WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC)
It has been estimated that the prevalence of anorexia nervosa is 0.5% in high school and college-aged women and that 1% to 3% of young women meet criteria for the diagnosis of bulimia nervosa. In addition, many more women display evidence of milder forms of eating disorder behaviors. The first step in detecting the onset of an eating disorder is to be familiar with the diagnostic criteria for the major types of eating disorders, including: anorexia nervosa -- identified most simply by significant weight loss and a decrease in nutritional input; bulimia nervosa -- marked by binge and purge behavior with or without weight loss; and eating disorder not otherwise specified -- which is a category that includes patients with eating disorder behaviors and thoughts who do not meet all of the official criteria of anorexia nervosa or bulimia nervosa. All these eating disorders are precipitated by a fear of weight gain and / or obsession with body image. Clinicians who treat young adult women in gynecologic settings will undoubtedly see many patients with eating disorders, especially since menstrual irregularity is one of the hallmarks of the condition.
The purpose of this document is to help early detection and management of eating disorders in adolescents and young adult females. Early detection and management of eating disorders are key factors in improving the course and outcome of the illness. The roles of the individual practitioner in the initial stages of management are to detect the presence of the eating disorder, to perform the initial evaluation, and to refer the patient to appropriate level of care. Coordination with the patient's family, primary care physician, nutritionist, and / or mental health provider is often necessary.
Three most common eating disorders are: Anorexia Nervosa, Bulimia Nervosa and Obesity. Anorexia Nervosa and Bulimia Nervosa are discussed in this chapter. Obesity will be addressed in a separate chapter.
I. Anorexia Nervosa:
It is an elusive and noteworthy disorder among adolescent and adult females. It is characterized by extreme weight loss, body-image disturbance, and an intense fear of becoming obese. This disorder has been recognized since the turn of century. The anorexia nervosa of the 20th century has historical correlates in the religiously inspired cases of "anorexia mirabilis" in female saints, such as Catherine of Siena (1347-1380) in whom fasting denoted female holiness or humility and underscored purity. The investigation of anorexia nervosa in the 20th century has focused on the psychological, physiological, psychodynamic, psychosocial, and multidimensional factors. Anorexia nervosa occurs less frequently in males. Although the course of anorexia in males does not differ from that in females, detection is often more difficult.
Lifetime prevalence of anorexia nervosa, according to large-scale population surveys, ranges from 0.1% to 0.7%. Prevalence of dieting concern and weight preoccupation measured in children, grades 3-6, was reported as 45% wanted to be thinner, 39% had tried to lose weight, and 6.9% scored within the high risk range of the Eating Attitudes Test. Age at onset ranges from 8 years to the mid - 30s, with bimodal peaks at 13-14 and 17-18 years. Prepubertal girls are presenting with anorexia nervosa with increasing frequency.
High Risk Population:
Populations most likely to be at a greater risk for anorexia because of occupational and recreational environments include ballet dancers, female models, and male long distance runners. Each of these activities requires highly focused attention on weight and appearance and on lean body mass. Other susceptible groups include women with mood disorders, particularly depression; and women in professions that require high standards of achievement and appearance. Although men constitute a smaller statistical group of anorexic patients, more susceptible groups are male homosexuals and runners. Sexual abuse is commonly found among clinical populations of anorexia nervosa.
Diagnostic Criteria for Anorexia Nervosa:
DSM-IV (American Psychiatric Association, 1994) criteria for anorexia nervosa are:
- Refusal to maintain body weight at or above a minimally normal weight for age and height; that is, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 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.
- In postmenarcheal females, amenorrhea, or the absence of at least three consecutive menstrual cycles (A woman is considered to have amenorrhea if her periods occur only following hormones).
Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Binge-eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Physical symptoms: Common complaints include cold intolerance, dizziness, constipation, abdominal discomfort and bloating. Despite having malnutrition, the patient with anorexia is often hyperactive. Lethargy is worrisome because it may indicate cardiovascular compromise or severe depression.
Physical Examination: Patients wear multiple layers of bulky, oversized clothing and appear younger. Cachexia and breast atrophy are noticeable. The skin is often dry and may be yellow-tinged as a result of carotenemia. Bradycardia, hypotension, hypokalemia, growth of lanugo hair, alopecia, and edema of legs are present, as well as dental enamel erosion and lesions on the hands.
Medical Complications: Life threatening complications involve the cardiovascular, hematological, gastrointestinal, renal, neurological, endocrine and skeletal systems of body. Death is frequently due to multiple organ failure.
Key Laboratory Tests:
- Electrolytes and urinalysis to evaluate diuretic use; exclusion of low potassium, phosphorus, acidosis and alkalosis is essential and could be life saving too.
- Thyroid function tests to exclude thyrotoxicosis in anorexia nervosa.
- Carotene to exclude malabsorption. It is high in anorexia nervosa.
- Erythrocyte sedimentation rate (ESR) to exclude inflammatory bowel disease. It is low in anorexia nervosa.
- Albumin, total protein - usually normal in Anorexia Nervosa.
- Gastric emptying study/ upper gastrointestinal (GI) radiography to exclude achalasia. These tests are often abnormal in anorexia nervosa.
- Cholesterol is usually normal or elevated in acute anorexia.
Organic illness may mimic signs and symptoms of eating disorders. They include diabetes mellitus, Crohn's disease, colitis, thyroid disease, inflammatory bowel disease, acid peptic disease, intestinal motility, and brain tumors. Psychiatric disorders that may manifest as weight loss and purging include conversion disorder, schizophrenia, and mood disorders.
Patients are typically resistant to initiating treatment focused on weight gain. Evaluation of the anorexic patient should incorporate a team approach and include medical, psychiatric, family, and nutritional assessment. Inpatient treatment of anorexia nervosa is mandated by the severity of the patient's physical and psychological status. Family must be aware that the administration of a feeding regimen is a life-saving act rather than a punishment. Many techniques seem to be effective, but none has been validated or proven effective in the long run by prospective, double-blind, empirical inquiry.
Psychotherapy, pharmacotherapy, group therapy, and family therapy are the treatment programs used to treat anorexic patients.
Keys to Treatment:
- Establish seriousness of the condition with patient and family.
- Evaluate and replenish metabolic and nutritional deficits.
- Behavior modification is a critical component of the treatment.
In conclusion, anorexia nervosa is a life-threatening disorder that has come to the forefront of public attention during the past 30 years. The successful collaboration of clinical researchers from all disciplines is necessary to understand its causes and treatment.
II. Bulimia Nervosa:
"No woman can be too rich or too thin" (an observation often attributed to Dorothy Parker) was a supposed catchphrase of upper-class women for 60 years or more. The "too thin" component has now permeated Western cultures to such an extent that reports of children worrying about being or becoming fat and starting to restrict food intake does not come as a surprise. The clinical course that leads to anorexia nervosa or bulimia nervosa usually starts with a female or male's dissatisfaction or unhappiness with herself or himself.
DSM-IV Diagnostic criteria for Bulimia Nervosa:
- Recurrent episodes of binge-eating. An episode binge-eating is characterized by both of following:
- Eating in a discrete period of time (that is, 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.
- A sense of lack of control over eating during the episode (that is, 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, such as self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur in average at least twice a week for 3 months.
- Self-evaluation is unduly influenced by body shape and weight.
Purging Type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Most bulimic patients are unhappy, and many have severe anxiety. Hunger is the initial stimulus to over-eat, but anxiety eventually takes its place. Binge eating has been described as an escape from self-awareness, and its use appears to block out cognitions and emotions. Some symptoms may meet the criteria of major depressive disorder. Perfectionism is frequently seen in patients with eating disorders. Abuse of alcohol and drugs also has been a co-variable with eating disorders.
Physical Examination Findings:
Most findings on physical examination are related to the degree of starvation or purging. Physical findings are quite similar to anorexia nervosa as stated above. Scarring may be seen on the back of fingers where front teeth abrade the skin during self-gagging.
It is the same as discussed above for anorexia nervosa. Diagnostic testing should be used prudently, as unnecessary testing may augment, encourage, or exacerbate the patient's denial.
Most of the drugs studied in the treatment of bulimia nervosa have been antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOI). Cognitive-behavior therapy, interpersonal therapy, and psycho-educational therapy is useful. Key points in the treatment are to evaluate and replenish metabolic and nutritional deficits. Establish seriousness of the condition with patient and family and behavior modification is a critical component of the treatment.
Your healthcare provider will guide you and do not hesitate to address the issues to your Primary Care or your Obstetrician and Gynecologist for help.
Professionals from many disciplines are getting involved to address the decline in self-esteem and self-confidence of girls entering puberty. For many girls thinness has become the promise to feel better, to look better, to have more friends, and to attract boyfriends. Dieting has become a primary coping strategy for many youngsters. How these aberrant values have developed and how to counteract ideas that promote such false notions and promises should be dealt with effectively. Western industrial countries worldwide appear to be spawning fat-phobic children and teenagers.
- World Health Organization (WHO)
Mental Health of Children and Adolescents
- National Institutes of Health (NIH)
- Centers for Disease Control and Prevention (CDC)
Screening High School Students for Eating Disorders
- American Academy of Pediatrics. Committee on Adolescence. Identifying and treating eating disorders. Pediatrics 2003;111(1):204-211
- Franko DL, Spurrell EB. Detection and management of eating disorders. Obstet Gynecol 2000;95:942-946
- Breech L, Quint EH, Spigarelli MG. Secondary amenorrhea and disordered eating. J Pediatr Adolesc Gynecol 2005;18:189-192
- Fisher M. Treatment of eating disorders in children, adolescents, and young adults. Pediatr Rev 2006;27(1):5-16
- Gittes E. Eating disorders in adolescents. J Pediatr Adolesc Gynecol 2004;17:417-419
- American Psychiatric Association Working Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry 2000;157(1Suppl.):1-39
- Kouba S, Hallstrom T, Lindholm C et al. Pregnancy and neonatal outcomes in women with eating disorders. Obstet Gynecol 2005;105(2):255-260
- Hall CH, Hewitt G, Stevens SL. Assessment and management of bone health in adolescents with anorexia nervosa: Part two: Bone health in adolescents with anorexia nervosa. J Pediatr Adolesc Gynecol 2008;21:221-224
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