#55: Eating disorders: Specified and Not Otherwise Specified

September 4, 2017 | By Paul Williams

Enhance your skills to identify and manage eating disorders with wise counsel from Dr. Rosalind Kaplan, Associate Professor of Clinical Medicine at Thomas Jefferson University and a Primary Care Physician in Jefferson Women’s Primary Care. We learn who to screen for eating disorders, what questions to ask, criteria for diagnosis, common complications, and how to manage them. This is a must listen if you’re like us and don’t know much about eating disorders specified and not otherwise specified.

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Case from Kashlak Memorial Hospital: 24yo F medical student with history of anxiety, weight loss, and restricting food senior year of high school. She regained weight with psychotherapy. Now she is a medical student who is over exercising, and abusing laxatives. She passes out one day after class and is referred to you at Kashlak.

Clinical pearls:

1. Hypokalemia in an otherwise healthy young patient should raise concern for eating disorder
2. Anorexia nervosa: Restriction of energy intake relative to energy needed for physical health; intense fear of gaining weight; distortion of body image
3. Bulimia nervosa: Marked by binging and purging; associated with significant shame
   1. Binging: Eating a larger amount of food in a specific time compared to a “normal” person
   2. Purging: Compensatory behavior, including exercise, laxative use, vomiting, or restriction
4. Binge eating disorder: Binging without compensatory behavior; associated with shame and a sense of being unable to stop
5. More evenly distributed among genders, age groups, and ethnicities
6. Eating disorders can morph from one form to another (anorexia–>bulimia)
7. Eating disorders can exist even in the absence of meeting full criteria
8. All young women and adolescents should be screened for eating disorders
   1. “Are you having any concerns about your eating behaviors?”
   2. “Has anyone else raised any concerns about your eating behaviors?”
   3. “Have you ever binged or purged?”
9. Young athletes should also be screened
10. Standardized questionnaires include SCOFF and ESP
11. Initial anorexia workup : Height and weight; EKG (if less than 75% of IBW) – bradycardia, long QTc, sudden cardiac death; CMP (liver enzyme abnormalities and hyponatremia); CBC (pancytopenia due to low intake), TSH, Mg, Phos; +/- estrogen if menstrual irregularities; Densitometry (treatment for loss of bone is increasing intake, NOT bisphosphonate)
12. Bulimia work up: Height and weight, Toxicology screen (significant crossover with substance abuse), CMP
13. Anorexia treatment: Standard of care: Psychotherapy, nutritional therapy, and medical monitoring. No approved medication for treatment
14. Bulimia treatment: Fluoxetine approved for treatment, but this is adjunctive therapy. Check labs given concern for hyponatremia. Bupropion should not be used given concern for precipitation of seizures
15. Binge eating treatment: Psychotherapy and nutritional therapy. Bupropion and fluoxetine can be used (off-label). Lisdexamfetamine approved for use
16. Eating disorders should be treated using a team approach
17. Patients in the active phase of anorexia and bulimia need short-term follow up. Patients with significant or persistent electrolyte disturbances may need inpatient management
18. Complications of purging include GERD, gastroparetic symptoms, Mallory-Weiss tears, parotitis,electrolyte disturbances

Goal: Listeners will recognize common eating disorders, the basics of management, and how to recognize who needs hospital admission.

Learning objectives:
After listening to this episode listeners will…

1. Be able to discuss how and who to screen for eating disorders
2. Describe the categories and initial work up of the major eating disorders
3. Recognize the potential complications of starvation and purging
4. List the treatment options and indications for referral for the major eating disorders

Disclosures: Dr. Kaplan reports no relevant financial disclosures

Time Stamps
00:00 Intro
01:19 Listener feedback
02:43 Picks of the week
06:50 Topic intro and guest bio
09:10 Getting to know our guest
15:18 Clinical case
20:15 Broad overview of eating disorders
26:40 Eating disorder not otherwise specified
29:19 Underreporting and under diagnosis in men
30:25 Who to screen and how to do it
34:33 Questionnaires: SCOFF, ESP, and Binge Eating Disorder Inventory
38:42 Initial lab workup for eating disorders
42:38 Bone density screening, treatment
45:41 Back to the case: Initial patient counseling
49:22 Medical therapy
52:20 Can we use bupropion?
54:02 What’s the role for primary care?
58:14 Hyponatremia in eating disorders
60:34 Complications of purging
66:25 How to be an ally for your patient
69:12 Treatment for binge eating
72:51 Take home points
74:30 Outro

Links from the show:
Mystery Team (film) 2008 on Amazon
Rain Main (film) 1988 on Amazon
How We Learn (book) by Benedict Carey
Scoff questionnaire: https://doi.org/10.1136/bmj.319.7223.1467
ESP questionnaire: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494802/
Eating Disorders in the Primary Care Setting: https://www.ncbi.nlm.nih.gov/pubmed/27262009
The Patient in the White Coat: My Odyssey from Health to Illness and Back by Rosalind Kaplan: https://www.amazon.com/Patient-White-Coat-Odyssey-Illness/dp/1607146940/ref=sr_1_1?ie=UTF8&qid=1504449109&sr=8-1&keywords=the+patient+in+the+white+coat+kaplan