Episode 76 - Eating Disorders - a podcast by Rio Bravo Family Medicine Residency Program

Episode 76: Eating Disorders. 

The malaria vaccine is announced by Dr Parker, eating disorders such as anorexia and bulimia are briefly discussed by Sophia, Jeffrey and Dr Arreaza. 

Introduction: Introducing the malaria vaccine (RTS,S)
Written by Hector Arreaza, MD; read by Tana Parker, MD.  

Today is November 26, 2021.

Malaria is a devastating disease that continues to kill thousands of people every year around the world. Since the year 2000, there have been 1.5 billion cases of malaria and 7.6 million deaths. In 2019, there were 229 million new cases, and 409,000 deaths, mostly children under 5 years of age.

Effective vaccines for many protozoal diseases are available for animals (for example, the vaccine against toxoplasmosis in sheep, babesiosis in cows, and more.) However, vaccines for protozoal disease in humans had not been widely available … until now. 

The RTS,S is a vaccine against malaria approved by the European Medicines Agency in July 2015 for babies at risk, and it was rolled out in pilot projects in Malawi, Ghana and Kenya in 2019.  In October 2021, the World Health Organization announced the recommendation of this anti-malaria vaccine. The trade name of this vaccine is Mosquirix®. The vaccination is recommended for children in sub-Saharan Africa and other regions with moderate to high transmission of Plasmodium falciparum, which is considered the deadliest parasite in humans.  

The approved vaccine has shown low to moderate efficacy, preventing about 30% of severe malaria after 4 doses in children younger than five years old. Implementation of vaccination is not free from challenges, and it should be executed not as the solution for the disease, but as part of the solution, along with other efforts such as mosquito control, effective health care, and more.

RTS,S is an add-on to continue the fight against malaria worldwide. Hopefully we can lighten the heavy burden of malaria for more than 87 countries that suffer the severe consequences of poor control of this devastating disease. 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

___________________________

Eating Disorders. 
Written by Sophia Dhillon, MS3, Jeffrey Nguyen, MS3. Discussion with Hector Arreaza, MD. 

 

This is not intended to be a comprehensive lecture on eating disorders. This episode is intended to give you basic information, hoping to motivate you keep learning about it. 

Let’s start talking about eating disorders today, specifically anorexia nervosa and bulimia nervosa. 

What is an eating disorder? An eating disorder is a disturbance of eating that interferes with health. As a reminder, health is “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.” So, an eating disorder, in a wide context, is any eating pattern that is out of what is considered “normal”, and that variation in feeding causes health problems. But in general, when we talk about eating disorders in medicine, we refer to anorexia nervosa and bulimia nervosa, but it includes also avoidant/restrictive food intake disorder, binge eating disorder, night eating disorder, pica, and rumination disorder. 

 

ANOREXIA

In general, anorexia is characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure or an irrational fear of weight gain as well as distorted body self-perception. There are 2 main subtypes of anorexia: restricting type vs binge-eating/purging type. Tell us the difference between anorexia restrictive type and binge eating-purging type.

Anorexia, restrictive type is when weight loss is achieved by diet, fasting and/or excessive exercise, meanwhile the binge-eating/purging type entails eating binges followed by self-induced vomiting and/or using laxatives, enemas or diuretics. These patients will have intense fear of gaining weight or becoming fat. They will have a distorted perception of body weight and shape or denial of the medical seriousness of one’s low body weight.

Anorexia nervosa is different than avoidant/restrictive food intake disorder. In anorexia, you have an altered perception of your body (“I’m fat”), but in avoidant/restrictive food intake disorder, your perception of your body weight and shape is not abnormal. “I’m skinny, and I’m OK with that.” This is new information for me. I thought anorexia was present always when a patient refused to eat, whether you liked your body or not.

Why do people develop eating disorders? 

There are so many reasons why people develop eating disorders. First, it can be psychological due to low self-esteem, feelings of inadequacy or failure, feeling of being out of control, response to change (i. e. puberty) or response to stress. Second, it can be due to interpersonal issues like having trouble with family and personal relationships, difficult expressing emotions or feelings, or even history of being teased based on size or weight. Lastly, it is the social and cultural norms that we grow up in. There are cultural pressures that glorify thinness and place value on obtaining the perfect body, narrow definitions of beauty that include women and men of specific body weights and shapes. 

Sometimes there is no reason. Some people just get obsessed with their weight and perceive themselves as “fat”. 

Effect of anorexia on different parts of the body

Since these patients are scared of gaining weight, how does it affect the entire body?

Anorexia can affect multiple systems in our body. Just to name a few symptoms that it can manifest as: amenorrhea, infertility, constipation, dizziness, hypothermia, bradycardia, hypotension, dry skin and even hair loss. Starvation induces protein and fat catabolism that leads to loss of cellular volume and atrophy of the heart, brain, liver, intestines, kidneys, and muscles. 

Cardiac: It can decrease cardiac mass, decrease cardiac chamber volumes, cause myocardial fibrosis and pericardial effusion. These manifestations are reversible if the patient gains weight. Functionally, it can cause bradycardia due to increased parasympathetic activity, hypotension, decreased heart rate variability and QT prolongation on ECG. 

Lungs: shortness of breath due to weakened and wasting of the respiratory muscles, pneumothorax and aspiration pneumonia. 

GI system: it leads to gastroparesis with bloating, constipation, severe pancreatitis and mild transaminitis. 

Hematologic: anemia, leukopenia and thrombocytopenia. 

Skin manifestations include dry/scaly skin, hair loss, acne, hyperpigmentation and acrocyanosis. You can also find lanugo, which is a very thin, light colored hair on the face and body. It is thought that the lanugo is an adaptation from the body to keep it warm. Lanugo is common in patients with anorexia nervosa or other causes of malnourishment. That’s why wearing coats in warm weather can be a silent sign of anorexia. 

Other subtle signs include social withdrawal, fidgeting (to burn calories), and always “eating” in private.  It is important to remember that all these manifestation that Jeffrey mentioned are not present with intermittent fasting because intermittent fasting is an intermittent restriction of food, the nutritional needs are met during the “feasting” periods after “fasting”. Some may argue that intermittent fasting may promote eating disorders, but I believe intermittent fasting is just an effective treatment for obesity.

Treatment plan for anorexia

There are several treatment options for these patients. We can refer them to nutritional rehabilitation where they can supervise meals. We can refer them to psychotherapy, such as cognitive behavioral therapy or motivational interviewing. There is also a drug called Olanzapine for this condition. 

Sometimes, patients may need admission to the hospital. I learned recently that UCLA has an Eating Disorder Program which includes inpatient services. Some centers are very specialized and include family therapy and group therapy. Listeners, you can continue to research about anorexia, it’s is fascinating. The prevalence of anorexia in the US is estimated to be 0.6%[3]. 

BULIMIA

By definition, bulimia nervosa is when a person binge eats and then uses certain behaviors to prevent weight gain. These behaviors may include self-induced vomiting, using laxatives or diuretics, exercising excessively, or fasting and having a restrictive diet. 

Signs and symptoms to look for

A physical examination is key. On physical presentation, these people usually can have overweight or obesity. That’s the main difference with anorexia. Anorexia: skinny people, bulimia: normal weight, overweight or obesity. Regardless of their weight, these patients are malnourished. They may lack some essential nutrients causing serious health consequences. That’s why nutrition cannot be assessed by BMI only. 

Common signs they will present with will include tachycardia, hypotension (systolic blood pressure below 90), dry skin, and hair loss. If the person uses self-induced vomiting to prevent weight gain, they may have erosion of the dental enamel from all the acid that comes up when they vomit. There may also be scarring or calluses on the dorsum side of the hand from all the acid too. Their parotid glands, that are located on the side of the jaws will also be swollen, causing a sign known as chipmunk face of bulimia.

From talking to this person and getting a detailed history, we will learn of the symptoms bulimia nervosa can cause. This will include lethargy and fatigue, irregular menstrual periods in a female, abdominal pain and bloating, and constipation

This disorder really does take a toll on the body. There’s plenty of complications that come with it as well. Let’s try to break it down by system. 

GI system has the most complications: esophageal tears from the vomiting called Mallory-Weiss syndrome, which will present with bloody vomits, a loss of gag reflex, esophageal dysmotility, abdominal pain and bloating, GERD, diarrhea and malabsorption of nutrients, fatty stools known as steatorrhea, colonic dysmotility leading to constipation, irritable bowel syndrome, rectal prolapse, and pancreatitis. 

Cardiac: serious complication is ipeac-induced myopathy, let’s spend a little time on this. Ipecac is a syrup that someone with bulimia nervosa may use to make themselves vomit. If a person uses this syrup frequently or for a long amount of time, there is a component called emetine will accumulate in muscle, including cardiac muscle. If a person uses ipecac chronically, it can be detected in the urine for up to 60 days. This will damage the heart muscles or myocardium and lead to cardiomyopathy. It will present with symptoms such as chest pain, shortness of breath, hypotension, tachycardia or bradycardia, T wave abnormalities on ECG, conduction delays, arrythmias, pericardial effusions, and even congestive heart failure. Cardiomyopathy may be irreversible. 

Renal system: dehydration, hypokalemia, hypochloremia, hyponatremia, and metabolic alkalosis. This could happen in patient who use diuretics as a purging mechanism. 

Endocrine system: Electrolytes and hormones imbalance. The endocrine system primarily impacts the reproductive and skeletal systems. Among 82 women treated for bulimia nervosa, menstrual irregularities were present in 45 percent at pretreatment and in 31 percent at 12-month follow-up. These irregularities may look like spotty or very light menstrual cycles. Cycles may be very erratic or completely absent. 

Skeletal system: osteopenia and osteoporosis are common with bulimia nervosa. Osteopenia means weaker and more brittle bones. Osteoporosis is more serious than osteopenia and can more easily result in fractures.

The diagnosis of bulimia nervosa can usually be made clinically. And after the diagnosis with bulimia nervosa, the first step in helping them is always getting a full lab work up to see what systems to the body have been impacted. 

Treatment options include nutritional counseling, behavioral therapy, and even medications. If a person needs help connecting with someone that can help with this disorder, there are organizations that they can contact which will connect them with proper resources in their area. Organizations include the Academy for Eating Disorders and the National Eating Disorders Association. 

Bulimia nervosa is more prevalent in females than males in all age groups. In the US, adult prevalence is 1.0% and adolescent prevalence is 0.9%, with the median age of onset of 18 years. After comparing different age groups, we have seen the prevalence of bulimia nervosa has increased over time. 

Conclusion: 

Anorexia nervosa and bulimia nervosa are eating disorders that can have consequences on the health of our patients. We should know the difference between these two diseases and know the resources available in our community to assist these patients. The diagnosis may be done clinically, but you will need to order labs or imaging for a full assessment. 

Eating disorders are an example of the direct effect a mental illness can have in the body. In the specific case, anorexia and bulimia cause malnutrition. The treatment of these diseases requires a multidisciplinary team to treat the patient and the family as well.

____________________________

Conclusion: Now we conclude our episode number 76 “Eating Disorders.” We started this episode with exciting news about the new malaria vaccine, a step forward on our fight against malaria. Sophia, Jeffrey, and Dr Arreaza presented an interesting overview about anorexia and bulimia. They taught us that if a patient perceives him or herself as “fat”, but they are actually underweight, they may have anorexia. Patients with bulimia tend to have normal or above normal BMI but have periods of binging and purging. Be aware of these conditions while assessing your patients’ nutritional status and treat appropriately or refer as needed. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Tana Parker, Sophia Dhillon, and Jeffrey Nguyen. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References: 

Malaria’s Impact Worldwide, Centers for Disease Control and Prevention, https://www.cdc.gov/malaria/malaria_worldwide/impact.html, accessed on November 15, 2021. 

 

Constitution of the World Health Organization, Basic Documents, Forty-fifth edition, Supplement, October 2006, accessed on Aug 26, 2021. Accessed on November 15, 2021.  https://www.who.int/governance/eb/who_constitution_en.pdf.

 

12 Secret Signs of Anorexia, CBS News, August 12, 2010, https://www.cbsnews.com/pictures/12-secret-signs-of-anorexia/3/. 

 

Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58. doi: 10.1016/j.biopsych.2006.03.040. Epub 2006 Jul 3. Erratum in: Biol Psychiatry. 2012 Jul 15;72(2):164. PMID: 16815322; PMCID: PMC1892232. https://pubmed.ncbi.nlm.nih.gov/16815322/. 

 

Mitchell, James E, MD; and Christie Zunker, PhD, CPH, CHES, Bulimia nervosa and binge eating disorder in adults: Medical complications and their management, UpToDate, October 2021. https://www.uptodate.com/contents/bulimia-nervosa-and-binge-eating-disorder-in-adults-medical-complications-and-their-management?search=Bulimia%20nervosa%20and%20binge%20eating%20disorder%20in%20adults:%20Medical%20complications%20and%20their%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

 

Yager, Joel, MD, Eating disorders: Overview of epidemiology, clinical features, and diagnosis, UpToDate, October 2021. https://www.uptodate.com/contents/eating-disorders-overview-of-epidemiology-clinical-features-and-diagnosis?search=Eating%20disorders:%20Overview%20of%20epidemiology,%20clinical%20features,%20and%20diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

 

Yager, Joel, MD, Eating disorders: Overview of prevention and treatment, UpToDate, October 2021. https://www.uptodate.com/contents/eating-disorders-overview-of-prevention-and-treatment?search=Eating%20disorders:%20Overview%20of%20prevention%20and%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Further episodes of Rio Bravo qWeek

Further podcasts by Rio Bravo Family Medicine Residency Program

Website of Rio Bravo Family Medicine Residency Program