Eating Disorders

Loss of appetite and/or inability to eat
Associated with: Cancer, HIV, GI problems, depression, infections, medication side effects, etc.

Eating disorder (a psychiatric disorder)

Significantly low body weight (< minimally expected) in relation to age, sex, development, and physical health
Intense fear of gaining weight
Disturbance in the way one’s body weight/shape is experienced and denial of the seriousness of the current low body weight

Intense fear of gaining weight
Disturbance in the way one’s body weight/shape is experienced and denial of the seriousness of the current low body weight

Same as for anorexia nervosa but without a low body weight

Fear of gaining weight
Preoccupation with food, cooking, and nutrition
Social isolation/withdrawal
Restlessness
Irritability
Ritualistic behaviors

Cutting food into small pieces
Avoiding meals
Switching to vegetarian/vegan diet
Calorie counting or restricting
Water loading

Delayed gastric emptying, slowed motility, constipation, abdominal pain

Cold intolerance, decreased metabolic rate, lethargy, brittle nails, dry skin

Lanugo(fine hairs), hypercarotenemia (yellowed skin)

Refeeding syndrome, hypoglycemia, low serum Cl, Na, K, Ca, Mg

Hypoestrogenic state, decreased FSH and LH, amenorrhea, infertility, premature births, risk for miscarriage

Cardiac muscle atrophy, decreased contractile force and output, bradycardia, hypotension, arrhythmias

Osteopenia/osteoporosis

Genetics
Female youth with type 1 diabetes
OCD personality class
Unhealthy family dynamics
trauma/life stressors

early to mid-adolescence

8 months

9-15 years

Nutritional Rehabilitation
Psychotherapy
Pharmacologic symptom relief (pro-motility agents) during refeeding

Pharmacologic treatment of depression, anxiety, or obsessive compulsive symptoms, with SSRIs and psychotherapy, but avoid bupropion due to seizures
SGAs for severe, unremitting resistance to weight gain, severe obsessional thinking and denial that assumes delusional properties. Not appropriate solely for weight gain.

Continued weight loss despite outpatient treatment, SBP <80 mmHg, arrhythmia, Na+ <125mmol/L, K+ <3 mmol/L, suicidal ideation, active self-harm

24 hours/day, 7 days/week

Treatment of acute risks (suicidality, severe electrolyte abnormalities, cardiac irregularities)

8-10 hours/day, 5-7 days/week

Treatment of chronic symptoms and relapse prevention

May occur as a result of fluid and electrolyte shift during aggressive nutritional rehabilitation, may be fatal (most deaths from CV complications)

Hypophosphatemia (predominant cause of refeeding syndrome): Carbohydrate intake causes release of insulin which triggers cellular uptake of phosphate, leads to hypoxia, myocardial dysfunction, and respiratory failure
Hypokalemia
Congestive heart failure
Peripheral edema
Rhabdomyolysis
Seizures
Hemolysis

daily multivitamin

Bulk-forming laxatives (polyethylene glycol), stool softeners (docusate sodium), preferred over stimulant laxatives

Metoclopramide 10 mg 30 min before meals (avoid long term)

Not recommended to induce menstruation pharmacologically. Typically resolves as weight normalizes.

Calcium 1500 mg daily + vitamin D 400 units daily

BMI > or equal to 17

BMI 16-16.99

BMI 15-15.99

BMI <15

1. Recurrent episodes of binge eating*
2. Recurrent, inappropriate compensatory behavior to prevent weight gain
Self-induced vomiting
Misuse of laxatives, diuretics, enemas
Fasting
Excessive exercise
3. These behaviors occur > or equal to 1 time per week for > or equal to 3 months
4. Self-evaluation is disproportionately influenced by body shape/weight

1-3 episodes per week

4-7 episodes per week

8-13 episodes per week

> or equal to 14 episodes per week

Depression
Impulsivity
Mood lability
Personality disorders
Substance use disorders
Anxiety disorders

Self-induced vomiting
Laxative/diuretic abuse
Fasting
Compulsive exercising
Over evaluation of shape/size
Eating preoccupations

Loss of dental enamel, dental cavities, parotid gland enlargement, gastric rupture

Lethargy, fluctuations in metabolic rate

Russel's sign (calluses on back of knuckles due to inducing gag reflex)

Low serum Cl, Na, K, Ca, Mg; metabolic alkalosis (high CO2), metabolic acidosis

Amenorrhea

Orthostatic hypotension, bradycardia, prolonged QTc, arrhythmias

Osteopenia/osteoporosis

genetic
trauma/life stressors
Personality Traits/Disorders

16-20 years

3 months

7-12 years

Nutritional Rehabilitation, develop structured meal plan
Psychotherapy: cognitive behavioral therapy (CBT), family therapy
Pharmacotherapy: SSRIs, May require higher doses than required for antidepressant effect, Fluoxetine has greatest efficacy data over placebo (60 mg daily)

Alternative types of psychotherapy: Interpersonal Therapy (IPT)
Alternative antidepressants depending on comorbid psychiatric illnesses

Daily multivitamin

Bulk-forming laxatives (polyethylene glycol), stool softeners (docusate sodium)

Replete electrolytes and fluids

Replete electrolytes and fluids

Implement routine dental care (dental erosion)

Recurrent binge eating without compensatory behavior to prevent weight gain
Patients feel a lack of control during these periods
Associated with >3 of the following:
• Eating rapidly
• Eating until uncomfortably full
• Eating large amounts when not hungry
• Eating alone out of embarrassment
• Feeling disgusted, depressed, or guilty after eating
These behaviors occur at least > or equal to 1 time per week for >greater than or equal to 3 months

1-3 episodes per week

4-7 episodes per week

8-13 episodes per week

> or equal to 14 episodes per week

Emotional stress
Impulsivity/loss of control
Feelings of guilt
Co-occurring anxiety or depressive disorders
Impulse control disorders

Eating rapidly
Eating until uncomfortably full
Eating large amounts when not hungry
Eating alone out of embarrassment
Feeling disgusted, depressed, or guilty after eating

GERD, acute gastric dilation and rupture

Elevated BMI, lethargy, fluctuation in metabolic rate, hyperlipidemia, hyperglycemia

striae distensae (stretch marks)

Abnormalities not typical without compensatory behaviors
Gallbladder disease

Hypertension, cardiovascular disease

genetics
patients with BED at high risk for Generalized anxiety disorder, Panic attacks, MDD and suicidality

18-20 years

seen in many BED patients, period of weight gain followed by weight loss

Nutrition Counseling
Psychotherapy: Cognitive behavioral therapy (CBT), IPT
Pharmacotherapy:
SSRIs (sertraline, citalopram, escitalopram preferred), Some guidelines include orlistat or topiramate

Psychotherapy: Alternative types of psychotherapy, IPT and dialectal behavior therapy (DBT)
Pharmacotherapy:
Topiramate (+/- phentermine)
Imipramine and other TCAs
Naltrexone
Atomoxetine
Lisdexamfetamine

Implemented as an adjunct to a dietary plan and increased physical activity
Discontinue treatment if no improvement in binge eating behaviors or not providing > 5% weight loss at 12 weeks

NE reuptake inhibitor indicated for ADHD

May decrease binge eating, obsessive features of BED, hunger, and body weight (1 small study, N=40)

10-12 weeks

Dry mouth, nausea, nervousness, insomnia, headache, constipation

BP, HR, changes in mood or behavior

Prodrug, converted to dextroamphetamine

Take in the morning, high fat meals can delay onset of action

Decreases number of binge days per week

12 weeks

Dry mouth, insomnia, decreased appetite, tachycardia, constipation, anxiety

Signs of misuse/abuse, baseline EKG, HR, weight, waist circumference, BP, psychosis

CII

Decreases absorption of dietary fats by 30% by forming covalent bond with gastric and pancreatic lipases within stomach and small intestine, unavailable to hydrolyze dietary triglycerides

Take with meal or up to 1 hour after eating
Must be used with a low fat diet plan (max 30% kcal from fat)
Separate from cyclosporine and levothyroxine by at least 3 hrs

Minimal systemic absorption (~83% excreted unchanged in feces)

24 weeks

GI (flatus with discharge), fecal urgency, fatty stool, severe liver injury

Pregnancy, chronic malabsorption syndrome, cholestasis

Weight, liver function tests

P: Stimulant that increases norepinephrine levels
T: Increases satiety and decreases appetite via GABA / glutamate modulation and / or carbonic anhydrase inhibition

P: Absorption unaffected by food, excreted in urine
T: Absorption unaffected by food, 15-41% protein bound, minimal hepatic metabolism, 70-80% excreted unchanged by kidneys

CIV

12 weeks

Anxiety, depression, suicidal thoughts, tachycardia, headache, cognitive impairment, constipation, dry mouth, insomnia, paresthesias, increased SCr

Hyperthyroidism, glaucoma, pregnancy (REMS), lactation

Weight, HR, BP, mood, pregnancy test, electrolytes

Serotonin 5-HT2C receptor agonist, stimulates hypothalamus resulting in satiety and decreased food intake

70% protein bound, extensive hepatic metabolism

CIV

12 weeks

Headaches, dizziness, fatigue, nausea, dry mouth, constipation, hypoglycemia, valvular heart disease, suicide risk, priapism, serotonin syndrome, increased prolactin, decreased blood counts (WBC, RBC), CNS effects

Pregnancy (Category X)

Weight, waist circumference, CBC, prolactin, mood, EKG

B: inhibits DA and NE reuptake
N: Opioid receptor antagonist

Do not take with fatty meals (increases absorption), swallow whole

N: Significant first-pass metabolism, 53% to 79% excreted by kidneys

12 weeks

N/V, constipation, headache, dizziness, dry mouth, insomnia, tachycardia, htn

Chronic opioid use or acute withdrawal and previously discussed contraindications to bupropion
Will block the effects of opioids and buprenorphine, must wait 7 to 10 days after opioid discontinuation prior to initiation of bupropion/naltrexone

BP, HR, weight, BMI, mood