Susan E Frates MS RD and Heidi Schauster MS RD

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Eating disorders are characterized by a disturbed relationship between nutritional intake and body image, often leading to subsequent medical problems. While eating disorders are found predominantly in the adolescent and young adult populations, they are increasingly being recognized in children and preadolescents. Eating disorders are the third most common chronic illness in adolescents following obesity and asthma.1 Anorexia nervosa is estimated to occur in < 3% of adolescent women and bulimia nervosa in 1 to 49r.- Undiagnosed disordered eating appears to afflict many school-aged Americans. In 1995. over one-third of Boston high school students reported that they were trying to lose weight. Six to seven percent of these students reported having vomited or taken laxatives "in the last 30 days" to avoid absorbing calories.-1 Males are also currently emerging as a population at risk for disordered eating. The age of onset of eating disorders appears to be decreasing.

The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV) details three official classifications of eating disorders: anorexia nervosa (both restrictive and binge/purge types), bulimia nervosa, and eating disorder NOS (not otherwise specified):4 these are summarized in Tables 24-1. 24-2. and 24-3.

Medical complications often lead to inpatient hospitalizations. The sequelae of physiologic complications detailed in Table 24-4 may afflict major body systems and include cardiac instability, electrolyte imbalance, endocrine dysfunction, and skeletal system weakness.s In serious cases, sudden death from cardiac arrest and refeeding syndrome have been reported. Refeeding syndrome refers to severe extracellular hypophosphatemia us the body moves from using catabolized muscle and fat to carbohydrate with refeeding. Ultimately this may result in decreased ATP, w hich can lead to cardiac and respiratory failure.''

Criteria for inpatient hospitalization, outlined in Table 24-5. include medical instability, severe malnutrition, acute food refusal, and psychiatric emergency.7 The National Center for Health Statistics tNCHS) growth charts are the common tool for determining ideal body weight ranges in children and adolescents (typically the l()th to 50th percentile weight/height/age). The most important evidence of a weight problem, however, is a sudden crossing of a percentile that does not correspond to linear growth.

Successful treatment for eating-disordered patients involves a treatment team consisting of a medical doctor, nutritionist (registered dietitian), therapist (individual and family), and in some cases a psychiatrist or psychophar-macologist.* Inpatient medical treatment includes a progression of caloric intake, with medical monitoring and restriction of physical activity. Meal plans usually start with a base calorie level of 1,500 for females and 1,750 for males. This may increase by 250 calories daily. Although a consistent protocol is important, care must be individualized to respond to the unique situations and needs of each patient. Table 24-6 outlines a sample of the Anorexia Nervosa Hating Disorder Protocol used at Children's Hospital, Boston.

Recommendations for treatment of eating disorders include a rapid diagnosis of problematic eating behaviors and assembly of a collaborative, multidisciplinary treatment team. Outpatient management of eating disorders typically takes a more gradual, integrated approach to weight management and normalization of eating habits. Efforts to educate children on the development of healthful eating habits, sound body image, and self-esteem are recommended as a means of prevention.

Table 24-1. DSM IV Diagnostic Criteria for Anorexia Nervosa (307.1)

Refusal to maintain body weight at or above a minimally normal weight lor age and height

Weight loss to < 85% expected weight for height Failure to make expected weight gain during a period of growth, leading to body weight < 85% of that expected

Intense fear of gaining weight or becoming fat, even though underweight

Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight

Amenorrhea in postmenarchal women

The absence of at least three consecutive menstrual cycles Also, if menstrual periods occur only after administration of hormones such as estrogen

Specify Type:

Restricting type: no regular use of binge eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge eating/ regular use of binge eating or purging behavior purging type: (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Adapted from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington (DC): American Psychiatric Association: 1994.

Table 24-2. DSM IV Diagnostic Criteria for Bulimia Nervosa (307.51)

Recurrent episodes of binge eating, characterized by:

1. Eating, in a discrete period of time (ie, within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances; and

2. A sense of lack of control over eating during the episode (ie. a feeling that one cannot stop eating or control what or how much one is eating)

Recurrent inappropriate compensatory behavior in order to prevent weight gain (ie, self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; tasting; excessive exercise)

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months

Self-evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during episodes of anorexia nervosa

Specify Type:

Purging type: Regular use of self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Use of other inappropriate compensatory behaviors, such as fasting or excessive exercise. No regular use of self-induced vomiting or misuse of laxatives, diuretics, or enemas

Adapted from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994,

Nonpurging type:

Table 24-3. DSM IV Diagnostic Criteria for Eating

Disorder Not Otherwise Specified (307.50)

This is a category for disorders of eating that do not meet the criteria for any specific eating disorder. Examples include:

• All of the criteria for anorexia nervosa but the individual has regular menses

• All of the criteria for anorexia nervosa except that, despite substantial weight loss, the individuals' weight is in the normal range

• All of the criteria for bulimia nervosa are met, except binges occur at a frequency of less than twice a week or for a duration of less than 3 months

• An individual of normal body weight who regularly engages in inappropriate compensatory behavior after eating small amounts of food (ie, self-induced vomiting after consuming two cookies)

• An individual who repeatedly chews and spits out, but does not swallow, large amounts of food

Binge eating disorder: recurrent episodes of binge eating in the absence of regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa

Adapted from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994.

Table 24-4. Medical Complications of Eating Disorders

Cardiovascular Bradycardia Orthostatic hypotension Electrocardiographic abnormalities Ipecac cardiomyopathy" Congestive heart failure

Dermatologic Acrocyanosis

Yellow dry skin (hypercarotenemia) Brittle hair and nails Lanugo Hair loss

Russel sign (calluses over knuckles)' Pitting edema

Electrolyte and Fluid Imbalance

Hypokalemia Hyponatremia Hypochloremic alkalosis Elevated BUN

Inability to concentrate urine Ketonuria

Gastrointestinal Parotid hypertrophy' Constipation

Delayed gastric emptying Esophagitis" Mallory-Weiss tears'

Neurologic Myopathy

Peripheral neuropathy Cortical atrophy

Endocrine

Growth retardation and short stature

Delayed puberty

Amenorrhea

Low T3 syndrome

Hypercortisolism

Hematologic

Bone marrow suppression Low sedimentation rate Impaired cell-mediated immunity

Skeletal

Osteopenia

Fractures

Cavities (dental and enamel erosion)'

BUN = blood urea nitrogen.

'Applies specifically to persons utilizing self-Induced vomiting behaviors.

Adapted by permission of Elsevier Science from Fischer M, Golden N. Katzman D. Eating disorders in adolescents: a background paper. J Adolesc Health 1995;3(16):420-37. Copyright 1995 by The Society for Adolescent Medicine.

Table 24-5. Criteria for Hospitalization for Eating Disorders

Unstable vital signs Orthostasis Severe bradycardia Severe hypothermia Severe hypotension Cardiac dysrhythmia

Severe malnutrition

Loss of > 25% ideal body weight Weight < 75% ideal body weight Arrested growth and development

Dehydration

Electrolyte abnormality

Refeeding syndrome

Acute food refusal

Uncontrollable binging and purging

Acute psychiatric emergencies Suicidality/suicidal ideation Acute psychosis Comorbid diagnosis disrupting treatment of eating disorder Severe depression Obsessive compulsive disorder Severe family dysfunction Failure of outpatient therapy

Adapted by permission of Elsevier Science from Fischer M, Golden N, Katzman D. Eating disorders in adolescents: a background paper. J Adolesc Health 1995;3(16):420-37. Copyright 1995 by The Society for Adolescent Medicine.

Table 24-6. Sample Inpatient Medical Protocol

Anorexia Nervosa Protocol, Children's Hospital, Boston

Goals:

To stabilize heart rate, blood pressure, electrolytes, and body temperature via improving nutritional status

Medical monitoring:

Vital signs taken every 4 hours

Minimal vital signs: HR >50 BP > 90/50

temperature > 97 F Heart monitor is used if HR is low at night If vital signs are below criteria, strict bed rest and restricted/

supervised use of commode If vital signs are WNL, supervised room rest, may walk to activity room and bathroom Weight taken every morning Urine specific gravity every morning

Nutrition therapy:

Start with 1,500 calorie meal plan for females Start with 1.750 calorie meal plan for males

(Lower base calorie levels may be established in more compromised patients) Meal plans typically increase 250 calories per day until calorie level is met for weight gain goals Nutrition consultation with RD within 24 hours of admission to create individual meal plans Vegetarian and religious dietary guidelines are respected Fat-free, lite, and diet products are not allowed Food from home is not allowed

Patients may select food preferences using exchange system for meal planning

Fluids:

Maintenance of fluid needs provided daily

Minimum of 8 oz calorie-containing fluid per meal is provided

Supplementation:

If meal is not completed within 30 minutes, supplement equivalent is offered, equaling the entire caloric content of meal

If patient is unable to drink the supplements within 10 minutes, nasogastric tube is placed and supplement is provided enterally

Standard multivitamin with minerals daily Phosphorus: 500 mg Neutraphos bid. Dose adjusted after follow-up phosphorus labs

Weight gain expectations:

Baseline weight established on first morning after admission, after adequate hydration is met Patient is weighed every morning, in johnny, after urine void (to check specific gravity) 0.2 kg weight gain is expected every day of hospitalization If expected weight gain is not met, additional supplement is provided as follows:

• additional 250 calories on day 1

• additional 500 calories for day 2

• additional 750 calories for day 3, etc.

Exercise:

Not permitted during hospitalization

HR = heart rate; BP = blood pressure; WNL = within normal limits;

RD = registered dietician.

References

1. The Society for Adolescent Medicine. Eating disorders in adolescence: a position paper of Ihe society for adolescent medicine. J Adolesc Health I 995:3( 161:476-80.

2. Fischer M, Golden N. Kat/man D. Ealing disorders in adolescents: a background paper. J Adolesc Health 1995:3(16): 420-37.

3. Massachusetts Department of Public Health. Youth Behavior Risk Survey data file for Boston Public Schools. 1993-1995.

4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washinglon (DC): American Psychiatric Association; 1994

5. Mitchel JE. Pomeroy C. Adson DE. Managing medical complications. In: Garner D. Garfinkel P. Handbook of treatment for eating disorders. 2nd ed. New York: The Gilford Press: 1997.

6. Solomon S. Kirhy D. The refeeding syndrome, a review. J Parenteral Enteral Nutr I990:14( I ):90-7

7. Home I:. Vu/quc/ IM. Kilians SJ. Nutritional problems in adolescence. In: Walker WA. Watkins J. Nutrition in pediatrics. Hamilton (ON): B.C. Decker. Inc.: 1997.

8. Keift' D. Reiff K. Kating disorders: nutrition therapy in the recovery process. Mercer Island (WA): Life Enterprises: 1997.

Additional Resources

Eating Disorder Organizations

AABA: American Anorexia/Bulimia Association 1265 West 46th St. #1 I OS New York. New York 10036 212-575-6200

http://meinhers.aol.com/Amanda

IAEDP: International Association of Eating Disorders

Professionals 123 NW 13th Street. #206 Boca Raton, Fl. 33432-1618 800-800-8126 www.iaedp.com

MEDA: Massachusetts Eating Disorders Association. Inc.

92 Pearl Street

Newton. MA 02158

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