1. Eating Disorders Anorexia Nervosa DSM-IV Definition 1) Refusal to maintain body weight within a normal range for height and age ( > 15% below ideal weight) 2) Fear of weight gain 3) Severe body image disturbances (self-worth and denial of serious illness) 4) Absence of menstrual cycle/ amenorrhoea (for > 3 cycles) 2 subtypes = restricting + binge/purging

2. Eating Disorders Bulimia Nervosa DSM-IV Definition 1) Episodes of binge eating (loss of control) 2) Followed by compensatory behaviour of –Purging type (vomiting, laxatives, diuretics) –Non-purging (execise, fasting, diets) 3) Occurring > 2x / week for 3/12 4) Dissatisfaction with body shape / weight

3. Epidemiology 1-2 million BN in USA 1/2 million AN in USA AN prevalence overall = 0.27% AN prevalence in 15-19y = 0.48% BN prevalence overall = 1.5% BN is more common in the >18y Women 10:1 Men Many more have ED-NOS ( eating disorder not otherwise specified

4. Pathogenesis Social pressure Female athelete triad (eating disorder, amenorrhoea, and osteoprosis) Related to a combination of psychological, biological, family, genetic, environmental and social factors. Decreased self esteem or self control then using dieting behaviour and weight loss as a way of providing stability/ control on life. Genetics = Monozygotic twins and 1st degree relatives have higher rates of eating disorders, Xolism, affective disorders

5. Pathogenesis Sexual abuse - no evidence Family characteristics = high parental expectations, difficulty managing conflict, poor communication skills, enmeshment, estrangement, devaluation of maternal role and maritial tensions. CNS / Hormonal –Nad = bradycardia and hypotension in starvation –Serotonin = high in AN, affects the appetite and satiety centres

6. Screening SCOFF Score >2 Sick Control ( or rather loss of it ) One stone in < 3/12 Fat Food dominates life

7. Examination Vital signs ( PR and BP) Lanugo hair Callous formation Parotid gland hypertrophy Erosion of dental enamel on anterior teeth CVS ( bradycardia, arrhythmias, MVP ) GI Neuro

8. Investigations FBC (anaemia) Ur + Cr (dehydration) Electrolytes + K, Ca, Mg, PO4 B- HCG TFTs Prolactin (prolactinoma) FSH

9. Complications Osteoporosis Cardiac impairment Psychiatric + Cognitive Changes Infertility GI Dysfunction ( slow motility, N, bloating) Electrolytes ( K, metabolic alkalosis ) Endocrine –low LH and FSH –Sick euthyroid ( high rT3 ) –low DHEA + IGF-1 –high cortisol + GH

10. Osteopenia / Osteoporosis Women accrue 40-60% of their bone mass during the adolescent years Seen in 90% of those with AN Long term risk of fracture increases x 3 Causes- oestogen deficiency - inadequate Vitamin D and Ca - Lean body mass and nutritional Pathophysiology - increased bone resorption - decreased bone formation (differing from meopause)

11. Osteopenia / Osteoporosis Rx Ix with DEXA then; 1) Weight gain 2) Elemental Ca 1200 - 1500 mg/ day 3) Multivitamins providing 400 IU Vit D / day 4) Oestrogen/ Progestin –no proven benefit as process is different to menopause –some benefit if < 70% ideal body weight 5) IGF-1 (short term effects) 6) DHEA –increases formation and decreases resorption in the short term

12. Cardiac Mx MVP occurs in 30 - 60% (3Xpopulation) –this is partly due to enhanced ability to detect MVP in patients with intravascular volume depletion Prolonged QT interval seen in 33% –independent marker for arrhythmias and sudden death Heart Failure in the first 2/52 of Re-feeding –Reduced cardiac contractility –Refeeding oedema –Mx by slow refeeding, repletion of PO4, avoid high Na

13. Amenorrhoea Seen in 90% of AN Low levels of LH + FSH = low Oestrogen Mx = Increase weight Menses restarts in 90% in < 6/12 after achieving 90% ideal body weight

14. Multidisciplinary Mx a) Medical Provider –Vital signs –Fluoxetine (proven benefits in BN>AN) –Anxiolytics in AN prior to eating –Metoclopramide (delayed transit = bloating + constip) b) Mental Health Provider –Individual and cognitive behavioral therapy –superior to medication, but synergistic with it c) Nutritionalist –Specific and meal plan requirements –Weight goals

15. Hospitalisation Severe malnutrition (<75% IBW) Dehydration Electrolyte Disturbance Cardiac Dysrythmias Physiological AbNs (eg brady, hypotensive) Arrested Growth and Development Failure of Outpatient treatment Complications (medical of psychiatrical) Admission long enough to increase weight >90% IBW improves eventual outcome

16. Management Nutritonal –IP Expected weight gain 0.9-1.4 kg/week –OP Expected weight gain 0.2-0.5 kg/week –Start intake at 30-40 kcal/day (1000-1600kcal/day) –Rapid early weight gain is related to fluid retention and to low metabolic rate Refeed Syndrome –At risk are those > 10% beneath their ideal body weight –Hypophosphataemia –Decreased IC ATP = impaired enegy stores –Decreased rbc 2,3-DPG = tissue hypoxia –

17. Outcome AN –50% good outcome –25% intermediate ( with relapses) –25% poor ( associated with later age of onset, duration, lower minimum weight, strong maturity fears ) –30 - 70% fully recovered at 20y follow up –10% continue to meet criteria for AN at 12y BN –30% continue to meet criteria for BN at 10y –Low self esteem associated with a poor outcome –Dehydration Mortality Rate in AN = 6.6% –54% complications, 27% suicide, 19% others