Course Authors

Kathryn J. Zerbe, M.D.

Dr. Zerbe is the Jack Aron Professor of Psychiatric Education and Women's Mental Health and Director of the Eating Disorders Program at the Menninger Clinic, Topeka, Kansas. Dr. Zerbe reports no commercial conflict of interest.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 

Learning Objectives

Upon completion of this Cyberounds^®, you should be able to:

• Discuss medical complications that afflict anorexia and

• List the major sequelae of malnutrition and the complications of the refeeding syndrome

• Describe the most common etiological factors and clinical manifestations important in the clinical management eating disorders patients.

 

Eating Disorders (e.g., anorexia nervosa and bulimia nervosa) are on the rise in our society and cause the highest mortality and medical morbidity of any psychiatric disorder.(1) Medical complications of these two disorders are ubiquitous and can affect every system of the body. While the plight of an emaciated, malnourished patient (i.e., anorexic) is apparent by observation alone, diagnosis of bulimia (see Table 1 below) can be more challenging.

Based on the American Psychiatric Association's Diagnostic and Statistic Manual, IV

Warning Signs Leading Toward a Diagnosis

Clinicians often suspect they have a patient with bulimia in their practice based on weight fluctuation, preoccupation with diet, foul breath or the reports of family members. A doctor might note on a weight chart, for example, the classic "saw-tooth" pattern of up and down weights over a period of months or years and/or some minor electrolyte problem on yearly blood chemistry. When the doctor asks questions about purgative methods such as diuretic abuse, chronic use of laxatives, over-exercise or self-induced vomiting, the bulimic patient is likely to deny them and continue to deny them for a long period of time.

Preoccupation with body image and obsession with "feeling fat" characterize eating disorders and are often the basis for a clinician's exploring this diagnosis.(2) In fact, preoccupation with body image and the fixed belief that one is fat, despite being normal or even underweight, is so pronounced in those with eating disorders that many clinicians may assume the patient is "delusional" or psychotic.(3) However, the definition for delusion is not fulfilled in these cases because when confronted by an experienced psychiatrist, the patient has some insight into the fact that her beliefs about herself are inaccurate. Usually, a relationship of trust must be built with the patient and her family members in order for the patient to acknowledge self-imposed periods of restrictive.

A suspected eating disorder in an older woman should otherwise be assessed with the same clinical tools as at any other point in the lifecycle. Look for preoccupation with body image, excessive attempts to lose weight or over-exercise to "keep one's weight off", preoccupation with other physical attributes, including turning to plastic surgery or liposuction to "stay thin" as well as other psychiatric syndromes which are often co-morbid with an eating disorder. These include depression, anxiety disorders (especially obsessive-compulsive disorder), borderline personality disorder and substance abuse.(9)

The Epidemiology of Eating Disorders

Before exploring the specific medical complications of these disorders, it is essential for clinicians to be aware that the epidemiology of eating disorders is changing. Once believed to be disorders that affect white, affluent girls or women and to be primarily observed in late adolescence and early adulthood, studies now show that African-Americans and other minorities are afflicted with eating disorders (especially Binge Eating Disorder and Bulimia) in growing numbers.(4)

Boys and men are also at increasing risk for eating disorder. Although the female to male ratio is 9:1, males who participate in certain sports (e.g., wrestling, gymnastics, running), are homosexual or have problems with addiction and personality disorders are at risk for an eating disorder.

Eating disorders occur in all socioeconomic classes. However, clinicians tend not to ask minorities or patients of lower socioeconomic status about eating disorder symptoms.(7),(8) Additionally, these individuals are less likely to seek psychiatric care than middle or upper class women. Moreover, eating disorders are observed throughout the entire lifecycle with children, even in pre-school or grade school, demonstrating eating problems, preoccupation with weight, size and dieting behaviors.

Clinicians must be aware of a natural bias towards ageism when assessing for an eating disorder. Several case reports have described full-fledged eating disorders in women from the climacteric to old age. In this population, depression must be ruled out as a cause for weight loss or weight gain.

Etiology

As with most mental disorders, one can't really speak of a specific cause of eating disorders so much as a set of influences that have a demonstrated correlation to the presence of eating disorders. Among pre-school children, a strong association exists between children's feeding problems, disturbed parental attitudes about food and weight and the presence of maternal eating disorders.(5) For example, one mother knew the difference in fat gram content between two leading kinds of baby food. Her astute pediatrician surmised she was struggling with a recrudescence of body image problem and food restriction after the birth of her daughter.

Ironically, being overweight is also a factor. As many as 50% of grade school children are overweight and with increased obesity in childhood comes an increase in diseases in children that we used to see only in adults. However, youngsters who are teased about their weight or are sensitive to cultural attitudes show higher levels of restrained eating and dieting behaviors than others. This fact is significant because it is postulated that restrained eating and dieting may be one of the predisposing factors to developing a full blown eating disorder. Some children with anorexia may have a pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). These children respond to conventional treatment plus antibiotics. The link between infectious disease and some cases of anorexia is made from clinical evaluation, throat culture and serological tests (i.e., antideoxyribonuclease B [anti-D nase B] and anti-streptolysis O [A SO] titres).(6)

New evidence points to a strong genetic predisposition as a cause in development of anorexia nervosa or bulimia nervosa.(10),(11) This potential genetic link can be useful in treatment, for it relieves the patient of the sense of guilt and responsibility that can be so intolerable to a patient as to encourage them to deny the problem. If you point out that the best medical evidence to date links genetic factors to a significant risk for anorexia nervosa and/or bulimia nervosa, you can establish a non-adversarial relationship with the patient.

Nevertheless, also be sure to ask about any history of childhood physical or sexual abuse, or adult trauma such as rape. A host of converging studies indicate that a significant number of patients (30 to 60%) will at some point in their course of treatment acknowledge or be able to identify a history of physical or sexual trauma. Indeed, post-traumatic stress disorder is another frequent co-morbid diagnosis of an established eating disorder.(12)

Medical Evaluation of the Patient with an Eating Disorder

The most commonly occurring medical syndromes are summarized by body systems in Table 2.

Table 2. Medical Complications of Anorexia and Bulima Nervosa.

Unfortunately, there are no pathognomonic findings or objective laboratory measures that absolutely rule out disordered eating. Frequently, a patient who has suffered with an eating disorder for an extended period of time will have absolutely normal laboratory values. However, it is still important to do a panel of recommended laboratory tests to detect any hidden difficulties that need immediate medical interventon (see Table 3).

Hematologic and Metabolic Concerns

Low white and red blood cell counts can occur, reflecting bone marrow suppression due to malnutrition. An increase in leukocytes from infection may be overlooked due to low baseline levels. In anorexic patients, one must be on guard for the development of possible infections. Also, these patients may not appear febrile in infectious states because of baseline hypothermia.

Patients with bulimia nervosa commonly develop electrolyte abnormalities as a result of binge eating and purging. One of the side effects of frequent purging, hypokalemia, is of special concern because of the possible complications of cardiomyopathy, cardiac conduction defects and nephropathy. Because hypokalemia is potentially life threatening, most authorities agree that serum potassium should be routinely assessed. However, studies of patients with bulimia have demonstrated that routine laboratory studies often reveal no abnormality in serum potassium.(13),(14) Furthermore, many patients with electrolyte abnormalities are clinically asymptomatic.

Some third party payers will only allocate benefits if there is a significantly abnormal level of serum sodium, potassium, chloride, creatinine, albumin, magnesium or phosphorous. Clinicians must work to have benefits not based on the presence or absence of laboratory values alone but, instead, on the overall medical condition of the patient, the longevity of the illness and the tenacity to which the patient appears to hold to her disordered eating or disordered exercise behavior. All parties involved in the case must be helped to understand the body's capacity to "adjust" to the malnourished state; sudden death can and does occur, regardless of normal laboratory values, due to other complications (refer to Table 2).

Blood glucose levels often decrease with low weight in anorexia nervosa. Individuals are generally asymptomatic even if blood glucose levels are in the 40 to 60 mg/dl range. It is usually considered a poor prognostic sign if levels are less than 40 mg/dl because this indicates depleted hepatic glycogen stores.

Endocrinologic Complications

Thyroid function tests should always be done, as patients with anorexia nervosa might be misdiagnosed as having hypothyroidism or hyperthyroidism. It is now generally recommended that patients who are 20% or more below ideal body might have a dual energy x-ray absorptionmetry (DEXA) scan to assess bone density of the hip and spine. Research studies have found that weight recovered patients continue to show signs of progressive bone loss and/or ongoing osteoporosis that is not reversible.(15),(16) Because the ability to restore bone mass is impaired, even with treatment, it is all the more important for clinicians to recognize an eating disorder early and to intervene with primary osteoporotic prevention strategies.

Most important for the malnourished patient is to restore weight because this halts the rapid decline in bone density. Low bone mass in the malnourished patient derives from a multiplicity of factors including estrogen deficiency, malnutrition, increased cytokine secretion, low calcium intake and stress-related enhanced cortisol secretion. Clinical opinion has converged that in the majority of patients, estrogen replacement therapy is not helpful for the patient with hypothalmic dysfunction, menstrual abnormalities and the loss of bone mass associated with anorexia nervosa.(17) Be aware that low bone mass is more prevalent in women with anorexia nervosa than those with bulimia nervosa.

Cardiovascular Complications

Patients with eating disorders are vulnerable to a wide range of cardiac complications related to semi-starvation and various methods of purging. The most immediately dangerous are cardiac arrythmias and prolonged QT intervals, especially when associated with electrolyte disturbances.(18) When the process of refeeding the patient is too rapid or aggressive, congestive heart failure can develop.

"Refeeding syndrome" was studied during World War II. Experiments using conscientious objectors who voluntarily agreed to lose a percentage of their body weight were performed to assess the medical and psychiatric effects of starvation. As a result of this weight loss, the volunteers became hypotensive and their cardiac size diminished (earlier, it had been believed that the heart was immune to the effects of chronic malnourishment). Now, it is understood that reduced heart mass makes it difficult to handle increased circulatory blood volume, which can result in heart failure early in the refeeding process. Skilled medical supervision is necessary to avoid fluid overload and calorie intake should increase by 200-300 Kcal every other day. Once the patient has achieved a stable recovery weight (usually within a few weeks), they are usually out of jeopardy for the refeeding syndrome.(19),(20)

Significant weight loss also produces increased vulnerability to mitral and tricuspid valve prolapse and regurgitation. Venticular valvular disproportion has been postulated to account for this "side effect" of malnourishment. With weight loss, the heart decreases in size and muscle mass but the valves, which are structural tissues, do not. Hence, the valve prolapses and blood is regurgitated into the heart chamber.(21)

Other symptoms that may indicate cardiac problems include fatigue, reduced exercise tolerance, light-headedness or syncopy, acrocyanosis, palpitations, chest pain, leg pains and dyspnea. Although capacity to exercise improves with weight restoration, it has not yet been demonstrated to normalize even after ideal body weight is achieved. It may take six or more months of being at a healthy weight to have normal tolerance to exercise.

Patients who abuse syrup of ipecac are prone to develop cardiomyopathy and have died from the cardiac toxicity of this substance. Other methods of purging (e.g., self-induced vomiting, abuse of enemas, abuse of laxatives, abuse of diuretics) result in low potassium levels contributing to cardiac arrythmias. Hypomagnesia or hypophosphatemia are also dangerous, necessitating inpatient hospitalization until stabilization. Usually, the frequency of purging behaviors determines the potential for associated cardiac complications.

Because most patients with electrolyte abnormalities have been ill for years, the majority of normal weight bulimics can be treated as outpatients while an eating stabilization program is attempted and psychotherapy begun. However, studies also demonstrate that a three-week residential or inpatient hospitalization is necessary to break the binge/purge cycle. Strict behavioral methods are employed by skilled nursing staff (e.g., locked bathrooms; supervised post-prandial meetings that are high risk times for the patient to purge; supervised access to kitchen) to help the patient gain control over this self-destructive symptom.

As stated, the possibility for sudden death is always present. Indeed, one wonders how many individuals have died as a result of electrolyte or cardiac abnormalities where the final common pathway was a covert but undiagnosed eating disorder. Likely, we will never know, but can only suspect, that many patients have died from an undiagnosed, untreated eating disorder which resulted in a sudden metabolic or cardiac catastrophy. Clearly, the accurate assessment of the morbidity and mortality of anorexia and bulimia is a significant issue for the women's health initiative because only then can we be sure of the actual toll these disorders take.

Dental Complications

Bulimia nervosa patients should have a thorough oral cavity examination by a dentist. Chronic regurgitation of acidic gastric contents causes dental problems which include angular cheilosis, enamel and dentin loss on the lingual surface of the teeth (perimolysis), dental caries, pharyngeal soreness, gingivitis and salivary gland hypertrophy (sialadenosis).(22) Sialadenosis results in the common finding, on physical examination, of "chipmunk face." A fractionated serum amylase level confirms any elevation that is due to salivary or pancreatic origin. Other causes of sialadenosis (e.g., infection, Sjogren Syndrome, diabetes and alcoholism) must be ruled out. Because pancreatitis is a less common but important complication of an eating disorder, with some cases presenting without characteristic abdominal pain, it is sometimes useful to draw a serum lipase level.(23)

Stopping self-induced vomiting is the best way to treat and to prevent oral complications of bulimia. However, if the patient is unable to curtail this self-destructive behavior, they are advised to rinse after each purging episode with water or with a baking soda and water mixture to neutralize acid residue. Advise the patient to avoid aggressive brushing with a fluoride toothpaste. Vitamin supplements (particularly B₂ and B₆) may be recommended to treat cheilosis.

Gastrointestional Complications

Gastrointestional complaints, while common in anorexia and bulimia nervosa patients, tend not to be life threatening, except for the rare occurrence of an esophageal or gastric rupture (see Table 2). In the past ten years, delayed gastric emptying time has been found to be a common complaint in these patients that contributes to pain and discomfort during refeeding. Gastroparesis develops when the patient has lost significant (usually at least 10 pounds) of weight.(24),(25) When it occurs, it is accompanied by bloating, nausea, satiety, reflux and vomiting that is no longer self induced. Weight gain typically improves the feeling of bloating but take several weeks to occur.

The refeeding process can be hampered by the physical sequella of gastroparesis, which makes the patient feel uncomfortable as weight is restored. Some oral medications [e.g., Propulsid^® (cisapride)] can improve this condition but caution must be exercised because cardiac conduction abnormalities that are common with the eating disorders can be exacerbated. Sometimes, patients benefit from ingesting liquid food supplements, instead of solid foods, or drinking a liquid load prior to eating in order to reduce the physical complaints of gastroparesis.

Other gastrointestional complaints include reflux, constipation, pain and irritable bowel syndrome. When weight gain does not improve, despite psychological treatment in a compliant patient, occult disease must be ruled out (see Table 4).

What distinguishes a patient with anorexia from a patient who loses weight due to a medical illness is the emphasis the anorexic places on body image and lack of investment in gaining weight (if female). Males with anorexia are preoccupied with body image but tend to want to have a slender waist and a muscular, athletic shoulder and chest ("reverse anorexia").

Be aware that most eating disordered patients will complain of constipation. Advise patients that this problem is usually alleviated when caloric intake returns to normal. Some patients mistakenly believe that the use of laxatives causes weight loss; they must be educated that this is not only an ineffective method of weight control but can lead to abdominal pain, hypokalemia and long-term damage to colonic nerve cells (especially if stimulant type laxatives are abused). Be sure to take into account any medications that may be exacerbating constipation (e.g., tricyclic antidepressants); newer antidepressants used in the treatment for bulimia nervosa (SSRIs) have the benefit of not producing as much constipation as the older drugs. Fluoxetine, in particular, has been demonstrated to be a helpful adjunct in the treatment of bulimia nervosa and weight-restored anorexics.

A Word About Treatment

A discussion of the comprehensive psychiatric treatment necessary for the recovery of a patient with an eating disorder is beyond the scope of this Cyberounds^®; state of the art research indicates that a multidimensional approach involving nutritional management, psychotropic medications, individual, group and family psychotherapy and patient education classes all work synergistically to improve long-term prognosis.(26) In particular, cognitive-behavioral and interpersonal psychotherapy used in conjunction with psychotropic medications seem to have the best results in the treatment of bulimia nervosa. In general, anorexia nervosa is a more difficult illness to treat and requires periods of inpatient and day-hospital intervention to addition to psychotherapy to reverse its chronic course.

Most eating disorder experts believe that treatment requires the concerted involvement of a primary care physician to realistically address the patient's physical states(27) and monitor laboratory studies. Including the primary physician as an essential member of the patient team (including psychiatrist, nutritionist) helps address the issue of trust alluded to earlier. The patient must be told that all members of the team will stay in close communication, which helps increase her feeling of security while confronting the tendency to keep important facts out of the treatment.

For each of these disorders, stabilization of nutrition is the keystone of recovery. Recovery weights should be targeted to at least 90% of normal body weight; as weight is restored to normal, many of the psychological effects of starvation (i.e., anergia, poor concentration, irritability, depression, etc.) disappear and a significant majority of patients resume their menses.

Most authorities now believe that a slow refeeding process is optimal with an average weight gain of two to three pounds per week. Some patients will need as many as 3,000 -- 3,600 calories per day in order to begin gaining weight again. For patients who have been restricting their diet to 500 -- 750 kilocalories per day, the thought of eating a varied diet, which contains elements from each level of the food pyramid including fat, can be terrifying. Hence, it is essential for a skilled nutritionist to be involved in the initial phase of "refeeding" to instruct the patient about maintaining a healthy diet.

Patients should be started on a 1,000 calories per day diet, divided into three to five meals, with gradual progression over a period of days. Optimally, meals should be supervised by experienced nursing staff members in an inpatient, residential or intensive day hospital setting. Here, medical complications that occur during the refeeding process can be monitored. Without adequate nutrition, patients are simply unable to participate in the kinds of psychotherapeutic activities that enable them to master their symptoms.

Psychotropic medications are effective only when patients have restored their weight to 85% of the ideal range. Research studies demonstrate that fluoxetine may aid selected anorexia patients in maintaining their weight added, help bulimics stop purging and prevent relapse in some groups of bulimics.(28),(29),(30),(31),(32),(33)

Conclusion

Treatment of the person with an eating disorder is challenging for the primary care clinician and the psychiatrist. While focus must be placed on the medical complications of these disorders and the possibility of sudden death or long-term morbidity, caregivers must also remember that at least 50% of patients improve if appropriately treated with nutritional stabilization, pharmacotherapy and psychotherapy.

Because the conditions are life threatening, those working with eating disordered patients must be able to tolerate the anxiety of having in their practice patients with a chronic, potentially fatal illness and being content with doing one's best. In this effort, it is important to be vigilant but straightforward about the medical complications that can arise quickly and unpredictably (e.g., arrhythmias) or over a long period of time (e.g., osteoporosis).

Clinicians who are patient and compassionate often make an impact by helping the eating disordered individual learn new methods of self-care. As the patient masters new coping skills in psychotherapy, she enhances her understanding of the relationship between her body, her feeling states and her cognitive dysfunctions and, thus, matures in her capacity to engage in interpersonal relationships and healthful behaviors. In these ways, treating the eating disordered patient is not only life-saving but gratifying.