Updated: 7/25/2018

Eating Disorders

Topic
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Questions
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Evidence
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Snapshot
  • A young woman who is 4 months pregnant comes into her primary care physician to discuss an unusual craving. She reluctantly admits that, for the past five weeks, she has been consuming large amounts of ice. She will often prefer to eat ice instead of food. She has never experienced this craving before, and eating ice is not a part of any of her social customs. She and her husband are both concerned about this behavior. (Pica)
Anorexia Nervosa
  • Definition
    • persistent behavior to prevent weight gain and intense fear of gaining weight
      • calorie restricting
      • increased exercise
      • disturbance in self-image of one's body weight
    • significantly low body weight weight for developmental age
    • specific types are based upon the behavior to avoid gaining weight
      • restrictive type: primarily restricts oral intake
      • purging type: primarily engages in self-induced vomiting, laxative/diuretic abuse, or excessive exercise
  • Female athlete triad syndrome:   
    • eating disorder
    • amenorrhea
    • osteoporosis   
  • Complications
    • osteoporosis
      • metatarsal stress fractures
    • amenorrhea
    • anemia
    • electrolyte imbalances
      • can lead to cardiac abnormalities
    • lanugo
      • very fine bodily hair
    • high mortality
  • Epidemiology
    • F > M
    • onset in adolescence
    • commonly coexists with depression
  • Treatment
    • nutritional rehabilitiation to increase weight
      • monitor for refeeding syndrome
        • possible complication of refeeding patients too quickly or aggressivley, leading to dramatic electrolyte shifts that can cause arrhythmias or heart failure
    • psychotherapy, including cognitive-behavioral therapy or family therapy
    • pharmacotherapy (only as an adjunct)
Bulimia Nervosa
  • Definition
    • recurrent episodes of binge eating
      • eating a large amount of food in a discrete period of time
      • a feeling of loss of control during the episode 
    • recurrent inappropriate compensatory behavior   
      • self-induced vomiting
      • laxative use
      • excessive exercise
    • episodes occur at least once a week for 3 months
    • self-evaluation unduly influenced by body image
    • patient does not meet criteria for anorexia nervosa
    • weight often normal or slightly above ideal body weight
    • specific types are based upon the compensatory behavior:
      • purging type: self-induced vomiting or misuse of laxatives, diuretics, or enemas  
      • non-purging type: restrictive eating, excessive exericse, or diet pills
  • Complications
    • parotid gland enlargement 
    • dental cavities   
    • electrolyte disturbances
      • alkalosis, hypokalemia
    • Russell's sign  
      • dorsal hand calluses from inducing vomiting
  • Epidemiology
    • F > M
    • onset in early adulthood
  • Treatment
    • nutritional rehabilitation
    • psychotherapy
      • cognitive-behavioral therapy has been found to be superior
    • pharmacotherapy, for comorbid anxiety or depression
Binge Eating Disorder
  • Definition
    • recurrent episodes of binge eating
      • eating a large amount of food in a discrete period of time
      • a feeling of loss of control during episode
    • no compensatory behaviors
    • episodes occur at least once a week for 3 months
  • Epidemiology
    • F > M
    • associated with other psychopathologies
Pica
  • Definition
    • repeatedly craving and eating non-food products, such as chalk, dirt, hair
    • inappropriate to developmental level or culture
    • occurs for at least 1 month
    • may be associated with other conditions, such as autism
  • Complications
    • anemia
    • malnutrition
    • electrolyte abnormalities
    • constipation
    • exposure to toxins
    • infections
  • Epidemiology
    • most common in pregnant women and school-age children
Rumination
  • Definition
    • repeated regurgitation of food that is not due to a gastrointestinal issue or an underlying eating disorder
    • occurs for at least 1 month
Avoidant/Restrictive Food Intake Disorder
  • Definition
    • avoiding or restricting food intake for a variety of reasons
      • disinterest in food
      • negative experience with eating
      • not caused by fear of weight gain, body dysmorphia, the unavailability of food, or social custom
    • associated with negative consequences
      • significant weight loss in adults or poor weight gain in children
      • malnutrition
      • supplemental feeding requirement to maintain health
      • psychosocial dysfunction
  • Epidemiology
    • among adolescents with eating disorders, patients with avoidant/restrictive food intake disorder are more likely to be male than patients with anorexia nervosa
    • onset usually occurs in infancy or early childhood
Other Specified Feeding or Eating Disorder
  • Definition
    • symptoms or behavior surrounding foods that cause significant distress but do not meet full criteria for another eating disorder
 

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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.PY.73) A 16-year-old female presents to your clinic concerned that she has not had her menstrual cycle in 5 months. She has not been sexually active and her urine pregnancy test is negative. She states that she has been extremely stressed as she is in the middle of her gymnastics season and trying to get recruited for a college scholarship. Physical exam is remarkable for a BMI of 16, dorsal hand calluses, and fine hair over her cheeks. What other finding is likely in this patient? Review Topic

QID: 106568
1

Polycythemia

5%

(2/39)

2

Elevated TSH

3%

(1/39)

3

Leukopenia

3%

(1/39)

4

Elevated estrogen levels

0%

(0/39)

5

Low bone density

85%

(33/39)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M1.PY.0) A 16-year-old 5' 7", 105 pound female ballet dancer presents to the orthopaedic surgeon for pain in her left foot, which is exacerbated when she is in the tip-toe position. She previously had recovered from a fracture of the shaft of the first metatarsal on the right foot 6-months ago. She was told by her coach that she would need to lose 15 lbs to be considered a competitive dancer, and she has successfully done so in one month. Which of the following symptoms would NOT be present in this female? Review Topic

QID: 107060
1

Decreased bone density

0%

(0/17)

2

Tachycardia

82%

(14/17)

3

Brittle nails

6%

(1/17)

4

Lanugo

12%

(2/17)

5

Amennorhea

0%

(0/17)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M1.PY.36) In your outpatient clinic you are seeing a 22-year-old female for her annual check-up. She has a past medical history significant for sexual abuse in her teens. Currently she has no complaints. She reports that her last menstrual period was 1 week ago. Her temperature is 98.5 deg F (36.9 deg C), pulse is 65/min, blood pressure is 110/75 mmHg, respirations are 11/min. Physical exam is notable only for dry mucous membranes with multiple dental carries and calluses on the dorsum of her right hand. Her BMI is 17. What is the most likely diagnosis? Review Topic

QID: 100036
1

Anorexia nervosa - restrictive type

11%

(2/18)

2

Anorexia nervosa - purging type

67%

(12/18)

3

Bulimia nervosa

6%

(1/18)

4

Obsessive compulsive disorder

11%

(2/18)

5

Eating disorder not otherwise specified

0%

(0/18)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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Topic COMMENTS (4)
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