The Case: - GLOWM
The Case:
This is the case of a 36 year old female who was referred by another provider for recent significant weight loss. She reported an eight-month history of weight loss totaling approximately twenty-five pounds. She reported an initial decline in weight starting about 18 months prior to presentation coinciding with a pregnancy. Her maximum weight measured 140 pounds in college. Her current eating habits consist mostly of “grazing”. She reported a recent history of multiple social stressors including current divorce proceedings and a stressful profession. She was confronted by multiple family members concerning her overall decline and agreed to seek assistance. A thorough evaluation was completed without evidence of an organic etiology.
Past Medical History:
• Postpartum Depression
• Pregnancy-induced Hypertension.
Past Surgical History:
• Fibroid removal (benign).
• Tonsillectomy / Adenoidectomy.
Medications:
• Oral contraceptive pill.
• Fluoxetine.
Social History:
• No history of alcohol / tobacco / recreational drug use.
Family History:
• Positive for Coronary artery disease in father.
Review of Systems:
• Positive for lightheadedness / dizziness with sitting or standing.
• No fever / chills / sweats.
• No gastrointestinal symptoms.
• No unusual swelling / bleeding / bruising.
• Otherwise negative.
Physical Examination:
• Vital signs:
o Height: Five feet two inches tall.
o Weight: One hundred pounds.
o Blood Pressure: 90/60 mmH
• General: Thin appearing female. Not cachectic.
• HEENT: Normocephalic. Eyes unremarkable. Neck supple. No thyromegaly.
• Cardiac: Regular rate and rhythm. No murmurs or rubs.
• Pulmonary: Clear to auscultation bilaterally.
• Abdominal: Soft, nontender, nondistended. No organomegaly.
• Extremities: Equal palpable pulses. No edema or cyanosis.
• Integument: Warm, dry and intact. No rashes or lesions.
• Neurological: Grossly intact. No focal deficits.
• Lymph Nodes: No palpable lymphadenopathy.
Diagnosis / Evaluation:
Differential Diagnosis:
• Anorexia.
• Anemia.
• Body Dysmorphic disorder.
• Bulimia.
• Chronic infection.
• Conversion disorder.
• Depression.
• Diabetes Mellitus.
• Graves / Thyroid disease.
• HIV.
• Inflammatory Bowel disease.
• Malabsorption.
• Malignancies.
• Metabolic acidosis.
• Substance abuse.
Evaluation:
Based on the results of clinical history, physical exam, and review of prior studies, the differential diagnosis was narrowed to include anorexia, bulimia, and other eating disorders.
Eating Disorders for the Internist:
Overview:
Eating disorders have long been a part of society that was significantly unrecognized by the health care profession. The current obsession in the United States and abroad to “be the best”, has driven individuals to target unrealistic goals in their appearance. A survey conducted in 2005 showed that over 30% of adolescent females feel that they are overweight. Greater than 60% reported that they were attempting to lose weight with a significant number reporting laxative or diuretic use in the recent past. These staggering statistics have increased awareness among health care providers and have promoted a more aggressive identification of these diseases. The most important diagnoses include anorexia and bulimia but binge eating and other disorders will also be addressed.
Anorexia:
Anorexia was first described in 1689 by Richard Morton. Since that time, it has been described with variable presentations by a number of different individuals. It was initially defined as self-imposed starvation although several other explanations have been subsequently issued. Multiple etiologies have been proposed although the exact mechanism continues to elude us at this time. There appears to variable ages of onset including very early (ages 7-12 years), adolescence (13 – 18 years) and in early adulthood.
Frequency:
• Ninety percent are female.
• One in every 100 – 200 females of late adolescence affected.
• Sub-threshold prevalence much higher.
• Similar prevalence in all developed countries.
• Social factors appear very influential.
• Slightly higher in Caucasian population.
Definition by DSM IV criteria:
• Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., 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 postmenarchal females, amenorrhea, i.e., the absence of at least three consecutive cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration.)
Specify by Type:
• Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., 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 (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Evaluation:
History
• Interview necessary.
• Denial common.
• Notoriously unreliable informants.
• Screen for co-morbid psychiatric factors.
• Competitive athletes (ballet/gymnasts/runners).
• Males – bodybuilders/wrestling.
• Structured interviews.
• Self–reporting questionnaires.
Physical Exam
• Accurate weight.
• Lanugo development.
• Brittle nails and dry skin.
• Yellowish discoloration due to carotenemia.
• Osteoporosis – early onset.
• Teeth – decalcification of lingual/palatal/posterior surfaces.
Clinical Pathology
• Cardiovascular
♣ Bradycardia.
♣ Low blood pressure.
♣ Conduction abnormalities.
♣ Cardiomyopathy.
♣ Excessive aggressive refeeding.
♣ Use of Ipecac to induce emesis.
♣ Mitral valve prolapse – weight loss.
♣ Prolonged QT.
♣ Arrhythmia/Nonspecific ST segments/T wave changes.
• Pulmonary
♣ Spontaneous pneumothorax.
♣ Pneumomediastinum.
• GI
♣ Parotid enlargement.
♣ Esophageal trauma / tears.
♣ Delayed gastric emptying.
♣ Peptic ulcers.
♣ Gastric dilatation.
♣ Superior mesenteric artery syndrome.
♣ Malabsorption.
♣ Pancreatitis.
♣ Hepatitis.
• Renal
♣ Acute renal failure (prerenal).
♣ Nephropathy.
♣ Renal stones.
• Hematological
♣ Anemia / Leukopenia / Thrombocytopenia.
• Endocrine
♣ Abnormal pituitary or adrenal axis.
♣ Menstrual irregularities.
♣ Delayed puberty.
• Metabolic
♣ Impaired glucose intolerance.
♣ Increased cholesterol levels.
♣ Protein deficiency.
♣ Increased carotene.
♣ Zinc deficiency.
♣ Sleep deficiencies.
♣ Metabolic alkalosis.
♣ Peripheral edema.
♣ Hyponatremia / -kalemia / -chloremia / -magnesemia.
♣ Dehydration.
• Mental status / Neurological
• Generally with co-morbid psychopathology.
♣ Mood / Anxiety disorders / Depression.
♣ Personality disorders.
♣ Substance abuse.
• Good orientation / reality testing.
• Depressed affect. Hallucinations uncommon
• Delusions
• Body image distortion / Dissatisfied with body.
• Appearance – Well-groomed and appropriately dressed.
♣ Loose clothing common to hide emaciation.
Mortality / Morbidity:
♣ Six to 20% die.
♣ Suicide – 50% of total number.
♣ Starvation.
♣ Infection.
♣ Electrolyte abnormalities.
Clinical Evaluation:
♣ Blood counts.
♣ Chemistries (Lytes / Calcium / Mg / Phos).
♣ Urinalysis / Renal functioning / B-HCG.
♣ Liver function / Albumin / Fecal occult blood.
♣ Urine / serum drug screen in appropriate setting.
♣ Thyroid function tests.
♣ ESR / CR-P if suspicious for infection.
♣ HIV testing if appropriate.
Additional studies / testing
♣ Chest and abdominal radiographs.
♣ EKG.
♣ Echocardiogram for suspected cardiomyopathy.
♣ Brain imaging (CT / MRI?).
Treatment:
• Multidimensional.
• Combination of approaches.
♣ Inpatient / Outpatient.
♣ Intensive psychotherapy.
♣ Education based therapy.
• Pharmacology – treatment of co-morbid diseases.
• Flexibility / Realistic goals.
• Support system critical.
Bulimia:
Bulimia is considered to be a disease consisting of loss of control with emotional distress. The patient has frequent episodes of binge eating in conjunction with dissatisfaction for their body habitus. However, they usually exhibit a compensatory behavior pattern consisting of strict dieting, self-induced emesis, diuretic / laxative abuse, appetite suppressants or other extraneous medications (thyroid meds) to compensate for their behavior. These patients may display an overlap of several disorders although around 60% have coexisting anorexia. The onset typically starts as a teenager or in the early third decade. Less than five percent are 14 years old or younger.
Frequency:
• Significantly underrecognized.
• One to 3% prevalence (10 – 15% are male).
• More common in athletes / actors / models / dancers.
• Female athletes four times more prevalent.
• Thirty – 50% of commercial weight loss program clients.
• Up to 25 -70% of those presenting for bariatric surgery.
• International increase after WW II.
• All races affected equally.
Definition by DSM IV Criteria:
• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
• Eating, in a discrete period of time (e.g., within any two-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 (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behavior to prevent weight gain such as: self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercising.
• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specify by type:
• Purging type: The person regularly engages in self-induced vomiting or the misuse of laxatives or diuretics.
• Nonpurging type: The person uses other inappropriate compensatory behaviors, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or the misuse of laxatives or diuretics.
Evaluation:
History
• Concern about weight or body image / Seeks help for weight loss.
• Bloating / Constipation / Abdominal pain / Flatus
• Menstrual irregularities.
• Extreme dieting with alternate binging.
• Episodes well planned.
• Foods easy to swallow / regurgitate.
• High calorie with binge (up to 10 times daily allowance).
• Physical activity cyclical in nature.
• History of Pneumonic symptoms (aspiration pneumonia).
Physical Exam
• Bilateral parotid enlargement.
• Periodontal disease / Extensive caries.
• Russell sign – Scarring, abrasions on knuckles due to inducing emesis.
• Bradycardia.
• Hypothermia.
• Nonspecific edema.
• Possible obesity.
• Neat appearance / Well dressed / attention to detail.
• Avoids eye contact.
Clinical Pathology
• Overall less severe than Anorexia
• Similar organ system presentations.
• Affect
♣ Mood / personality / anxiety disorders.
♣ Suicidal thoughts; No plan usually.
♣ Delusions / hallucinations generally absent.
♣ Comprehension normal.
♣ Poor judgment / impulse control.
♣ Insight variable.
♣ Thoughts revolve around food.
Morbidity / Mortality:
• Reportedly low. Prognosis variable.
• Long, fluctuating course.
Clinical Evaluation:
• Same as Anorexia.
• Chemistries / CBC / LFT / Renal function important.
• Elevated BUN (volume depletion).
• Hypokalemic metabolic alkalosis.
• Metabolic acidosis with laxative abuse.
• Hyperamylasemia.
♣ 30% due to hypersecretion of salivary glands.
• Urinalysis for Specific Gravity.
♣ Water loading to gain weight before visit.
Treatment:
• Similar to Anorexia.
• Intense psychotherapy.
• Nutritional education / treatment.
• Pharmacology.
♣ SSRI / TCA – require much higher doses than for depression.
♣ Antiepileptic agents / Ondansetron showing promise.
Other Eating Disorders:
The increasing prevalence of anorexia and bulimia in society has created new areas in research with the goal of diagnosing and treating the disorders. This new areas of interest has also promoted the recognition and identification of other eating disorders. These illnesses include an entity known as the binge eating disorder. It is defined as eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances) two days per week for a six month duration. It includes a lack of control over the eating with associated distress over the binge eating. The criteria include eating much more rapidly than usual; eating until uncomfortably full; eating large amounts of food when not feeling hungry; eating alone because of embarrassment; and feeling depressed or guilty because of the eating. Three of these criteria must be met to consider this diagnosis. The mean lifetime duration of binge eating is longer than the other disorders. Treatment is very similar to the other disorders. However, there are still many questions about the etiology and relationship with other pathology. The increasing prevalence of these disorders and their contribution to our overall health will begin to yield more diagnoses and treatment regimens in the area of eating disorders.
RESOURCES:
1. Diagnostic and statistical manual of mental disorders (DSM-IV). (1994). Washington, D.C.: American Psychiatric Association.
2. Walsh BT. Eating Disorders. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo, DL Jameson, JL, eds. Harrison’s Principles of Internal Medicine. 15th edition. New York, NY: McGraw-Hill; 2001:486-490.
3. Forman SF. Eating Disorders: Treatment and Outcome. Up To Date Online. Available at . April 2007. Accessed August 2007.
4. Forman SF. Eating Disorders: Epidemiology, pathogenesis, and clinical features. Up To Date Online. Available at . April 2007. Accessed August 2007.
5. Levey R, Williams-Wilson B, Curfman, WC. Anorexia Nervosa. EMedicine. Available at med/topic144.htm. April 17, 2006. Accessed August 2007.
6. Uwaifo GI, Daly RC. Bulimia. EMedicine. Available at med/topic255.htm. December 1, 2005. Accessed August 2007.
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