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Eating disorders

Specialties > Child health

Background knowledge 🧠

Definition

  • Eating disorders are a group of mental health conditions characterised by abnormal eating habits that negatively impact physical and mental health.
  • They primarily include Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder.
  • Often associated with an intense fear of weight gain and a distorted body image.
  • Can lead to severe medical complications and high mortality rates.

Epidemiology

  • Eating disorders commonly develop during adolescence or early adulthood.
  • Prevalence is higher in females (approximately 10:1 ratio compared to males).
  • Anorexia Nervosa affects about 1% of females; Bulimia Nervosa about 1-2%.
  • Increasing incidence of eating disorders in males and older adults.

Aetiology and Pathophysiology

  • Multifactorial causes include genetic, environmental, psychological, and sociocultural factors.
  • Genetic predisposition may involve serotonin dysregulation.
  • Cultural emphasis on thinness, dieting, and body image significantly contributes.
  • Psychological factors such as low self-esteem, perfectionism, and anxiety disorders are common.
  • Neuroendocrine changes, including hypothalamic dysfunction, can be seen in severe cases.

Types

  • Anorexia Nervosa: Characterised by restrictive eating, intense fear of gaining weight, and a distorted body image.
  • Bulimia Nervosa: Involves episodes of binge eating followed by compensatory behaviours such as vomiting, fasting, or excessive exercise.
  • Binge Eating Disorder: Recurrent episodes of eating large quantities of food without subsequent purging behaviours.
  • Other Specified Feeding or Eating Disorders (OSFED): Atypical eating behaviours that do not meet full criteria for Anorexia or Bulimia.
  • Avoidant/Restrictive Food Intake Disorder (ARFID): Limited food intake due to a lack of interest, sensory characteristics, or fear of aversive consequences.

Clinical Features 🌡️

Symptoms

  • Anorexia Nervosa: Extreme weight loss, fatigue, insomnia, amenorrhea in females.
  • Bulimia Nervosa: Recurrent episodes of binge eating, feelings of loss of control, guilt, and subsequent purging.
  • Binge Eating Disorder: Eating rapidly, eating until uncomfortably full, eating large amounts without hunger.
  • Emotional symptoms: Depression, anxiety, and irritability are common across all eating disorders.
  • Preoccupation with food, dieting, and body weight.

Signs

  • Anorexia Nervosa: Low BMI, bradycardia, hypotension, hypothermia, lanugo hair.
  • Bulimia Nervosa: Normal or slightly overweight BMI, parotid gland enlargement, dental erosion, Russell’s sign (calluses on knuckles).
  • Binge Eating Disorder: Often associated with overweight or obesity, without compensatory behaviours.
  • Evidence of self-induced vomiting, such as halitosis or tooth decay.
  • Dry skin, brittle hair and nails, and other signs of malnutrition in severe cases.

Investigations 🧪

Tests

  • Full Blood Count (FBC): May show anaemia, leukopenia.
  • Electrolytes: Hypokalaemia, hyponatraemia in Bulimia Nervosa.
  • Liver function tests (LFTs): Elevated transaminases may indicate malnutrition.
  • Thyroid function tests (TFTs): Low T3, normal or low T4 and TSH in Anorexia Nervosa.
  • Bone mineral density (DEXA scan): Osteopenia or osteoporosis in long-term Anorexia Nervosa.
  • ECG: Bradycardia, QT prolongation in severe Anorexia Nervosa.

Management 🥼

Management

  • Multidisciplinary approach involving medical, psychological, and nutritional support.
  • Psychotherapy: Cognitive Behavioural Therapy (CBT) is first-line, particularly for Bulimia Nervosa and Binge Eating Disorder.
  • Nutritional rehabilitation: Gradual refeeding with monitoring for refeeding syndrome.
  • Pharmacotherapy: Antidepressants (SSRIs) may be used in Bulimia Nervosa, limited role in Anorexia Nervosa.
  • Hospitalisation: Indicated for severe malnutrition, medical instability, or failure of outpatient treatment.
  • Family-based therapy (FBT): Particularly effective for adolescents with Anorexia Nervosa.

Complications

  • Cardiac: Arrhythmias, heart failure, sudden death (particularly in Anorexia Nervosa).
  • Endocrine: Osteoporosis, infertility, electrolyte imbalances.
  • Gastrointestinal: Gastroparesis, constipation, oesophageal rupture (in Bulimia Nervosa).
  • Psychiatric: High comorbidity with depression, anxiety, and suicide risk.
  • Refeeding syndrome: Life-threatening shifts in fluids and electrolytes after refeeding in malnourished patients.

Prognosis

  • Anorexia Nervosa has the highest mortality rate of any psychiatric disorder, primarily due to medical complications and suicide.
  • Bulimia Nervosa and Binge Eating Disorder have better prognoses but still carry significant morbidity.
  • Early intervention improves outcomes significantly.
  • Long-term treatment and follow-up are often necessary.

Key Points

  • Eating disorders require a holistic and multidisciplinary approach to treatment.
  • Early recognition and intervention are crucial for better outcomes.
  • Monitoring for complications such as refeeding syndrome is essential during treatment.
  • Long-term psychological and medical support is often required.

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Child health