Presentation is loading. Please wait.

Presentation is loading. Please wait.

Eating Disorders in Adolescents Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College.

Similar presentations


Presentation on theme: "Eating Disorders in Adolescents Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College."— Presentation transcript:

1 Eating Disorders in Adolescents Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College

2 Anorexia Nervosa (DSM-IV) Body weight less than 85% of expected Body weight less than 85% of expected Intense fear of gaining weight even though underweight Intense fear of gaining weight even though underweight Disturbance in body image Disturbance in body image In post-menarchal females absence of at least three consecutive menstrual cycles In post-menarchal females absence of at least three consecutive menstrual cycles Two types are defined: Two types are defined: Restricting type Restricting type Binge-eating or purging type Binge-eating or purging type

3 Bulimia Nervosa (DSM-IV) Recurrent episodes of binge eating Recurrent episodes of binge eating A sense of lack of control over eating during these episodes A sense of lack of control over eating during these episodes A regular cycle of self-induced vomiting, laxatives, diuretics, exercise or dieting A regular cycle of self-induced vomiting, laxatives, diuretics, exercise or dieting Two binge-eating episodes per week for at least three months Two binge-eating episodes per week for at least three months Two types identified: Two types identified: Purging type Purging type Non-purging type Non-purging type

4 Epidemiology Anorexia Nervosa Anorexia Nervosa Incidence1/100,000worldwide, in white females in western countries 1/200 Incidence1/100,000worldwide, in white females in western countries 1/200 Incidence in adolescent females 0.5-1% Incidence in adolescent females 0.5-1% Female predominance of 9-10:1 Female predominance of 9-10:1 Becoming more diverse Becoming more diverse Mean age 13.75 (range 10-25 yrs) Mean age 13.75 (range 10-25 yrs)

5 Epidemiology Bulimia Nervosa Bulimia Nervosa Prevalence 1-3% in young females Prevalence 1-3% in young females Prevalence of 3-10% in college aged females Prevalence of 3-10% in college aged females 90-95% female 90-95% female Onset is usually during late adolescence, age range of 13-58 years Onset is usually during late adolescence, age range of 13-58 years

6

7 Family Risk Factors Achievement oriented Achievement oriented Intrusive, enmeshed, overprotective, rigid Intrusive, enmeshed, overprotective, rigid Unable to resolve conflicts Unable to resolve conflicts Frugal with support or encouragement Frugal with support or encouragement Maternal preoccupation with diet, weight and appearance Maternal preoccupation with diet, weight and appearance Positive family history of Eating Disorder Positive family history of Eating Disorder

8 Individual Risk Factors Perfectionist- good little girls Perfectionist- good little girls Feeling of low self-esteem Feeling of low self-esteem Obsessional style Obsessional style Early puberty Early puberty Overweight Overweight History of sexual abuse History of sexual abuse Athletes Athletes

9 Eating Behaviors 40-60% girls in high school have dieted 40-60% girls in high school have dieted 18% reported fasting >24 hrs to control weight 18% reported fasting >24 hrs to control weight 30-40% of Jr. high school girls were concerned with wt. 30-40% of Jr. high school girls were concerned with wt. 42% of college women diet, 10% purge, 7% use diet pills 42% of college women diet, 10% purge, 7% use diet pills 80% of girls in LI HS reported they would be happier at a lower weight 80% of girls in LI HS reported they would be happier at a lower weight

10 Comorbidity Major depression and dysthymia in 50- 75% AN/BN Major depression and dysthymia in 50- 75% AN/BN Bipolar 4-13% of AN/BN Bipolar 4-13% of AN/BN OCD in 25% of AN OCD in 25% of AN Substance abuse 30% of BN, 15% of AN Substance abuse 30% of BN, 15% of AN Personality disorders 42-75% of AN/BN Personality disorders 42-75% of AN/BN Sexual abuse 20-50% of BN Sexual abuse 20-50% of BN Anxiety disorders high in AN/BN Anxiety disorders high in AN/BN

11 History –Eating Disorder Symptoms Pinpoint exact time Pinpoint exact time Reinforcement of behavior Reinforcement of behavior Food faddism, rituals and para-eating behaviors Food faddism, rituals and para-eating behaviors Family characteristics Family characteristics School behavior School behavior Peer contacts Peer contacts Lack of concern Lack of concern Food as a battleground Food as a battleground

12 History Parental concern or patient concern? Parental concern or patient concern? Weight loss- highest wt, lowest wt, patients personal goal wt. Weight loss- highest wt, lowest wt, patients personal goal wt. Menstrual history Menstrual history Exercise Exercise Binging, purging, laxatives, diet pills or diuretics Binging, purging, laxatives, diet pills or diuretics Body image Body image Family conflicts over food Family conflicts over food 24 hour food recall 24 hour food recall

13 History HEADS assessment HEADS assessment Home Home Education Education Activity Activity Drugs/Depression Drugs/Depression Suicide/Sexual Activity Suicide/Sexual Activity ROS- dizziness, syncope, cold intolerance, constipation and abd pain, dry skin and hair, fatigue ROS- dizziness, syncope, cold intolerance, constipation and abd pain, dry skin and hair, fatigue

14 Physical Exam- Vital Signs Bradycardia Bradycardia Hypothermia Hypothermia Orthostatic hypotension- HR inc. 20, BP dec. 20 Orthostatic hypotension- HR inc. 20, BP dec. 20 Weight and height Weight and height

15 Physical Exam General-cachectic, depressed, dehydrated General-cachectic, depressed, dehydrated HEENT- dental enamel erosion, parotid hypertrophy HEENT- dental enamel erosion, parotid hypertrophy Breasts- atrophic Breasts- atrophic Abdomen- scaphoid, palpable stool Abdomen- scaphoid, palpable stool Extremities- acrocyanosis, Russells sign, peripheral edema Extremities- acrocyanosis, Russells sign, peripheral edema Skin- lanugo hair, yellow skin discoloration, bruising Skin- lanugo hair, yellow skin discoloration, bruising

16 Laboratory Evaluation CBC- leukopenia, anemia, thrombocytopenia CBC- leukopenia, anemia, thrombocytopenia ESR- low ESR- low UA- specific gravity, ketones UA- specific gravity, ketones Chemistries- hypokalemia, hyponatremia, BUN high, low Ca, Mg, Phos, LFTs and chol high, carotene elevated Chemistries- hypokalemia, hyponatremia, BUN high, low Ca, Mg, Phos, LFTs and chol high, carotene elevated TFTs- TSH nl, T4 low or nl, T3 low TFTs- TSH nl, T4 low or nl, T3 low Hormones- estradiol low in females, testosterone low in males, prolactin nl, LH and FSH low or low nl Hormones- estradiol low in females, testosterone low in males, prolactin nl, LH and FSH low or low nl

17 Complications Cardiac Cardiac EKG- bradycardia, low voltage, t wave changes, prolonged QTc EKG- bradycardia, low voltage, t wave changes, prolonged QTc Echocardiography- decreased cardiac size, reduced myocardial contractibility, increased prevalence of MVP, Ipecac CM, pericardial effusion Echocardiography- decreased cardiac size, reduced myocardial contractibility, increased prevalence of MVP, Ipecac CM, pericardial effusion

18 Complications Gastrointestinal Gastrointestinal Delayed gastric emptying- abdominal bloating/pain Delayed gastric emptying- abdominal bloating/pain Hypomotility- constipation Hypomotility- constipation Fatty infiltration of the liver Fatty infiltration of the liver Superior mesenteric artery syndrome Superior mesenteric artery syndrome Esophagitis Esophagitis Mallory-Weiss tear Mallory-Weiss tear

19 Complications Neurologic Neurologic Poor attention and concentration Poor attention and concentration Poor problem solving skills Poor problem solving skills Cerebral atrophy Cerebral atrophy Cerebral ventricular enlargement Cerebral ventricular enlargement Atrophy correlates with degree of malnutrition and is reversible with weight gain Atrophy correlates with degree of malnutrition and is reversible with weight gain

20 Complications Osteoporosis Osteoporosis Related to amenorrhea and hypoestrogenism Related to amenorrhea and hypoestrogenism Can lead to increased fracture risk Can lead to increased fracture risk DEXA (Dual Energy X-ray Absorptometry) if amenorrheic >6months DEXA (Dual Energy X-ray Absorptometry) if amenorrheic >6months Exercise not protective Exercise not protective Adequate Ca intake necessary Adequate Ca intake necessary NOT completely reversible even with weight gain and resumption of menses NOT completely reversible even with weight gain and resumption of menses

21 Treatment Multidisciplinary approach Multidisciplinary approach Physician Physician Psychiatrist Psychiatrist Therapist- individual, group, family Therapist- individual, group, family Nutritionist Nutritionist Family involvement a must!!!! Family involvement a must!!!!

22 Out-Patient Management Multidisciplinary approach Multidisciplinary approach Weekly visits- UA, Wt in gown, Food records Weekly visits- UA, Wt in gown, Food records No exercise until Wt gain No exercise until Wt gain Behavioral contract can be used Behavioral contract can be used Medications-SSRIs Medications-SSRIs Weight gain- expect about 1-2lbs per week until goal weight-90% of IBW-resumption of menses Weight gain- expect about 1-2lbs per week until goal weight-90% of IBW-resumption of menses Parents and family need to avoid food conflicts Parents and family need to avoid food conflicts Bulimia- focus on binging not purging Bulimia- focus on binging not purging

23 Indications for Admission Weight <75% of IBW Weight <75% of IBW Dehydration or Electrolyte disturbances Dehydration or Electrolyte disturbances EKG abnormalities EKG abnormalities HR<40, SBP<70, T<35C, Orthostatic HR<40, SBP<70, T<35C, Orthostatic Failure of outpatient management Failure of outpatient management Acute food refusal Acute food refusal Uncontrollable binging and purging Uncontrollable binging and purging Medical/ Psychiatric emergencies Medical/ Psychiatric emergencies

24 In-Patient Management Multidisciplinary approach Multidisciplinary approach Daily weights after voiding and in hospital gown Daily weights after voiding and in hospital gown Behavioral Modification Protocol: Privileges- phone, TV, visitors Behavioral Modification Protocol: Privileges- phone, TV, visitors Start at 1400 Kcal and increase calories slowly, 200Kcal/day Start at 1400 Kcal and increase calories slowly, 200Kcal/day Follow electrolytes carefully for the first week Follow electrolytes carefully for the first week If food refusal use supplements or NGT If food refusal use supplements or NGT Day treatment program as a transition Day treatment program as a transition

25 The Refeeding Syndrome Starved state- catabolic breakdown of fat and muscle- Inc. nutrients in blood Starved state- catabolic breakdown of fat and muscle- Inc. nutrients in blood Refeeding- Carbohydrates inc Insulin leading to anabolic protein synthesis and inc uptake of glucose, phosphorous, and water into cells Refeeding- Carbohydrates inc Insulin leading to anabolic protein synthesis and inc uptake of glucose, phosphorous, and water into cells Combo of TBD of phosphorous during catabolic phase and intracellular influx during anabolic phase leads to severe extracellular phosphorous depletion Combo of TBD of phosphorous during catabolic phase and intracellular influx during anabolic phase leads to severe extracellular phosphorous depletion

26 Refeeding Severe phosphorous depletion leads to decrease in ATP production Severe phosphorous depletion leads to decrease in ATP production Leads to muscle problems- cardiac, hepatic, neuromuscular, respiratory Leads to muscle problems- cardiac, hepatic, neuromuscular, respiratory Most lethal- altered myocardial function/arrhythmia Most lethal- altered myocardial function/arrhythmia

27 Recommendations to Avoid the Refeeding Syndrome Be aware of the syndrome Be aware of the syndrome Recognize the patient at risk Recognize the patient at risk Cardiac monitoring during refeeding Cardiac monitoring during refeeding Increase caloric delivery slowly Increase caloric delivery slowly Administer multivitamins routinely and neutrophos if phosphorous drops <3.0 Administer multivitamins routinely and neutrophos if phosphorous drops <3.0 Carefully monitor electrolytes daily for the first week and then biweekly Carefully monitor electrolytes daily for the first week and then biweekly

28 Prognosis 50% good outcome, 25% intermediate outcome, 25% poor outcome 50% good outcome, 25% intermediate outcome, 25% poor outcome Mortality less than 4% Mortality less than 4% Of those that recover- 1/3 recover over 3yrs, 1/3 by 6yrs, 1/3 by 12yrs Of those that recover- 1/3 recover over 3yrs, 1/3 by 6yrs, 1/3 by 12yrs Adolescents better prognosis than adults Adolescents better prognosis than adults

29 Prognosis Poor prognosis Poor prognosis Early Onset Early Onset Longer duration of illness Longer duration of illness Lower weight Lower weight Failed previous treatment Failed previous treatment Personality disorder/ depression Personality disorder/ depression Difficult family relationships Difficult family relationships Social Isolation Social Isolation


Download ppt "Eating Disorders in Adolescents Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College."

Similar presentations


Ads by Google