normal activity –Include growth Exercise Exercise

33. Basal Metabolic Rate Child Child –Higher than adult to include growth Adult Adult – 10 X weight in pounds

34. Basal Metabolic Rate vs. Weight

35. BMR Goes down with starvation Goes down with starvation Goes down with Binge/Purge Goes down with Binge/Purge Goes up with temperature extremes Goes up with temperature extremes Goes up with frequent feedings Goes up with frequent feedings

36. Calorie Needs 25% of a person’s calories should be from fat. 25% of a person’s calories should be from fat. 50 - 60 grams of fat per day = low fat diet. 50 - 60 grams of fat per day = low fat diet.

37. Dietary Guidelines Not gaining weight? Not eating enough or Not eating enough or Too much exercise Too much exercise

38. Anorexia Nervosa & Amenorrhea 25% Precedes weight loss 25% Precedes weight loss 50% Occurs with weight loss 50% Occurs with weight loss 25% Follows weight loss 25% Follows weight loss BMI < 19 kg/M² BMI < 19 kg/M² Exercise prior to menarche Exercise prior to menarche Low fat diet. Low fat diet.

39. Birth Control Pills Osteopenia/Osteoporosis = complication of eating disorder Osteopenia/Osteoporosis = complication of eating disorder Birth Control pills have not been shown to help Birth Control pills have not been shown to help False sense of security False sense of security

40. Review Diagnosis – r/o medical causes as well as fulfilling DSM-IV Diagnosis – r/o medical causes as well as fulfilling DSM-IV Physician should give parameters Physician should give parameters –Medical stability –Weight goals –Activity guidelines –Hospitalization guidelines