Medical Medical ParametersParametersfor Healthfor Health

Or Or “What does the “What does the doctor do, anyway, doctor do, anyway, and why does she do and why does she do it that way?”it that way?”

Laura Koenigs, MDDirector, Adolescent MedicineBaystate Children’s Hospital

Springfield, MA

ObjectivesObjectives

Describe differential diagnoses Describe differential diagnoses of weight loss and vomitingof weight loss and vomiting

Describe techniques for Describe techniques for determining ideal body weightdetermining ideal body weight

Describe common medical Describe common medical complications of eating complications of eating disordersdisorders

Tasks for ProviderTasks for Provider

Establish diagnosisEstablish diagnosis Set parameters for normal Set parameters for normal

weightweight Set guidelines for activitySet guidelines for activity Clarify need for Clarify need for

hospitalizationhospitalization Organize a team Organize a team

Why is intervening Why is intervening critical?critical?

Irreversible Medical Irreversible Medical ConsequencesConsequences

Growth retardationGrowth retardation Structural brain changesStructural brain changes Decreased peak bone Decreased peak bone

massmass Loss of dental enamelLoss of dental enamel

Establish Establish DiagnosisDiagnosis

Establish Establish DiagnosisDiagnosis

HistoryHistory PhysicalPhysical Laboratory testsLaboratory tests ECGECG

Differential Differential DiagnosisDiagnosis

Endocrine diseasesEndocrine diseases

Differential Differential DiagnosisDiagnosis

Endocrine diseasesEndocrine diseases Gastrointestinal diseasesGastrointestinal diseases Neurologic diseasesNeurologic diseases MalignanciesMalignancies Connective tissue diseasesConnective tissue diseases Chronic infectionChronic infection Other psychiatric illnessesOther psychiatric illnesses

Symptoms of Symptoms of StarvationStarvation

Cold all the timeCold all the time TiredTired Full easilyFull easily ConstipatedConstipated Sad/ IrritableSad/ Irritable Hair changesHair changes

Signs of StarvationSigns of Starvation

BradycardiaBradycardia HypotensionHypotension HypothermiaHypothermia Lanugo / BaldingLanugo / Balding Yellow discoloration – handsYellow discoloration – hands AcrocyanosisAcrocyanosis KetosisKetosis

Signs of VomitingSigns of Vomiting

OrthostasisOrthostasis Parotid SwellingParotid Swelling Subconjunctival Subconjunctival

hemorrhageshemorrhages Facial petechiaeFacial petechiae Tooth enamel erosionTooth enamel erosion Russell’s signRussell’s sign Extremity edemaExtremity edema

Medically Stable?Medically Stable?

Severe malnutrition (≤ 75% av.)Severe malnutrition (≤ 75% av.) Heart rate (<45)Heart rate (<45) Temperature (<96)Temperature (<96) Heart dysrthymiaHeart dysrthymia HypoglycemiaHypoglycemia Electrolyte or divalent Electrolyte or divalent

abnormalitiesabnormalities Orthostasis/ HypotensionOrthostasis/ Hypotension

Criteria for Criteria for AdmissionAdmission

Medical instabilityMedical instability Medical complications of Medical complications of

malnutritionmalnutrition Arrested growth/developmentArrested growth/development Uncontrolled binging / purgingUncontrolled binging / purging Acute psychiatric emergenciesAcute psychiatric emergencies Failure of outpatient treatmentFailure of outpatient treatment

Society Adol Med Position Paper J Adol Health 2003; 33:496-503

What Should a What Should a Person Weigh?Person Weigh?

Preadolescent: 11-14% body fatPreadolescent: 11-14% body fat

Adult woman’s body: 20-25% Adult woman’s body: 20-25% fatfat

Adult male’s body 8- 11% fatAdult male’s body 8- 11% fat

Determining WeightDetermining Weight

Adult woman (≥18 y/o)Adult woman (≥18 y/o)

100 lbs for first 5 feet100 lbs for first 5 feet

5 lbs per inch over 5 feet5 lbs per inch over 5 feet

Give/take 5-10%Give/take 5-10% Works best at normal Works best at normal

heightsheights

Height & Weight Table For WomenHeight (Feet, Inches)

Small Frame Medium Frame

Large Frame

4' 10" 102-111 109-121 118-131

4' 11" 103-113 111-123 120-134

5' 0" 104-115 113-126 122-137

5' 1" 106-118 115-129 125-140

5' 2" 108-121 118-132 128-143

5' 3" 111-124 121-135 131-147

5' 4" 114-127 124-138 134-151

5' 5" 117-130 127-141 137-155

5' 6" 120-133 130-144 140-159

5' 7" 123-136 133-147 143-163

5' 8" 126-139 136-150 146-167

5' 9" 129-142 139-153 149-170

5' 10" 132-145 142-156 152-173

5' 11" 135-148 145-159 155-176

6' 0" 138-151 148-162 158-179

ages 25-59. Weight in pounds (in indoor clothing weighing 3 lbs.; shoes with 1" heels)

Men 1" heels

Elbow Breadth

Women 1" heels

Elbow Breadth

5'2"-5'3" 21/2"-27/8"

4'10"-4'11"

21/4"-21/2"

5'4"-5'7" 25/8"-27/8"

5'0"-5'3" 21/4"-21/2"

5'8"-5'11" 23/4"-3" 5'4"-5'7" 23/8"-25/8"

6'0"-6'3" 23/4"-31/8"

5'8"-5'11" 23/8"-25/8"

6'4" 27/8"-31/4"

6'0" 21/2"-2"

Elbow Breadth for Frame Size

BMI ChartsBMI Charts

CDCCDC Weight divided by height Weight divided by height

squaredsquared Change with ageChange with age

– Adults NL: 18.5-24.9 kg/MAdults NL: 18.5-24.9 kg/M22

Elite athletes, strength Elite athletes, strength sports - 50sports - 50thth% BMI% BMI

OK135S060

OK135S069

Sample ChildSample Child

12 year old girl12 year old girl 4’10” tall 62 pounds4’10” tall 62 pounds BMI of 13 kg/MBMI of 13 kg/M22

OK135S060

OK135S060

Sample ChildSample Child

12 year old girl12 year old girl 4’10” tall, 62 pounds4’10” tall, 62 pounds BMI of 13 kg/MBMI of 13 kg/M22

Ideal BMI 16.5-20.2 kg/MIdeal BMI 16.5-20.2 kg/M22

79- 96 lbs., 87 lbs. 5079- 96 lbs., 87 lbs. 50thth % %

OK135S060

Sample ChildSample Child

12 year old girl12 year old girl 4’10” tall, 62 pounds4’10” tall, 62 pounds BMI of 13 kg/MBMI of 13 kg/M22

Ideal BMI 15.4-18.0 kg/MIdeal BMI 15.4-18.0 kg/M22

71-87 lbs., 87 lbs. 5071-87 lbs., 87 lbs. 50thth % %

Following PatientFollowing Patient

Make diagnosisMake diagnosis Established normal weight Established normal weight

rangerange Gather teamGather team Criteria for admissionCriteria for admission

Following PatientFollowing Patient

Orthostatic vital signsOrthostatic vital signs Same scaleSame scale Wearing only hospital gown Wearing only hospital gown Post voidPost void Check urine for specific Check urine for specific

gravitygravity Check oral temperature after Check oral temperature after

bathroombathroom

Weight Restoration Weight Restoration GoalsGoals

OutpatientOutpatient– ½ to 1 lb per week½ to 1 lb per week

InpatientInpatient– 2-3 lb per week2-3 lb per week

Caloric NeedsCaloric Needs

Basal Metabolic RateBasal Metabolic Rate– Going 24/7Going 24/7– Higher if more muscleHigher if more muscle

Normal activityNormal activity– Include growthInclude growth

ExerciseExercise

Basal Metabolic RateBasal Metabolic Rate

ChildChild– Higher than adult to include Higher than adult to include

growthgrowth AdultAdult

– 10 X weight in pounds10 X weight in pounds

Basal Metabolic Rate Basal Metabolic Rate vs. Weightvs. Weight

BMRBMR

Goes down with starvationGoes down with starvation Goes down with Goes down with

Binge/PurgeBinge/Purge Goes up with temperature Goes up with temperature

extremesextremes Goes up with frequent Goes up with frequent

feedingsfeedings

Calorie NeedsCalorie Needs

25% of a person’s calories 25% of a person’s calories should be from fat.should be from fat.

50 - 60 grams of fat per 50 - 60 grams of fat per day = low fat diet.day = low fat diet.

Dietary GuidelinesDietary Guidelines

Not gaining weight?Not gaining weight?

Not eating enough or Not eating enough or Too much exerciseToo much exercise

Anorexia Nervosa & Anorexia Nervosa & AmenorrheaAmenorrhea

25% Precedes weight loss 25% Precedes weight loss 50% Occurs with weight loss50% Occurs with weight loss 25% Follows weight loss 25% Follows weight loss BMI < 19 kg/MBMI < 19 kg/M²² Exercise prior to menarche Exercise prior to menarche Low fat diet.Low fat diet.

Birth Control PillsBirth Control Pills

Osteopenia/Osteoporosis = Osteopenia/Osteoporosis = complication of eating complication of eating disorderdisorder

Birth Control pills have not Birth Control pills have not been shown to helpbeen shown to help

False sense of security False sense of security

ReviewReview

Diagnosis – r/o medical causes Diagnosis – r/o medical causes as well as fulfilling DSM-IVas well as fulfilling DSM-IV

Physician should give Physician should give parametersparameters– Medical stabilityMedical stability– Weight goalsWeight goals– Activity guidelinesActivity guidelines– Hospitalization guidelinesHospitalization guidelines