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OUTPATIENT MANAGEMENT OF

EATING DISORDERS
Beth Gargaro, MD
Triple Board Chief Resident
beth.gargaro@hsc.utah.edu
PCH, 7/16/18
BUT I’M NOT A PSYCHIATRIST…
PEDIATRICIANS ARE ON THE
FRONT LINE

See children and adolescents regularly

Are often parents’ first stop when they have a concern

Are used to monitoring growth curves, weight


TREATMENT IS A TEAM EFFORT

Requires multidisciplinary
approach:

Pediatrician

Dietitian

Psychotherapist

+/- Psychiatrist and/or


Adolescent Medicine Specialist
MORE THAN JUST ANOREXIA

Anorexia Nervosa
Restricting type
Binge/Purge Type
Bulimia Nervosa
Binge Eating Disorder
ARFID
OSFED
Pica
Rumination disorder
Unspecified Feeding or Eating Disorder (only use if not enough info to diagnose;
usually NOT billable/reimbursed by insurance)
QUICK PRIMER ON ETIOLOGY
OF EATING DISORDERS

Genetically susceptible individual

environmental triggers

Eating Disorder
IF YOU SUSPECT AN EATING
DISORDER…

…ALWAYS screen for suicidality, self-harm, and


substance abuse!
CASE #1

A 14 yo girl presents for pre-sports physical.Your MA


notifies you that she is bradycardic with pulse of 53.
You immediately glance at height and weight, which are
the 25th and 28th percentile respectively. This is
reassuring to you, but you vaguely remember this
patient being on the heavier side last time you saw her.

Parents note that indeed she had been on the heavier


side previously, but that after you counseled her on
importance of healthy lifestyle and weight management
last year, she has adopted a vegan diet and joined the
cross country team. She is now running daily.

You mention the bradycardia and parents aren’t


concerned because they know athlete’s heart rates are
often lower and think it’s a sign of good conditioning.

Adapted from “Eating Disorders” by Rome & Strandjord. Pediatrics in Review, Vol. 37 No. 8, August 2016
CASE #1-CONTINUED
You now look at her full growth chart
rather than just today’s measurements and
realize she has dropped from 61.2 kg to 50
kg (60th %ile to 28th %ile) over the past 6
months.

You immediately become concerned and


begin asking questions regarding her
perception of the weight loss and body
image.

She acknowledges wanting to lose more


weight and fear of being “fat” again, but
continues to have menses, though they’ve
become a bit more irregular.
INITIAL WORK-UP
History, history, history!!! Collateral is key!
weight history Alexithymia (inability to
body image recognize/express
diet history emotions) and anosognosia
exercise history (inability to recognize the
binge eating/purging disorder) are common in
reproductive health eating disorders
psychiatric history
substance use
family history
full review of systems
HEADS exam.
But if I ask about purging behaviors and they are not engaging in
them, won’t I be giving adolescents ideas that could lead to
further disordered eating behavior?
Coupling questions with education reduces the risk of putting
“ideas” in adolescents’ heads.
i.e. “While most teenagers who make themselves throw up
are doing so in an attempt to avoid gaining weight, vomiting
signals the brain to tell the body to store up nutrients for
the next episode of vomiting and can actually lead to weight
gain”
PHYSICAL EXAM

Pay attention to vitals including orthostatics


Look for physical stigmata of undernutrition,
purging
DIAGNOSIS??
DDX FOR WEIGHT LOSS

Celiac disease

Inflammatory bowel disease

Malabsorption

Hyperthyroidism

Addison Disease

Occult malignancy

Acquired immunodeficiency syndrome


LABS/TESTING
Based on history
EKG
with bradycardia, voltage helps differentiate
“athlete’s heart” from bradycardia due to
malnutrition
CBC
CMP
TSH
TTG IgA (if concern from history)
ESR
FSH, LH, estradiol (if ammenorhea)
B-hCG (if ammenorhea)
DEXA (if ammenorhea >6 months and then
yearly)
Lipids (if overweight/obese)
HgbA1c (if overweight/obese)
DSM 5 DIAGNOSTIC CRITERIA
Anorexia Nervosa
A. Restriction of energy intake related to requirements, leading to significantly
low body weight in context of age, sex, developmental trajectory and physical
health. Significantly low - weight less than minimally normal OR less than
minimally expected (e.g. falling off a previously followed growth curve)
B. Intense fear of gaining weight or of becoming fat or persistent behavior that
interferes with weight gain despite being at a significantly low weight.
C. Disturbance in way in which one’s body weight/shape is experienced, undue
influence of body weight/shape on self-evaluation or persistent lack of
recognition of seriousness of current low body weight.
Types:
Restricting
Binge-eating/Purging
I’VE MADE THE DIAGNOSIS, NOW
WHAT?

Partner with parents- they are key to child’s recovery


Pediatricians are used to doing this with other chronic medical
conditions

Determine appropriate treatment setting (next) and assemble


treatment team if necessary (slide 4)

Know the therapies (both pharmacologic and psychologic) with


evidence supporting efficacy in Eating Disorders
CRITERIA FOR MEDICAL
ADMISSION
HR <50 bpm while awake
HR <45 bpm while asleep
SBP <90
Temp <35.6
Prolonged QTc or other arrhythmia
Orthostatic BP changes (>10 mmHg diastolic, >20 mmHg systolic)
Orthostatic HR changes (>20 bpm)
Syncope
Electrolyte abnormalities
Esophageal tears or hematemesis
Intractable vomiting
Suicide risk
Weight <75% expected body weight or body fat <10%
Ongoing weight loss despite intensive outpatient management
Acute weight loss with food refusal
TREATMENT SETTING
Inpatient- medical
At risk of acute medical complications of eating disorder; length of stay = days to weeks
Treatment should address medical aspects of eating disorder and also begin addressing underlying ED pathology
Inpatient- psychiatric
Medically stable with regards to physiological aspects of ED, but needing acute nutritional rehabilitation, inability to maintain safety
at home, need for treatment of co-morbid psychiatric disorder or significant family dysfunction interfering with treatment; length of
stay = days to weeks
Residential- typically reserved for failure of outpatient levels of care without acute medical/safety concerns; may be necessary if high
levels of family dysfunction, poor parent-child relationship; length of stay = months
Partial Hospitalization/Day Treatment
Typically 4-6 days/week, 8 hrs/day; intensive therapy- individual, group, and family; structured meal settings; educational consultants
and/or tutoring to address educational needs; psychotropic medication management usually available; may also consider if
concurrent substance abuse issues, frequent purging
Typical duration depends on insurance, but often 4-8 weeks
Intensive Outpatient
Usually 3 days/week, about 4 hrs/day. Include structured meal where family can get feedback from therapists regarding how to help
their child recover; includes individual, group therapy and family therapy; may or may not provide medication management services;
length of programs vary significantly
Outpatient- weekly or biweekly therapy, regular visits with dietician, PCP
TREATMENT APPROACHES

Anorexia Nervosa (AN)


Weight restoration is critical
Restoration of menses (if absent) key to preventing bone density
issues; OCPs do NOT help bone mass and may falsely reassure
parents, patients
No medications proven effective for AN, though studies of
olanzapine in adults with modest benefit; SSRIs do not prevent
relapse
Family Based Therapy (FBT, Maudsley Approach) = best evidence
in AN; Adolescent Focused Therapy (AFT) useful if high parent/
child conflict; some studies with promising results for CBT/DBT
PEDIATRICIAN’S ROLE

Monitor weight, labs, safety, co-morbidities


as needed; may need to see weekly initially.

Work with pediatric dietician to help


family with meal plans, caloric
requirements; some teens may need
upwards of 4000 kcal daily to adequately
weight restore

Goal is weight gain of 0.2-0.5kg per week


as outpatient; target weight based on
patient’s previous growth curves, targeting
at least 50%ile BMI.

Weight restoration has not been achieved


if menses remain absent/irregular
COULD THIS HAVE BEEN
PREVENTED?
You are troubled by the fact that
this eating disorder seems to have
been precipitated by your weight
management counseling.

However, you also see the obesity


epidemic every day in your office
and know there are health risks
associated with overweight/obesity.

You wonder if there are any


evidenced based recommendations
regarding how to prevent both
obesity and eating disorders…
AAP- PREVENTING OBESITY AND
EATING DISORDERS IN ADOLESCENTS
Published by NH Golden, M Schneider, C Wood, AAP Committee on Nutrition, Committee on Adolescence, and
the Section on Obesity in Pediatrics in August 2016.
Findings/Recommendations:
1. Dieting (caloric restriction for the purpose of weight loss) is a risk factor for both obesity and eating
disorders
It is counterproductive to weight management efforts
It was the most important predictor of developing an ED in a large prospective cohort study
2. Family meals (most days or every day) are associated with improved dietary quality and have been shown to
be protective against disordered eating behaviors in girls
3. Weight talk (comments made by family members about their own weight or to the child to encourage
weight loss) is linked to obesity and eating disorders
If focus was ONLY on healthful eating behaviors, adolescents were less likely to diet & use unhealthy weight
control behaviors
4. Weight teasing (by peers or family members) in one study predicted development of overweight status,
binge eating and extreme weight-control behaviors in girls and overweight status in boys; in another, it was
associated with unhealthy weight-control behaviors and binge eating in both males and females
5. Healthy body image; dissatisfaction with body image is a risk factor for EDs and disordered eating
Ok, so there are a bunch of risk factors/protective factors that obesity and eating disorders
have in common, but that doesn’t tell me what I can do…

Ways Pediatricians can help:


1. Advocate for policies that promote healthy body image in advertising, media, etc.
In France, models must have a physician’s note attesting to their overall health and
proving their body mass index (BMI) sits within a healthy range in order to work.
(though pushback from the industry eliminated at BMI threshold)
2. Watch your own language when counseling adolescents regarding healthful behaviors-
focus on improving nutrition and exercise for purpose of health and strong bodies
rather than for weight management.
3. Warn families about the danger of dieting and weight talk/teasing
4. Get really good at motivational interviewing!
“Pediatricians and dietitians who used MI to counsel families with overweight
children were successful in reducing children’s BMI percentile by 3.1 more points
than a control group” -Golden et al. 2016
Can reduce risk of “triggering” eating disorder by focusing on family centered
(rather than child centered) MI to promote healthy behaviors
CASE #2
You are seeing an 11 yo in clinic whom
you know well. In reviewing his growth
charts prior to entering the room, you
notice he has dropped from the 25%ile
for weight and height to the 3%ile for
weight and 15%ile for height over the
past 2 years.

Mom reports he has become


increasingly picky about what he will
eat and has recently been refusing to
eat anything that isn’t white. He also
will not eat any foods that have
touched another food on his plate.
CASE #2 CONTINUED

When you ask him how he feels about his


weight and height, he states he does not
like being smaller than most of the other
boys (and for that matter, girls) in his class
and wants to gain weight and grow taller.

You recall that he had difficulty with


introduction of textured foods as an
infant/toddler and was not able to advance
beyond purees until he was almost 18
months old.

Physical exam is unremarkable except for


appearing small for age.
DSM 5 DIAGNOSIS?

Avoidant/Restrictive Food Intake Disorder


(ARFID)

Previously known as Feeding Disorder of Infancy


or Early Childhood.

Eliminates requirement of presentation before


age 6.
DSM 5 DIAGNOSTIC CRITERIA
Avoidant/Restrictive Food Intake Disorder (ARFID)
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based
on the sensory characteristics of food; concern about aversive consequences of eating) as
manifested by persistent failure to meet appropriate nutritional and/or energy needs associated
with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in
children)
2. Significant nutritional deficiency
3. Dependence on enteral feeding or oral nutritional supplements
4. Marked interference with psychosocial functioning
B. The disturbance is not better explained by lack of available food or by an associated culturally
sanctioned practice
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or
bulimia nervosa and there is no evidence of disturbance in the way in which one’s body weight or
shape is experienced
D. The eating disturbance is not attributable to a concurrent medical condition or not better
explained by another mental disorder. When the eating disturbance occurs in the context of
another condition or disorder, the severity of the eating disturbance exceeds that routinely
associated with the condition or disorder and warrants additional clinical attention.
TREATMENT
No great evidenced based recommendations yet.
Should take a multivitamin due to likelihood of nutritional deficiencies, but goal is
to improve eating such that supplementation is not necessary
Because early onset AN can look like ARFID, nutritional rehab (aka weight
restoration) is very important
Dietitians can help parents with developing feeding plans that gradually introduce/
re-introduce new foods to improve nutritional status
CBT, OT/SLP (especially if issues with sensory/texture/dysphagia), Exposure
therapy can all be useful in improving the nutritional variety tolerated in ARFID
Avoid liquid supplementation if possible as this may exacerbate the issue
May require g-tube as nutritional safety net in the process
Address co-morbidities (often seen in conjunction with OCD, anxiety disorders,
developmental disorders)
Screen for and address nutritional deficiencies as indicated by diet history
CASE #3

16 yo is brought to your office


after parents found her forcing
herself to vomit in the bathroom.
She also has a history of self harm
and substance abuse.

On exam you notice BMI of 22


(~60%ile for age), mild parotitis
and some erosion of dental enamel

Labs are normal except for mild


hypokalemia of 3.3

Adapted from “Eating Disorders” by Rome & Strandjord. Pediatrics in Review, Vol. 37 No. 8, August 2016
DIAGNOSIS??
DDX FOR VOMITING

Migraine

Pseudotumor cerebri

Hydrocephalus

CNS malignancy

GI disease

Cyclic vomiting
DSM 5 DIAGNOSTIC CRITERIA
Bulimia Nervosa
A. Recurrent episodes of binge eating. Episode of binge eating characterized by both
of the following:
1. Eating, in a discreet period of time (e.g., within any 2-hour period), an amount
of food that is definitely larger than what most individuals would eat in a
similar period of time under similar circumstances
2. A sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain,
such as self induced vomiting; misuse of laxatives, diuretics, or other medications;
fasting; or excessive exercise
C. The binge eating and inappropriate compensatory behavior both occur, on
average, at least once a week for 3 months
D. Self-evaluation is unduly influenced by body shape and weight
E. Disturbance does not occur exclusively during episodes of anorexia nervosa.
TREATMENT

Medical complications directly related to method(s) of purging and/or mechanical


effects of binge episodes (e.g., acute gastric rupture)
Rarely require inpatient admission unless significant electrolyte abnormalities
Often require PHP/day treatment at first to break binge/purge cycle
CBT = first line, though FBT and DBT are promising
Grade A evidence for use of tricyclics, high dose fluoxetine (60-80 mg in adults), or
topiramate to reduce binge eating/purging
Be aware that patients who have been purging frequently for an extended period
of time may have developed pseudohyperaldosteronism and can experience
marked edema with rapid hydration (e.g via IVF) or cessation of purging
CASE #4

A 19 yo male comes to see you on break


from college about his weight/diet.
Weight is 114 kg with BMI 35.

You begin to ask a detailed eating history


and he states that he sometimes feels
out of control with regards to eating and
eats beyond the point of feeling full.

Given the all-you-can-eat style of the on


campus cafeterias, he notes these
episodes are becoming more frequent
and now happening a few times per week

Adapted from “Eating Disorders” by Rome & Strandjord. Pediatrics in Review, Vol. 37 No. 8, August 2016
CASE #4 CONTINUED

Lately, he has felt more guilty


about these episodes and has
started to avoid eating with/
around his friends.

You remember that he had always


been overweight as a child and his
mother is always asking about the
latest diet craze. In fact, last time
you saw him, he had been on a
“diet” to lose weight before
starting college
DIAGNOSIS??
DDX FOR BINGE EATING

Obesity

Major Depressive Disorder

Borderline Personality Disorder

Prader Willi Syndrome

Kleine-Levine syndrome
DSM 5 DIAGNOSTIC CRITERIA
Binge Eating Disorder (BED)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both:
A. Eating, in a discreet period of time (e.g., within any 2-hour period), an amount of food that is
definitely larger than what most individuals would eat in a similar period of time under similar
circumstances
B. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating
or control what or how much one is eating).
B. The binge eating episodes are associated with three (or more) of the following:
A. Eating much more rapidly than usual
B. Eating until uncomfortably full
C. Eating large amounts of food when not feeling physically hungry
D. Eating alone because of feeling embarrassed by how much one is eating
E. Feeling disgusted with oneself, depressed, or guilty afterward
C. Marked Distress regarding binge eating is present
D. The binge eating occurs, on average, at least once a week for 3 months
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in
bulimia nervosa and does not occur exclusively in the course of bulimia nervosa or anorexia nervosa.
TREATMENT APPROACH

Binge Eating Disorder (BED)


CBT and DBT = first line psychotherapeutic approaches
If obese, need to pair with weight management treatment as
cessation of binging episodes DOES NOT typically result in
significant BMI reduction
TCAs, SSRIs (particularly sertraline and citalopram), or
topiramate; if >18,Vyvanse 30mg daily is FDA approved for
BED
Monitor lipids, HgbA1c
Manage medical complications of obesity
OTHER SPECIFIED FEEDING AND
EATING DISORDERS (OSFED)
Previously known as ED NOS
Examples:
Atypical Anorexia Nervosa: all AN criteria met but weight remains normal/
above normal despite weight loss
Bulimia Nervosa (of low frequency and/or limited duration): does not meet
frequency (i.e. once/week) or duration criteria (3 months), but other criteria
met
Binge Eating Disorder (of low frequency and/or limited duration)
Purging Disorder: recurrent purging behavior without binge eating
Night Eating Syndrome: recurrent episodes of night eating, either after
awakening from sleep or excessive food consumption after evening meal. There
is awareness and recall of the eating. Night eating causes significant distress and/
or impairment in functioning. Not better explained by another eating disorder
or substance abuse or attributable to medication or medical disorder
PROGNOSIS

Anorexia = most lethal psychiatric disorder (50% of deaths 2/2 AN due to medical
complications, 50% due to suicide)

Bulimia- twice as likely to die as general population; high suicide rates and co-morbid
substance abuse

BED- no substantial increase in mortality except as related to medical complications


of obesity if present

MOST patients with eating disorders will recover, but it can take years (some studies
of anorexia in adults have shown as long as 15-20 years until full recovery)

Adolescents and those caught earlier in disease course = much better outcomes than
adults
CLINICAL RESOURCES

PCH Behavioral Health Intake

PCH C/L Service

UNI and Wasatch Canyons can manage eating disorders locally either inpatient or in
Day Treatment/IOP; UNI can take NGs on their inpatient unit.

Center For Change

Amelia McBride, RD (PCH dietician)

UNI call center (801-585-1212, option #1): have access to a referral database that can
be searched by insurance, location, ages served, specialty/type of therapy offered
REFERENCES

Rome ES and Srandjord SE. Eating Disorders. Pediatrics in Review. 2016; 37(8). Accessed April 2018

Phalen, J. Managing Feeding Problems and Feeding Disorders. Pediatrics in Review. 2013; 34(12). Accessed April 2018.

Golden NH, Schneider M, Wood C, AAP Committee on Nutrition. Preventing Obesity and Eating Disorders in Adolescents.
Pediatrics. 2016; 138(3):e2016161649; Accessed April 2018.

Rosen D, AAP Committee on Adolescence. Identification and Management of Eating Disorders in Children and Adolescents.
Pediatrics. 2010; 126(6). Accessed April 2018. http://pediatrics.aappublications.org/content/pediatrics/126/6/1240.full.pdf

AACAP Practice Parameter


https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Eating%20Disorders%20JAACAP%20Submit%20final.pdf

Resource for families


AACAP Parent Resource on ED:
https://www.aacap.org/aacap/Families_and_Youth/Facts_for_Families/FFF-Guide/Teenagers-With-Eating-Disorders-002.aspx

Search for eating disorders on healthychildren.org (both in English and Spanish)

Help Your Teenager Beat an Eating Disorder by Lock and Lagrange

National Eating Disorders Association: https://www.nationaleatingdisorders.org/