Update Management of Eating Disorders
The incidence and prevalence of eating disorders in children and adolescents has increased significantly in recent decades, making it essential for pediatricians to consider these disorders in appropriate clinical settings, to evaluate patients suspected of having these disorders, and to manage (or refer) patients in whom eating disorders are diagnosed. Medical complications of eating disorders may affect any organ system, and careful monitoring for these complications is required. The range of treatment options, including pharmacotherapy, is described in this report. Pediatricians are encouraged to advocate for legislation and policies that ensure appropriate services for patients with eating disorders, including medical care, nutritional intervention, mental health treatment, and care coordination.
Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual’s physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific forms in the United Kingdom.Though primarily thought of as affecting females eating disorders affect males as well. An estimated 10 – 15% of people with eating disorders are males. Although eating disorders are increasing all over the world among both men and women, there is evidence to suggest that it is women in the Western world who are at the highest risk of developing them and the degree of westernization increases the risk. Nearly half of all Americans personally know someone with an eating disorder. The skill to comprehend the central processes of appetite has increased tremendously since leptin was discovered, and the skill to observe the functions of the brain as well.
The precise cause of eating disorders is not entirely understood, but there is evidence that it may be linked to other medical conditions and situations. Cultural idealization of thinness and youthfulness have contributed to eating disorders affecting diverse populations. One study showed that girls with ADHD have a greater chance of getting an eating disorder than those not affected by ADHD.Another study suggested that women with PTSD, especially due to sexually related trauma, are more likely to develop anorexia nervosa.One study showed that foster girls are more likely to develop bulimia nervosa. Some think that peer pressure and idealized body-types seen in the media are also a significant factor. Some research show that for certain people there are genetic reasons why they may be prone to developing an eating disorder.
While proper treatment can be highly effective for many suffering from specific types of eating disorders, the consequences of eating disorders can be severe, including death(whether from direct medical effects of disturbed eating habits or from comorbid conditions such as suicidal thinking
The specific cause/ causes of eating disorders are unknown. However, it is believed to be due to a combination of biological, psychological and/or environmental abnormalities. A common belief is that “Genetics loads the gun, environment pulls the trigger. This would mean that some people are born with a predisposition to it, which can be brought to the surface pending on environment and reactions to it. Many people with eating disorders suffer also from body dysmorphic disorder, altering the way a person sees themselves.There are also many other possibilities such as environmental, social and interpersonal issues that could promote and sustain this illness.Also, the media are oftentimes blamed for the rise in the incidence of eating disorders due to the fact that media images of idealized slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves. The media are accused of distorting reality, in the sense that people portrayed in the media are either naturally thin and thus unrepresentative of normality or unnaturally thin by forcing their bodies to look like the ideal image by putting excessive pressure on themselves to look a certain way.
Treatment and Management
Treatment varies according to type and severity of eating disorder, and usually more than one treatment option is utilized.However, there is lack of good evidence about treatment and management, which means that current views about treatment are based mainly on clinical experience. Therefore, before treatment takes place, family doctors will play an important role in early treatment as patients suffering from eating disorders will be reluctant to see a psychiatrist and a lot will depend on trying to establish a good relationship with the patient and family in primary care.That said, some of the treatment methods are:
- Cognitive behavioral therapy (CBT),which postulates that an individual’s feelings and behaviors are caused by their own thoughts instead of external stimuli such as other people, situations or events; the idea is to change how a person thinks and reacts to a situation even if the situation itself does not change. See Cognitive behavioral treatment of eating disorders.
- Acceptance and commitment therapy: a type of CBT
- Cognitive Remediation Therapy (CRT), a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning.
- Dialectical behavior therapy* Family therapyincluding “conjoint family therapy” (CFT), “separated family therapy” (SFT) and Maudsley Family Therapy
- Behavioral therapy: focuses on gaining control and changing unwanted behaviors.
- Interpersonal psychotherapy (IPT)
- Music Therapy
- Recreation Therapy
- Art therapy
- Nutrition counselingand Medical nutrition therapy
- Medication: Orlistat is used in obesity treatment. Olanzapine seems to promote weight gain as well as the ability to ameliorate obsessional behaviors concerning weight gain. zinc supplements have been shown to be helpful, and cortisol is also being investigated
- Self-help and guided self-help have been shown to be helpful in AN, BN and BED;this includes support groups and self-help groups such as Eating Disorders Anonymous and Overeaters Anonymous.
- Inpatient care
Most adolescent patients with eating disorders will be treated in outpatient settings. Pediatricians play an important role in the management of these patients, assessing treatment progress, screening for and managing medical complications, and coordinating care with nutrition and mental health colleagues. Some pediatricians in primary care practice will feel comfortable in coordinating care; others will choose to refer some or all patients with eating disorders to those with special expertise. Depending on the availability of local resources, these providers may be a specialty eating disorders program, an adolescent medicine specialist, a psychiatrist, or another mental health provider.32,91
- Collaborative Outpatient Care Most children and adolescents with eating disorders will be managed in an outpatient setting by a multidisciplinary team coordinated by a pediatrician or medical subspecialist with expertise in the care of children and adolescents with eating disorders. Pediatricians generally work with nursing, nutrition, and mental health colleagues in provision of the medical, nutrition, and mental health care required by these patients. It is generally accepted that medical stabilization and nutritional rehabilitation are the most important determinants of short-term outcomes and are essential for correcting cognitive deficits to allow for effective mental health interventions. Components of nutritional rehabilitation required in the management of patients with eating disorders have been presented in several reviews.32,33,92,–,95 In the United States, oral refeeding is clearly the preferred modality for nutritional rehabilitation. However, for patients who are unwilling or unable to eat, supplements or nasogastric feeding may be life-saving. Meals and snacks generally are reintroduced or improved in a stepwise manner for those with AN, which leads, in most cases, to an eventual intake of 2000 to 3000 kcal (or more) per day and a weight gain of 0.25 to 1 kg per week. Smaller, more frequent meals; increasing the caloric density of foods; and substituting nutrient fluids (eg, fruit juice) for water can sometimes help patients overcome the postprandial fullness and psychological barriers associated with the substantial increase in caloric intake that is required. Patients with abdominal complaints from acquired nutritionally mediated lactase deficiency may benefit from supplemental lactase. Meals are changed to ensure ingestion of 2 to 3 servings of protein per day. Daily fat intake should be slowly shifted toward a goal of 30 to 50 g per day. The stereotypical and obsessional eating habits favored by many patients with eating disorders and the observation that similar levels of weight loss and malnutrition can lead to dramatically different medical consequences suggest that deficiencies of specific micronutrients may share responsibility with protein-calorie malnutrition for the medical consequences in eating disorders.70 Food variety should be encouraged, and a multivitamin should be recommended. Behavioral interventions are often required to encourage reluctant (and often resistant) patients to meet necessary caloric intake and weight-gain goals. Ranges for treatment goal weight should be individualized and based on age, height, pubertal stage, premorbid weight, and previous growth trajectory. Furthermore, for growing children or adolescents, the goal weight range should be reevaluated at regular intervals (eg, every 3 to 6 months) on the basis of changing age and height. In postmenarcheal girls, resumption of menses provides an objective measure of biological health100; in 1 recent study, resumption of menses occurred at a mean BMI percentile of 27; 75% of the girls resumed menstruating once they had achieved and sustained approximately the 40th percentile for BMI.101 Resumption of menses can also be used to refine the treatment goal weight.
- Family-Based (“Maudsley”) Therapy Over the past decade, specialized eating disorder–focused family-based interventions, based on work originally performed at the Maudsley Hospital in London, have gained attention in the treatment of adolescent AN because of promising short-term and long-term outcomes. Although the etiologic underpinnings of this treatment approach have lost much of their support over time (ie, it is no longer believed that eating disorders are caused mainly by family dysfunction), family-based interventions, nevertheless, remain an effective and evidence-based treatment strategy for adolescent AN in both open trials and randomized controlled studies. Family-based interventions are typically described as having 3 phases. In the first phase, parents, supported by the therapist, take responsibility to make certain that their adolescent is eating adequately and limiting other pathologic weight-control behaviors. In the second phase, substantial weight recovery has already occurred, and the adolescent is helped to gradually resume responsibility for his or her own eating. In the final phase of treatment, weight has been restored, and the therapy shifts to address the more general issues of adolescent development and how they may have been derailed by the eating disorder.102 A manual for providers106 and a family-support manual are now available. Unfortunately, family-based treatment by experienced providers is not available in all communities. Nevertheless, the essential principles of family-based treatment can still be encouraged by community providers in their work with patients and families. Family-based treatment may not be suitable for all patients; caution has been advised for families in which there is parental psychopathology or hostility toward the affected child, for older patients, or for patients who are the most medically compromised. Additional randomized controlled studies of family-based treatment, including studies of long-term outcomes, are still needed. Family-based approaches are now being evaluated for the treatment of BN as well. Treatment of BN in adolescents has been poorly studied, and there is little evidence to guide treatment recommendations. For adults, BN-focused cognitive behavioral therapy is the treatment of choice. Pharmacotherapy (see “Pharmacotherapy”) has been helpful as well.
- Day-Treatment Programs Day-treatment programs (day hospitalization, partial hospitalization) have been developed to provide an intermediate level of care for patients with eating disorders who require more than outpatient care but less than 24-hour hospitalization. These programs have been used in an attempt to prevent the need for hospitalization; in some cases, they are used as a “step-down” from inpatient to outpatient care. Day-treatment programs are less costly and more accessible than traditional hospitalization. In addition, they allow for more family and social support and for recovery to occur in a more naturalistic environment that may be more generalizable.109 Day treatment typically involves 8 to 10 hours of care (including meals, therapy, groups, and other activities) by a multidisciplinary staff 5 days/week. Evaluation of day-treatment programs has been characterized by small samples and the difficulty in undertaking randomized controlled trials Still, short-term outcomes have generally been reported to be good. A recent study that used a range of outcome measures, including BMI and measurement of binge-purge behavior, demonstrated day treatment to be highly effective in the treatment of both restrictive and binge-purge AN and BN. Furthermore, these results were sustained or improved over 18 months of follow-up.
- Hospital-Based Treatment Hospital-based treatment for eating disorders is less common when intensive outpatient or day-treatment programs are available. Hospitalization is much more frequently required for adolescent patients with AN than for patients with BN. Criteria for hospitalization of children and adolescents with eating disorders have been enumerated by the Society for Adolescent Medicine and are Similar criteria are endorsed in the American Psychiatric Association’s practice guideline for the treatment of patients with eating disorders33 and by other organizations.115 These criteria acknowledge that hospitalization may be required because of medical or psychiatric needs or when there is failure of outpatient treatment to achieve medical, nutritional, or psychiatric goals. Unfortunately, many third-party payers in the United States do not adhere to these criteria and make it difficult for some children and adolescents with eating disorders to receive the recommended level of care. Children and adolescents have the best prognosis if their disease is treated rapidly and aggressively (an approach that may not be as effective for adults with a more long-term, protracted course).91 Hospitalization, when indicated, allows for medical stabilization, adequate weight gain, and establishment of safe and healthy eating habits and improves the prognosis for children and adolescents. Discharge of hospitalized patients too soon often results in medical complications, a worse clinical course, and readmission. In 1 study, patients with AN who were discharged while still underweight had a 50% readmission rate compared with a rate of less than 10% for patients who had reached at least 90% of their recommended average body weight before discharge.118
In treating anorexia nervosa, the first step is the restoration of normal body weight. The greater the patient’s weight loss, the more likely the individual is to require hospitalization to ensure adequate food intake. Outpatient programs have become common in recent years; some centers have day programs where patients may spend eight hours a day, five days a week.
- Anorexic patients are given a carefully prescribed diet, starting with small meals and gradually increasing the caloric intake. Each patient is given a goal weight range, and as she or he approaches the ideal weight, more independence in eating habits is allowed. If, however, she or he falls below the set range, greater supervision may be reinstated.
- As they begin to gain weight, each patient usually will begin individual, as well as group, psychotherapy. Counseling usually involves education about body weight regulation and the effects of starvation, clarification of dietary misconceptions, and working on the issues of self-control and self-esteem. Follow-up counseling for anorexia may continue for six months to several years after healthy weight is restored.
- Treatment of bulimia nervosa first involves the management of any serious physical complications. In some cases, when the binge-purge cycle is so severe that the patients cannot stop on their own, hospitalization may be necessary. In such instances, individual counseling, sometimes combined with medication, is the standard treatment.
- Counseling involves issues similar to those discussed in the treatment of anorexia and usually lasts for about four to six months.
- In addition, group therapy has been found especially effective for bulimics. Antidepressant medications also may be an effective way of treating bulimia.
- In outpatient treatment, bulimic patients are often asked to keep a food intake diary, making sure they eat three meals a day of moderate caloric intake, even if they are still binge eating. Exercise is limited, and if the patient becomes compulsive about it, it is not permitted at all.
- In the treatment of both anorexia and bulimia nervosa, family support is extremely important, especially in helping the recovering anorexic or bulimic with everyday tasks, such as grocery shopping.
- In many cases, anorexic and bulimic patients and their families will attend family counseling sessions. Even after the eating disorder has been controlled, follow-up counseling for the patient, as well as the patient’s family, may be recommended.
- While many people with an eating disorder will recover fully, relapse is common and may occur months or even years after treatment. An estimated 5 to 10 percent of anorexics will die from the disorder; their deaths most commonly result from starvation, suicide or electrolyte imbalance. More favorable outcomes for anorexics have been associated with a younger age of onset of the disorder, less denial, less immaturity, and improved self-esteem.
- The outcome for bulimia nervosa is not as well documented, and mortality rates are not yet known. It is a chronic, cyclic disorder. Of those bulimics who are treated for the disorder, fewer than one-third will be fully recovered three years after treatment, more than one-third will show some improvement in their symptoms at a three-year follow-up, and about one-third will resume chronic symptoms within three years.
There are few studies on the cost-effectiveness of the various treatments.Treatment can be expensive;due to limitations in health care coverage, patients hospitalized with anorexia nervosa may be discharged while still underweight, resulting in relapse and rehospitalization.
Prognosis estimates are complicated by non-uniform criteria used by various studies, but for AN, BN, and BED, there seems to be general agreement that full recovery rates are in the 50% to 85% range, with larger proportions of patients experiencing at least partial remission
- No medications have been approved by the US Food and Drug Administration for the treatment of AN.
- Pharmacotherapy is sometimes prescribed but is typically targeted at comorbid symptoms of depression and anxiety. Selective serotonin-reuptake inhibitors (SSRIs) are most often used but may not be effective in severely malnourished patients. There is also limited evidence for the use of SSRIs for relapse prevention in AN.
- In recent case reports and open-label trials, atypical neuroleptic agents, predominantly olanzapine (Zyprexa), have been noted to improve both weight gain and dysfunctional thinking in patients with AN.126 A recently completed randomized, double-blind, placebo-controlled trial in adults showed a significant increase in weight gain in those who were taking olanzapine and a concomitant decrease in obsessive symptoms, although the effect size was modest.
- Further evaluation of the effectiveness of these agents is underway, and caution is warranted because of the risk of developing insulin resistance and metabolic syndrome.
- In contrast to AN, several pharmacologic agents have been demonstrated to be effective for the treatment of BN. Although only fluoxetine has been approved by the Food and Drug Administration, other SSRIs, serotonin/norepinephrine-reuptake inhibitors (eg, venlafaxine), and tricyclic antidepressants have also been shown to decrease binge-eating and purging in BN.
- Topiramate has been shown to significantly decrease binge-eating and may be an option for patients who do not respond to or are not able to tolerate SSRIs.
- Other drugs, including naltrexone and ondansetron (Zofran), are being used with some success in BN, although data are lacking to recommend their use more broadly.130
- Hormonal supplementation, although capable of restoring menstruation, has not been shown to reliably improve bone mineral density and is not a substitute for nutritional rehabilitation and restoration of positive energy balance
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