Fear of fatness

Fear of fatness

Eating disorders do not discriminate. They are complex psychiatric disorders that can affect anyone, regardless of age, sex, or race, states Eating Disorders South Africa.

The Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) and the 11th revision of the World Health Organisation’s International Statistical Classification of Diseases and Related HealthProblems published in 2019, classify feeding and eating disorders as:

1. Anorexia nervosa

2. Bulimia nervosa

3. Binge eating disorder (BED)

4. Avoidant/restrictive food intake disorder (ARFID).

Diagnostic features

People with an eating disorder have a“complex, problematic relationship with food”that are enhanced during difficult times such as we are currently experiencing, write Touyz et al. They caution that during Covid-19, patients with eating disorders should be even more closely monitored.

Prevalence

According to Hay, the true prevalence of eating disorders is unknown. However, studies suggest an increase in bulimia and in BED. Increases in anorexia have also been noted –especially in young women.

The estimated lifetime prevalence of anorexia is estimated to be 1.4% in women, and 0.2%in men. It is slightly higher for bulimia (1.9%in women and 0.6% in men). The lifetime prevalence for BED is 2.8% in women, and1% in men. An Australian study found that the three‐month prevalence of ARFID was 0.3%.

The long road to recovery and stumbling blocks

The road to recovery is a long one. A 22‐year follow‐up study (n=228) in women with anorexia or bulimia, treated in a specialist centre, found that 66% of patients recover within nine years. Less is known about long-term outcomes for BED and other eating disorders, according to Hay.

Patients with eating disorders often have concurrent depressed mood, higher body image concerns, and poor relationships, as well as other co‐morbidities. These factors negatively impact the recovery process and are often associated with poorer outcomes.

According to Hay, a major challenge in the management of eating disorders is closing the ‘treatment gap’. Studies show that the majority of people with anorexia, bulimia and BED delay seeking care for a decade or longer.

She notes that many factors contribute to this problem. The most important are low levels of health literacy, help‐seeking for weight loss management rather than theeating disorder, stigma, shame, as well as poor affordability and access to evidence‐based psychological therapies.

March is eating disorder awareness month

Treatment

The authors of a 2018 consensus document about the nutritional evaluation and management of eating disorders, stress the importance of an individualised and multidisciplinary (registered dietitian, specialist physician/paediatrician, psychiatrist, nurse/s, an exercise therapist, activity/occupational therapist and social worker or family therapist) approach. According to Candela et al, patients with anorexia and bulimia are often malnourished, and have severe nutritional deficiencies. A nutritional approach is recommended, which should include individualised dietary advice, which guarantees an adequate nutritional state and nutritional education.

The objective is to facilitate the voluntary adoption of eating behaviours that promote health and allow the long-term modification of eating habits, and the cessation of purgatory and bingeing behaviours, explain the authors.

Psychological support (eg trans‐diagnostic cognitive behaviour therapy [Enhanced]) is a first-line treatment. Support must address eating behaviour as well as psychiatric comorbidities. Psychotropic drugs are effective and widely used although these drugs are not essential, note Candela et al.

Treatment should preferably be managed by an expert in eating disorders and can be undertaken in an outpatient setting. Hospitalisation should be reserved to correct serious somatic or psychiatric complications or as a measure to contain non-treatable situations, according to Candela et al and Hay.

In addition to specific psychological therapy, treatment needs to address important nutritional issues.

Does nutritional supplementation have a role in the treatment of eating disorders?

According to Díaz-Marsá et al, the pattern of food intake in patients with eating disorders is 'erratic', which can lead to altered neuronal mechanisms in the dorsal striatum and its connections with the frontal circuits.

Decreased brain volume and thinning of the cerebral cortex have also been reported, which imply a deficit in different nutrients, namely electrolytes, vitamins and minerals, among others.

Electrolyte abnormalities are caused by purging (self-induced vomiting and incorrect use of laxatives, diuretics, or enemas). In addition, vomiting may cause hypokalaemia (low potassium levels) and/or hypochloraemic alkalosis (low chloride intake or excessive chloride wasting).

Laxative abuse can cause hypomagnesaemia (low magnesium levels) and hypophosphataemia (low levels of phosphate). These anomalies may require emergency supplementation to address individual needs, note Díaz-Marsá et al.

Hypocalcaemia is common in patients diagnosed with eating disorders, which can lead to poor bone density. Hypophosphataemia is easily detectable and treatable, but extremely serious if not detected in time.

As a result of poor nutrition, patients with eating disorders also have low plasma iron levels. In addition to diet, erythrocyte haemolysis in these patients may also contribute to iron deficiency.

Food restriction can lead to low plasma thiamine levels, which can cause various neuropsychological symptoms, such as worsening of depressive symptoms.

Vitamin B9 or folic acid deficiency has also been reported in patients with eating disorders. This vitamin is essential for human growth, nerve function, and for reducing levels of the amino acid homocysteine.

Short-term cobalamin deficiency can produce symptoms of anaemia (fatigue or weakness), or affective symptoms, while long-term deficiency has been associated with brain damage.

Vitamin C is necessary for the growth and repair of tissues in all parts of the body and acts as an antioxidant. Anorexia is associated with loss of bone mass. Vitamin D supplementation have been shown to improve bone mineral density, according to Díaz-Marsá et al.

Nutritional rehabilitation

The aim of nutritional rehabilitation or refeeding in patients with anorexia is to achieve weight restoration. Gastric feeding and total parenteral nutrition (TPN) may be indicated for refractory cases.

TPN is a specialised procedure and should be undertaken only when medically necessary and by an experienced clinician.

Patients with refractory anorexia is classified as mild, moderate, severe, or critical, based on whether they are 10%, 20%, 30%, or more, respectively, below ideal body weight.

Mehler et al warn that before refeeding is attempted, the possibility of complications should be considered. The most 'catastrophic' of these is refeeding syndrome, which is common in significantly malnourished patients during the early phase of nutritional replenishment whether it is by the oral, enteral(ENT), or parenteral (TPN) route.

The risk of refeeding syndrome directly correlates with the degree of weight loss, which occur as a result of anorexia. Patients who are more than 30% below their IBW should initially be refed in a hospital setting.

Several approaches can be used to minimise the risk of refeeding syndrome. The most important of these is avoidance of overly aggressive refeeding early on. Mehler et al recommend that intake levels should be started at about 600kcal/day–1000kcal/day, and steadily increased by 300kcal–400kcal every three to four days.

Supplementing the diet with a liquid supplement in the early stages of refeeding to achieve the prescribed calorie goal is a very effective strategy to achieve large caloric intake and weight gain, note the authors.

Some programmes recommend ultimately attaining an intake of 4000kcal/day-5000kcal/day per day, while others recommend 3000kcal/day-3600kcal/day. Mehler et al caution that even for normal weight adults, weight gain does not correlate exactly with the total excess calories ingested over basal requirements.

Therefore, it may be difficult to precisely define the factors that consistently correlate with the number calories needed to gain one pound. The basal metabolic rate on admission is invariably low, but it begins to increase early on in the nutritional rehabilitation process.

In general, starved anorectics are metabolically inefficient, and may require more than the expected 3500kcal/day beyond maintenance caloric needs to restore 0.5kg of body weight. The caloric requirement necessary for weight gain can vary between 1800kcal/day and 4500kcal/day.

Some simple general rules to follow when considering refeeding are:

1. The total energy expenditure should never exceed twice the basal energy expenditure

2. Caloric intake should rarely exceed 70kcal/kg-80kcal/kg of body weight

3. In the severely anorectic patient, begin a diet at 20kcal/kg to 25 kcal/kg

4. Protein intake should not exceed 1.5gr/kg-1.7gr/kg grams of body weight (generally in the 1gr/kg to 1.5gr/kg range)

5. If TPN or EPN feedings are used, carbohydrate intake should not exceed 7 mg/kg/min

6. Weight gain should be in the two to 1kg-12kg per week range.

Conclusions

The prevalence of anorexia, bulimia and BED are increasing – especially among young women.Studies show that the majority of patients with bulimia, and about half of those with anorexia will recover. The road to recovery is long (on average nine years). One of the big challenges in the treatment of eating disorders is that patients take ten years or more before seeking help. Most patients can be treated in an outpatient setting. Hospitalisation should be reserved to correct serious somatic or psychiatric complications or as a measure to contain non-treatable situations. Patients with eating disorders have severe nutritional deficits. In patients with anorexia, nutritional rehabilitation using liquid supplements, have shown to be successful. The risk of refeeding syndrome should be assessed before this is attempted.

References available on request. SF