Food fights

A familiarity with the symptoms of common eating disorders is essential for physicians who work with adolescent girls.

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By  Healthcare Middle East Published  December 6, 2006

|~|fork2.jpg|~|“Whenever a patient fails to attain age-appropriate weight, height, body composition, or stage of sexual development, the diagnosis of anorexia nervosa may be considered.”|~|Eating disorders are among the most common psychiatric problems to affect adolescent females, especially in industrialised nations. Anorexia nervosa, bulimia nervosa and binge eating disorder impose a high burden of morbidity and mortality. Unfortunately, these disorders are often accompanied by shame and stigma, leading patients to conceal symptoms, both figuratively and literally by wearing baggy clothing, and to many cases going unrecognised. This is troubling because early diagnosis with intervention, and younger age at diagnosis, are correlated with improved outcomes in patients who have eating disorders. This article, based on an interview with Dr Estherann Grace, associate clinical professor of paediatrics, Harvard Medical School, and clinical chief, division of adolescent medicine at Children’s Hospital Boston, and on published guidelines, provides clinicians with insight on how to recognise and prevent the most common eating disorders, and summarises medical complications and current treatment methods.||**||Common eating disorders|~|fork2.jpg|~||~|Eating disorders are characterised by excessive concerns about body size and shape that can have a severe impact on psychosocial function. They occur in all ethnic, socioeconomic, and age groups, but females make up more than 90% of patients presenting with classic anorexia nervosa and bulimia nervosa. In addition, more than 75% are adolescent when symptoms of an eating disorder first appear. There are many types of eating disorders, but the three physicians are mostly likely to encounter are anorexia nervosa, bulimia and binge eating disorder. Bulimia and binge eating are far more prevalent than anorexia, with an estimated 1% of adolescent and young adult females thought to suffer from bulimia. - Anorexia nervosa Anorexia nervosa is a syndrome marked by determined dieting, often accompanied by compulsive exercise and in some patients, purging behaviour with or without binge eating, resulting in sustained low weight. Patients have a disturbed body image, are fearful of gaining weight and, in postmenarchal females, are amenorrheic. Other psychiatric conditions often coexist with anorexia nervosa, including depression, anxiety disorders and obsessive-compulsive disorder. Anorexia nervosa occurs in two types; food restricting and binge eating and purging. The restrictive type is characterised by severe caloric reduction and is often associated with excessive exercise. In the binge type, the patient regularly engages in binge-eating, followed by purging. This is commonly accomplished with the use of self-induced vomiting, by abuse of laxatives, or with the use of diet pills or diuretic agents. - Bulimia nervosa Bulimia nervosa is a syndrome in which binge eating and inappropriate compensatory methods to prevent weight gain occur, on average, at least twice a week for three months. There is frequent misuse of laxatives, diuretics and diet pills amongst patients with the purging type, while patients with the non-purging type compensate with fasting or excessive exercise. As with anorexia nervosa, bulimia patients have a distorted perception of body weight. A high prevalence of depression, anxiety disorders, substance abuse and personality disorders have been noted among females with bulimia. - Binge eating disorder Patients with binge-eating disorder consume large quantities of food without compensatory behaviours, failing to recognise their own sense of satiety. Binge-eating is defined as eating an amount of food within a set time frame that is markedly larger than most people would eat in a similar period of time, and feeling a lack of control during the episode. Binge-eating episodes are associated with at least three of the following: eating more rapidly than usual, eating until uncomfortable, eating large amounts when not hungry, eating alone and feeling disgusted, depressed or guilty after overeating. Grace notes that obesity is typically a consequence of binge-eating disorder. ||**||Risk factors|~|fork2.jpg|~|"Genetic influences, a family history of depression and obesity, traits of perfectionism and compulsiveness and peer, familial and cultural pressures have all been shown to play a role."|~|Females are at greater risk of developing an eating disorder than males, although males are increasingly suffering from this disorder as well. The typical age window is 15 to 18 years old, although girls as young as 9 have been diagnosed with anorexia in the US. In recent years, studies have revealed more males engaging in disordered eating. Certain sports (such as wrestling, gymnastics, skating and distance running) emphasise leanness and encourage strict weight control, which may contribute. The precise cause of eating disorders is unknown, but their etiology appears to be multifactorial. Genetic influences, a family history of depression and obesity, traits of perfectionism and compulsiveness and peer, familial and cultural pressures with regard to physical appearance have all been shown to play a role. In the US, risk factors include being a middle-class or upper-class female, having a family history of eating disorder, participating in activities that value thinness, unsuccessful attempts at weight loss, a history of sexual abuse, family issues (such as overinvolvement or abandonment), psychiatric comorbidity (depression, anxiety, or substance abuse), and type 1 diabetes. Much has been made of the role of the media in the incidence of eating disorders. Certainly, society’s norm of an extremely thin, sculpted body is unattainable by the vast majority of females and failure to achieve the “perfect body” results in a nearly universal dissatisfaction with body image. The media reinforces the artificial ideal rather than the healthy norm.||**||Diagnosis|~|fork2.jpg|~||~|Whenever a patient fails to attain age-appropriate weight (e.g a body weight more than 15% below the expected weight), height, body composition, or stage of sexual development, the diagnosis of anorexia nervosa may be considered. Associated physical findings include bradycardia and orthostasis, muscle wasting, regression of secondary sex characteristics, abnormal bowel sounds, pitting oedema, and lanugo. Impaired menstrual function and hair loss may also be observed. Following semi-starvation, laboratory measures may also be affected, specifically serum electrolyte levels and thyroid function. When the presence of anorexia nervosa is suspected, the clinician should obtain a detailed eating history from the patient and, ideally, his or her family members. Important history clues include preoccupation with weight loss, food, calories, and fat grams; phobic avoidance of entire categories of food (for example, fats, carbohydrates, or sweets); developing rituals around food and mealtimes; excessive and rigid adherence to exercise regimens; purging behaviour and abuse of laxatives; and withdrawing from friends and activities. For young children, the medical complications resulting from inadequate nutrition (anorexia nervosa) will stunt growth and delay pubertal development. In early- to mid-adolescence, the starved state affects virtually all systems of the body, but has a particularly harmful effect on the endocrine system and bone metabolism, resulting in irreversible osteoporosis. Women who have had anorexia nervosa also have higher rates of miscarriage and lower infant birth weights than seen in healthy women. Bulimia nervosa is characterised by recurrent binge eating and compensatory behaviors, which may or may not include vomiting. Other compensatory behaviors include fasting, excessive exercise, and use of diuretics, laxatives, or enemas. Patients with bulimia nervosa overemphasise body shape and weight as a means of self-evaluation. Because most affected patients are of normal weight, the disease is more difficult to diagnose than anorexia nervosa. Depression, anxiety disorders, substance abuse, and personality disorders often accompany bulimia nervosa. The primary concern in bulimia is death secondary to hypokalemia. Also, the regurgitated stomach acid can cause severe periodontal disease with resultant loss of teeth. Physical effects of bulimia nervosa include scarring on the dorsum of the hand from repeated, self-induced vomiting, eroded dental enamel, swollen cheeks due to enlarged salivary glands, and poor skin turgor. Laboratory testing may reveal electrolyte abnormalities, most commonly hypokalemia. The serum amylase level may also be elevated. This finding commonly signifies the parotid hyperplasia associated with frequent vomiting but may also suggest an evolving pancreatitis. Persons with binge-eating disorder feel a lack of control over their eating behaviours and have distorted attitudes about eating, shape, and weight. Depression is often present, and sometimes anxiety, obsessive-compulsive and impulse control problems, substance abuse, and personality disorders. BED can result in significant obesity with associated insulin resistance, resulting in menstrual irregularities and eventually type II diabetes.||**||Treatment|~|fork2.jpg|~|“The vast majority will enter a recovery phase, but there appears to be a lifelong struggle with food and consequent weight loss or gain.”|~|Normalising eating patterns in patients in an outpatient setting often requires a multidisciplinary team approach, typically involving a primary care physician, a psychiatrist or psychologist familiar with eating disorders, and a registered dietician. Interventions should include medical management, nutrition consultation, and both individual and family therapy. In the case of anorexia nervosa, patients should be seen regularly, usually weekly, to monitor weight. Of note, education of both the patient and family is critical with regard to the nature of the eating disorder, serious health risks, effective treatments and comprehensive follow-up. Inpatient treatment is mandated in cases involving acute food refusal, bradycardia, a weight less than 75% of ideal body weight, and symptomatic orthostasis (syncope), intent to commit suicide, severe electrolyte imbalances, intractable purging, psychotic symptoms, or failure of outpatient management. Observational data suggests that hospitalisation in a unit that specialises in the care of patients with eating disorders yields a better outcome than hospitalisation in general medical units. To achieve full remission, ongoing care after discharge and a specific aftercare plan is essential. Controlled trials have established cognitive behavioural therapy as the psychosocial treatment of choice for patients with bulimia nervosa. Other treatments to consider are interpersonal therapy, group therapy, behavioural approaches, and nutritional counselling. A Cochrane review also noted that, for anorexia nervosa patients, psychotherapy resulted in improved restoration of weight, return of menses among female patients and improved psychosocial function. The SSRI class of drugs, which have been well tolerated by patients with eating disorders, are prescribed to deal with the depression frequently associated with an eating disorder. They stabilise moods, improve sleep patterns, reduce fatigue and, in bulimics, may decrease the incidence and frequency of vomiting. ||**||The outcome of eating disorders |~|fork2.jpg|~|"Inpatient treatment is mandated in cases involving acute food refusal, bradycardia, a weight less than 75% of ideal body weight, and symptomatic orthostasis."|~|The prognosis for patients with eating disorders is varied. Treatment is a slow process usually lasting three to five years. The vast majority will enter a recovery phase, but there appears to be a lifelong struggle with food and consequent weight loss or gain. The mortality ranges from 3% to 5% and is usually caused by a cardiovascular event. Suicide is a significant risk in older patients, particularly those with anorexia nervosa. Patients with the binging-purging form of anorexia, and also alcohol and substance abuse, have a higher risk of premature death than other patients with anorexia nervosa. The prognosis for patients with bulimia nervosa is much better than for patients with anorexia nervosa. In one study at 7.5 years of follow-up, a full recovery rate of 74% and a partial recovery rate of 99% were observed in patients who sought treatment. For patients recovering from an eating disorder, education, advice and support should remain prominent features of long-term care plans.||**||Conclusion|~||~||~|Eating disorders remain challenging to treat and difficult to prevent. To some extent, providing guidance to new parents can help prevent disorders in their children. Encourage parents to avoid using food as a behavioural reward and to provide variety in appropriate portion sizes. Parents should carefully monitor growth and development, helping their children avoid obesity through sensible eating and physical activity. Emphasis should be placed upon health and fitness, rather than thinness, and discussions aimed at minimising distress about food, body weight and body shape. ||**||

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