DISORDERS OF EATING BEHAVIOR

ROSAURA LAMBRUSCHINI NILE AND LEIS

The importance and health relevance and disorders of social behavior food,
presented by anorexia nervosa and bulimia as well as the intermediate representations or
disorders
the atypical eating behavior, has been in increase in the last two decades because the
increase in its prevalence and its effects negative cough on psychological development
and adolescent health. In the past 15 years the number of patients has been multiplied
do 10 estimated that 3% of the adolescent girls and young have anorexia or bulimia and
probably 6% suffering from major clinical variants.

In Spain, in recent years has grown from a rare pathology comparable figures
to those of other European countries, becoming the third most common disease count in
adolescence, after asthma and obesity. Today, between 1% and 2% of girls teens with
anorexia, increasing the percentage to 2-4% in the conduct bulimic. Furthermore, it can
be stated that of two teenagers aged 15 and 16 years "thinks" that its weight is high.

In a recent study, carried out by the Department of Pediatrics Complex

University Hospital of Santiago de Compo stela, within Galinut Project in order to
determine the risk of the disorder us on feeding behavior in the adolescents and their
relationship with self-image and body composition, and which is carried the Eating
Attitudes Test (Eating Attitudes Test-EAT) to 509 healthy adolescents, between 14 and
18 who do not meet criteria DSM-IV anorexia and / or bulimia nervous , evidenced an
incidence of
preanorexgenas behaviors index EAT greater than or equal to 30, 5.5% of the sample
Overall, 9.6% of women compared to 0.8% boys. These data corroborate the above
figures and reflect the high frequency of such behaviors in adolescent ado- and the
increased susceptibility of female.

ANOREXIA NERVOSA
 Anorexia nervosa is not an affectation new, existing references already in the
second century, in 1694, 1767 or 1783 and in 1874 Lasegue Gull perfectly
individualized syn- drome from the clinical point of view and their developmental
risks, having existed variations, according to the times, in terms of their physiology or
psychopathology.

From the second half of our century, the nature of psychiatric condition has not
been questioned, despite the complexity of the disorder in terms of pathogenic factors,
which currently mind tries to find a genetic basis modified by environmental factors,
which discharge chained disorder conduct food mentary.

CONCEPT

It is defined as a psychiatric syndrome multifactorial, manifested by loss

voluntarily gives weight conditions a series of organic alterations. The cause
immediate is the intense fear of gaining weight Despite being in a normal weight,
which is the result of an alteration of its body image. Its incidence is higher in
females, especially on the age or pre pubertal. The casuistry of income in the Hospital
Sant Joan de Deu, during the years 1996-98 on 66 patients shows a 10: 1 ratio in favor
of females, with an average age of 12-income 14 years old. This entity is described in
exceptional in underdeveloped countries.

Factors involved in the pathogenesis genetic, psychological, social, cultural,

nutritional, hormonal and neurochemical, acting as predisposing, triggering
maintainers or altered. Among the predisposing factors, at present bility fam- studies
known pedigrees twin Liares and alignment as well as the initiation of studies based on
genetic molecular, showing a predominance of 1438 genotype A / A in the promoter
region gene 5-HT 2, approximately 41% of restrictive anorexics compared to 9% of
control subjects. Also, it has been observed ford increased feeding disorders in
families of anorexic patients and It has been found in one monozygotic increased
concordance vs. Twins dizygotic.

Environmental factors include functional neatly changes patterns diet, the

influence of the media transmitting communication The actuators les canons and
stereotypes of beauty and success social, the influence of the food industry ria and
fashion, new skills and roles of women, gender equality, the urbantion and progressive
predominance of sedentary lifestyles. Thus, significant evidence highlights the role of
cultural factors in the etiology of eating disorders.

Anorexia and bulimia nervosa are presented so fundamentally in industrialized

countries sized, where contain two events occur tradictory; on the one hand, a wide
availability both in quantity and variety of foods, and secondly, the stereotypes
social, image of success and prestige is thinness, particularly women.

This body size difference between desired and high food availability has been
frequently invoked to explain the high prevalence of behavioral disorders eating in
adolescent girls.

The strong social and cultural trend considered sider thinness as an ideal
situation acceptance and success is increasingly influencing more on adolescents,
especially women, who have a great concern for their aesthetic, they are afraid of
gaining weight and therefore want to lose weight, regardless spective of their actual
weight.

There before, the low incidence in non-Caucasians has been attributed to

differences in body image Ideal existing between ethnic groups. The black women,
which are not frequent behavioral disorders presentation food, tend to manifest a more
satisfied with their image than white woman of equal weight. In the Studio Galinut
when value perception of self-image in adolescent ado- with EAT 30 index shows
that 82.1% want to lose weight in your thighs 78.6% in the buttocks, 75% at the waist
and 64.3% at the hip, all percentages

Them significantly above presetting by adolescents with an index < 30 It should

be noted that these regions corporation rales corresponding to the distribution gynoid
body fat, typical of dimor- sexual phism, which is set at this stage life.
This could explain why the Puberty is a period of increased risk for the
development of behavioral disorders food, given the increase in the gain weight and
adiposity occurring in relation to sexual maturation in a society that values thinness.
 One thing to note is the impact of television viewing behavior in these disorders
to food, to serve as a means of disseminating the "social stereotype" and behaviors and
habits cough life. The influence of the media communication in the configuration of
the estimated the lives of adolescents is stronger that doctors or parents.

They choose their heroes and the media "choose" because exposed through them to a
variety of news, ideas and attitudes, and ENSA yan to conform his life to the style of
these. The advertising, especially television, the persuaded to buy and consume, what
each day easier given the significant amount of spending money at their disposal,
converting tindose therefore a coveted goal.

The television series and introduces their an- ts sports heroes, popular artists
and models that reinforce in adolescents men desire to purchase and consume food
ments that make them strong and athletes, and the teens, slim and trim, regardless
spective of the behaviors of its heroes are suitable from the standpoint nutritional and
well-nourished or not.

As proof of this, note that 88% of advertisers are thin or average, and just 12%,
obese, reinforcing the association between thinness and intelligence, popularizing,
attractiveness or social success. Furthermore, the Most foods or beverages prepared
sent television have little value nutrition and are more focused on satisfying emotional
or social needs that nutrition.

A study of exception to this respect is conducted by Dr... BEC Anne Ker on

changes in feeding habits rivers in Fiji (Oceania) archipelago from 1988, where it is
noted that since the arrival television in 1995 there has been a marked increase in
behaviors anorexics and bulimics.

These mixed signals, which, for hand, promote thinness and on the other,
offered food consumption of high value calorie, low nutritional value, are adolescence
in a period of great guilty, as the teenager has a profounder desire to exercise their
independence, search for identity and body image ideal, to make their own decisions,
experience new lifestyles, not accept the existing values, and one of the consequences
of these developments is the adoption new eating patterns, not a few sometimes related
to ecological motivations Cal, philosophical, religious, independence influence of
family or peers or their heroes.

Also at this stage having a satisfactory self-image and be seen by attractive way
for others is a priority. This state of vulnerability and body image anxiety predisposes
them set to make diets, which in most sometimes performed without any control part
of the family or doctor.

This looks favored by little or no supervision which is at present under the

feeding children and adolescents and number of meals that children perform alone, as
reflected in the study EUFIC in that in 70% of cases the child is the decide which
breakfast and about 25% also decide what foods consumed in noon meal and dinner;
likewise, It is revealed that 45-50% of the Children do not make or breakfast or lunch
with his family.

This fact, together they nutritional knowledge have not known what fat, slim
or makes muscles it, causes the risk of inadequate diet da is high. Besides this fear of
gaining weight leads teens to skip meals and diets with reduced fats, which are foods
with caloric density, or refined sugars deleted, making the energy from other foods can
be insular cient, with the risk of causing not only loss gives weight but also delay
growth ment and sexual development.

Among the factors developers and disseminators the new social model must
thinness highlight the role of fashion designers, where industry has collections each
more and more thin models and sizes with lowest numbered. These models are now
reference more manifestly economic success nomic, social and loving. An example of
this industry pressure is reflected in the recent decision by the designers and
commercial British traders change makes and reduce the sizes to overcome the
psychological barrier chological obese, so the "size 42 will now one 40 ".
 As factors related with the sex exist today work involving serotonin (5-HT),
neurological transmitter that performs multiple function psychobiological regulators,
including mood and appetite, are intimately involved with anorexia. Thus, it appears
that women res after a hypo caloric diet for 3 weeks show a decreased basal prolactin
indirect change indicator bios in brain serotonin and provisions crease of plasma
tryptophan, made does not happen in men subjected controls mitted to the same
experience.

Among the factors agrarian maintenance and / or now also involve a number of
neurotransmitter systems, observed decrease in turnover of brain norepinephrine and
reduced activity of the dopaminergic system and its influence neuropeptide Y, one of
the appetite stimulants. However, the investigations of endogenous opioids in
anorexic patients are ambiguous, although speculated that the decrease in betaendor-
Fine contribute to decreased appetite.

DIAGNOSIS

The diagnosis is easy in cases evolve Swim; currently the criteria used are
those of the American Academy of Psi- chiatry 1994 (DSM-IV) and processed by
WHO in 1992 (ICD-10) (Table I). Given the importance of early diagnosis, to prevent
the complications of evolution, the suspected diagnosis should assessed in those
patients prepbe- res or teenagers, especially if they are of female displaying any of
the
following characteristics:

Making hypo caloric diet absence of obesity or overweight.

P eri ears of semiayuno alternated with normal intake.
Fear exaggerated to overweight or weight gain.
Rejection of body image.
Assessment of weight or figure as a priority .
Assessment of food exclusively you regarding weight gain.

During the developing process will anorectic oping some abnormal eating habits
(Table II) and gastrointestinal symptoms dominated by the feeling of fullness, mete-
orison and abdominalgias, attributed in part to a functional disorder and partly to the
altered relative interceptive perceptions the sphere of appetite and satiety as a
manifestation of impaired synthesis of brain neurotransmitters.

Anorexia nervosa is a model malnutrition protein energy (MPE) of predominant

minimum energy, slow onset and pro progressive, with little impact on the analytical
routine, since the body takes adaptation process. In nutritional assessment, we observe
a decrease in anthropometric parameters, as weight, height, fat mass, muscle mass,
body mass index (BMI) and index weight / height, a significant deficit of the fold
triceps and arm circumference. On examination, the clinical signs observed cos own
PEM and its impact on organs and systems.

Endocrine metabolic disorders

1 Axis hypothalamic-pituitary-thyroid: device crease of T3, T4 and normal TSH.

2 axis hypothalamus-pituitary-gonadal axis: levels low estrogen and gonadotropins
with inversion ratio LH / FSH and lack of response to acute stimulation with GnRH.
3 Prolactin levels decreased in basal times.
4 Growth hormone: is decreasing elevated IGF-I.
5 Insulin and glucagon: insulin and lowered elevated glucagon.
6 axis hypothalamus-pituitary-adrenal: cortisol elevated baseline.
7 Hypercholesterolemia: A cholesterol-based LDL of unknown cause, although it is
believed T3 because of decreased excretion decreased bile.
8 Hipercarotinemia: Due to increased transport by lipoproteins.
9 hyperaminoacidemia with impaired relationship Phe / Tyr, Met / Cys and Gly / Val.
Diagnostic and therapeutic protocols in pediatrics

TABLE II. Abnormal eating habits that develop during the process anorexic

Selective rejection of certain foods

Handling of food (hide, wash, crumble, remove fat and find
large amount of waste)
Development obsesivocompulsivas attitudes to food or drink (rituals, potomania)
Isolation for meals or standing or moving
 exaggerated meal time extension
Changes in eating and sleeping schedules
Excessive interest by culinary themes
Excessive attention to the intake of the rest of the family is trying to get the same rich
Digestive disorders
1 Gastroparesis delayed gastric emptying gastric.
2 Constipation.
3 Bloating
Cardiac disorders

1 bradycardia and hypotension.

2 mitral prolapse.
3 Decreased cardiac silhouette, left ventricular cardiac index.
4 T wave inversion

Blood disorders
1 Mild anemia.
2 Decreased bactericidal action and granulocyte adherence. Reduction in CD4 and
CD8 lymphocytes.
3 Decreased serum complement ment.
Bone loss
1 rapid and permanent loss and only reversible partially possible. Possibly in relation
with estrogen deficiency, hyper- cortisolismo and reduced IGF-I, as we have seen in
our patients, sometimes leading to deficits score of -3 in Z. It correlates directly
ly with time of amenorrhea.

Nutritional management of anorexia

The control is of Anorexia Nervosa performed using a multidisciplinary team nario,

the objectives are:

Correcting malnutrition and its sequelae.

Act on psychological problems, behavioral, social and family, which has process
initiated or maintained.
The recovery of optimal nutritional status is a primary goal in the management of
these patients. Nutritional objectives Immediate are:
Restore normal eating patterns ills.
Recover the lost weight.
Adjust the weight to size.
Prevent relapse. In the assessment of patients with anorexia nervous, we must be
attentive to the presence warning signs, which can make us criteria vary outpatient
treatment or hospital admission; these signs are:
Fast extreme weight loss.
Tendency to hypotension, being able associated bradycardia below 50 Latin
Two / minute.
Presence of sustained hypothermia.
less than 2.5 Hypokalemia mEq / l.
Changes in the state of consciousness, pre- sitting apathy and great prostration.
Presence of vomiting.
We base our performance in four phases:

Phase I

In which we correct the acute condition is say, dehydration, electrolyte imbalances and
alterations of acid-base balance.

Phase II

We started feedback in patient Initially the needs adjusting des calorie weight resented
by the patient to be increasing every 24 hours as tolerated rance, the needs of your
ideal weight relative to their size; initially it has to attempt an oral nutrition, which
get a diet calorically more adequate nutritional supplement offer an energy density of
1 kcal / ml or 1.2 kcal / ml. In cases of manifest rejection to vomiting or presence of a
food is established mentation nasogastric enteral or od nasduodenal; never
rebasaremos initially mind volume 2000 ml per day.

Phase III
Once the patient is in one lump ca recover your ideal weight, you start a nutritional
rehabilitation in order to achieve stabilize the disorder and achieve goals by weight
corresponding to the patient; It achieved this goal, is passed to the phase IV.

Phase IV
Discharge with outpatient controls of nutritional status and education of their eating
habits. On the first visit we make these patients value their nutritional status and
according to the data obtained and the degree collabora ration showing the patient still
Schemes 1, 2, 3 and 4 of Figure 1 in the Currently, although the possibility of
parenteral nutrition in these sick We, the indications are very slim, stagnant do
reserved for those with a large dete rioration nutritional and life-threatening, with severe
altered psychic impossible to feed ration enteral.

Bulimia nervosa

Bulimia nervosa was first described Russell in 1979, as an entity anorexia nervosa
different, in which patients after performing massive intakes food, intended to control
your weight induced vomiting or using laxatives or diuretics. The incidence in our
is approximately 1-3%, the ado- cence the period in which it starts disease most
commonly affecting females in a ratio 10: 1.

It is a disease difficult to detection, since the absence of malnutrition, pre- sometimes

even sitting overweight cannot be observed "signs of severity Nutrition "; their
scattered demonstrations (Dental, endocrine, gynecological case, ORL) can make us
think more an entity and the fact practiced in secrecy also makes it difficult discovery
within the family.

Diagnosis

The diagnostic criteria are accepted 1994 in the DSM IV: A. Recurrent binge eating
characterized terizados by food intake in amounts high and in a short space of tiem- ty
po, feeling of loss of control on intake.

B. inappropriate compensatory behavior repeated to prevent weight gain: overuse

of laxatives, diuretics, enemas, provocation of vomiting, excessive exercise.
C. The binge eating and compensatory behaviors occurs at least two times a week
over a period of 3 months.
D. Self-evaluation is influenced too much about weight and body shape.
E. The disturbance does not occur exclusively during anorexia nervosa.

TYPES

Purging Type 1. During bulimia nervosa , the patient induces vomiting, uses
laxatives, diuretics or enemas excessively. Type 2 Nonpurging. The compositions
behaviors Countervailing are fasting or strenuous exercise.

CLINICAL MANIFESTATIONS

Clinical complications occur in the 40% of patients, with the intent of suicidal
cide the most common risk of death in these patients reaching 3%, although lower
in anorexia nervosa. The most frequent somatic alterations occur in the digestive tract,
with the oral cavity the most affected. Presented erosions of the tooth enamel,
especially inner surface of incisors and canines, due to acidic pH of the gastric juice
and its continued action on the enamel.

Similarly pathogenesis is the presence of gingivitis, pharyngitis and cheilitis.

Sometimes it has been observed hypertrophy parotid, related to vomiting and causes
increased plasma amylase; by usually is symmetrical, painful, disappeared giving at
the end of the process in most cases.

The abnormalities in the esophagus ranging from the onset of the syndrome
esophagitis Mallory-Weiss. The capacity of the stomach is greatly increased, reaching
cause acute gastric dilatation phenomena local ischemia that can produce gastric
perforation. Laxative abuse rectal enemas or may occur, which forced to make a
differential diagnosis with inflammatory bowel disease.
 Also, there are reports of pancreatitis acute intake related compounds food,
cardiac complications , which are not uncommon, still the proposed mitral valve within
the alteration more frequently, but are also observed arrhythmic- mine heart.

Other common complications are untouchable by abuse of emetics, diuretics

cos and laxatives. However, osteoporosis is rare presentation. Of note is the possibility
of the association between bulimia and diabetes mellitus (IDDM), describing
Garfunkel in 1987, a 6.9% prevalence of bulimia in IDDM, and these patients by
manipulating dose insulin as a method to remove the excess sive calorie intake at risk
for ketoacidosis coma and poor control. In the Today stresses the importance of
investigate a behavioral disorder food in all patients with IDDM bad
controlled.

METABOLIC COMPLICATIONS

Recurrent vomiting and brought produced cen depletion of water, chlorine and
potassium increasing the latter if used diure ticos; the result is the presence of insular
renal failure secondary to hydrocarbon depletion saline, hypochloremic metabolic
alkalosis and hypokalemic nephropathy. The biochemical pattern of bulimia nervosa
serious is the following:
Plasma
- Metabolic alkalosis
- pH> 7.42,
- CO3H > 30, pCO2> 40
- Elevated BUN and creatinine
- Cl <85 mEq / l
- K <3.5 mEq / l

Urine

- Urea and high K

- Na and Cl <10 mEq / l

Treatment
 A. A. Treatment of the Metabolic Syndrome

1 NPO aspiration nasogs- trica if acute gastric dilatation.

2 Perfusion with saline as estimated losses and electrolytes with replacement infusion
containing potassium continuous.
3 Monitor TA moisture balance.

B. Reset oral diet

1 Phasing food or phased depending on the tolerance calorically suitable for
weight / height.
2 If there is no cooperation Nutrition Total enteral SNDuodenal.

C. Goals of treatment in bulimia nervous

1 Avoid crisis by treating bulimia ing psychopathological-pharmacological co.

2 Adjust the ideal weight for height: - Technical education food
tary.
- Diet adjusted to actual needs.

Binge Eating

The "overeating" as a syndrome or feeding behavior disorder was first described in

1992, characterized by "binge" as those bulimia observed, but they will not
followed by vomiting or other measures to curb the appetite. It can be as frequent
like bulimia, but is presented in both sexes and all ages. In clinical to lose weight,
about 1/4 or 1/3 of the patients met criteria for excessive intake will "binge" (BED).
Not all obese exhibit intake excessive binge.

This behavior seems be associated, regardless of weight, with a higher prevalence of

psychiatric problems citric, such as depression, greater and more frequent weight
fluctuations and increased anxiety related to it.
A pre- provision obesity and the presence of factors tors of risk for nonspecific
alterations psychiatric tions as negative experiences you're in childhood or parental
depression, appear to increase the risk of But why an individual with these risk factors
becomes a obese with "binge binge" on a bulimic normal weight or an individual duo
without any behavioral disorder normal weight food is still elucidated.

Diagnosis

DSM-IV is characterized by:

1 Epic hatred of recurrent binge eating (at least two per week in 6 months).
2 Upset with at least three points of the following:
a) Eating too quickly.
b) Eating until you feel bad.
c) Eating when not hungry.
d) Eating alone.
e) Feeling disgusted or guilty after eating.
3 Do not use purging (self-induced vomiting or laxatives), or increasing exercise
physical, or fasting.
4 Absence of anorexia nervosa.

Prevention of disorders eating behavior

Disorders of eating behavior presented Sentan important symptoms and organic signs
cos and complications that may lead to death of the patient, so that is extremely
important early detection in order to establish prevention strategies tive and necessary
treatment.

Therefore, it should be aware that there are a number of somatic and behavioral changes
that can den alert the primary care pediatrician or the family about the possible
existence of a eating behavior disorder without tics diagnosis-, such as the existence of a
diet associated restrictive to decreased weight and an inability to win, year excessive
physical, family history of anorexia or bulimia, amenorrhea, diet associated to social
isolation, etc.

(Table III). While the treatment of these patients has be multidisciplinary, involving the
pediatrician , adolescent pediatrician, the pediatrician nutritionist at paidopsiquiatra and
endocrine pediatric, primary care pediatrician maria will have an important role in
detection, assessment and orientation of the proposed problem, as well as education of
the child, families, educators and community

(Table IV). The primary care pediatrician maria should be alert to any symptoms or sign
indicating an alteration in the eating behavior; and should assess the LEAKS measure
weight, you want to help your teen slimming, performing a monitoring diet and weight
loss plan, to guide activity, set the loss limit weight according to it and interconsultar
with specialists or refer the patient to these before any warning signs

(Table III).

In the prevention of these conditions it is a must thinkable acting on cultural factors

rales; the presumed etiological role of these strategies has led to modified car the impact
of their influences. However go, widespread prevention programs, that increase
alertness in Review public about the health risks of inappropriate weight loss methods
and promote resistance to the cultural obsession ral for thinness, they have not had in
many Sometimes the desired effect; in fact, Some experts argue that even be more
harmful than beneficial.

A adequate nutritional education along with greater control and supervision of the diet
children and adolescents by their families, as well as television messages food industry
and fashion, probably favor the decline frequency of these pathologies.

Without any doubt, the prevention of these disorders social change requires large scale,
but if professionals and parents contain trarrestan destructive cultural messages ture
making the contemporary adolescent ado- feel they are considered valuable who listens
to and respects, which have a position and expectation of equality with response respect
to the man, they will no longer need the diethyl tas and destructive maneuvers to feel his
self-control and power. At that time, if no we have won the war, yes we will have won a
good battle.

TABLE III. Changes that may indicate a disorder feeding behavior undiagnosed

1 Somatic:
a) Brake growth
b) significant or frequent fluctuations in weight change
c) Inability to gain weight
d) Fatigue
e) Constipation or diarrhea
f) susceptibility to fractures
g) Delayed menarche
h) hypokalemia, hypophosphatemia, metabolic acidosis or alkalosis or high levels of
amylase

2 Behaviors:

a) Changes in eating habits

b) Difficulty eating in social settings
c) Resistance to be heavy
d) Depression
e) Social isolation
f) Conduct or misleading reserved
g) school or work absenteeism
h) Stealing food
i) Substance Abuse
j) Excessive exercise

TABLE IV. Role of the primary care pediatrician in eating disorders

Assessment of weight loss (intent, methods and Symptoms)

Assessment and monitoring of diet and weight loss plan
Give daily activity guides: schedule of meals, exercise, sport and leisure
 Referral to a pediatric nutritionist to carry out the diet plan and education
nutritional
Set the limit of weight loss, according to the patient's target
Interconsulta with, or refer to a specialist in the treatment of behavioral disorders
food
Reassessment

In conclusion, it is clear that much you have to move for all pathophysiological
mechanisms involved in the development of food behavior disorders mentary, allowing
us to establish most appropriate strategies for prevention and intervention. However,
there are reasons for optimism. Advances in genetic molecular may allow identification
of genes that predispose an individual to develop anorexia or bulimia nervosa.

The greater understanding of the biological factors cos involved in weight control,
including leptin, may also shed light on this field. And the study of patients with
recovery Full or partial differential ration help CIAR biological alterations that are
cense- result of the disease from those presented give in to the symptoms or contribute
to its terms Nance.

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