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Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Severe Anorexia Nervosa in Males: Clinical Presentations and Medical Treatment ab
cd
Allison L. Sabel , Elissa Rosen
& Philip S. Mehler
cd
a
Department of Patient Safety and Quality, Denver Health Medical Center, Denver, Colorado, USA b
Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA c
Click for updates
Department of Internal Medicine, Denver Health Medical Center, Denver, Colorado, USA d
Department of Medicine, University of Colorado, Aurora, Colorado, USA Published online: 11 Mar 2014.
To cite this article: Allison L. Sabel, Elissa Rosen & Philip S. Mehler (2014) Severe Anorexia Nervosa in Males: Clinical Presentations and Medical Treatment, Eating Disorders: The Journal of Treatment & Prevention, 22:3, 209-220, DOI: 10.1080/10640266.2014.890459 To link to this article: http://dx.doi.org/10.1080/10640266.2014.890459
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [York University Libraries] at 20:49 30 December 2014
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Eating Disorders, 22:209–220, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.890459
Severe Anorexia Nervosa in Males: Clinical Presentations and Medical Treatment
Downloaded by [York University Libraries] at 20:49 30 December 2014
ALLISON L. SABEL Department of Patient Safety and Quality, Denver Health Medical Center, Denver; and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
ELISSA ROSEN and PHILIP S. MEHLER Department of Internal Medicine, Denver Health Medical Center, Denver; and Department of Medicine, University of Colorado, Aurora, Colorado, USA
The clinical presentation and medical complications of severe anorexia nervosa among males were examined to further the understanding of this increasingly prevalent condition. Fourteen males were admitted to a medical stabilization unit over the study period. Males with severe anorexia nervosa were found to have a multitude of significant medical and laboratory abnormalities, which are in need of treatment via judicious, nutritional rehabilitation and weight restoration to prevent additional morbidity and to facilitate transfer and admission to traditional eating disorder programs.
Anorexia nervosa (AN) is thought of as an almost exclusively female eating disorder. In the past, ratios of 20:1 were quoted as the female to male prevalence. However, more recent studies indicate that males may account for 10–25% of anorexia and bulimia cases (Hudson, Hiripi, Pope, & Kessler, 2007; Weltzin, 2005). The National Institute of Mental Health recently reported that upwards of one million males struggle with eating disorders. Thus, more males are currently seeking help with their anorexia nervosa. Despite the growing prevalence of eating disorders amongst the male population, there is a paucity of literature surrounding the clinical presentation and medical complications faced by this cohort. As the recent Address correspondence to Philip S. Mehler, Department of Internal Medicine, Denver Health Medical Center, 777 Bannock Street, MC0278, Denver, CO 80204, USA. E-mail: [email protected] 209
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A. L. Sabel et al.
retrospective cohort study by Gueguen et al. (2012) suggests, there may in fact be a higher short term (less than 3 year) post treatment mortality in males compared to females. Therefore, a greater understanding of the differences in anorexia nervosa between genders may help to tailor more specific psychological and medical treatments for males, and, thus, reduce morbidity and mortality. Current literature does demonstrate a difference in the clinical presentation of eating disorders in males versus females and a delay in diagnosis. Males are more likely to present at a later age, to have premorbid obesity, and to over exercise (Gueguen et al., 2012; Norris et al., 2012). The delay in diagnosis is in part due to continued gender stereotypes surrounding eating disorders—primarily the belief that it is a female predominant illness. In fact, Robinson, Mountford, and Sperlinger (2013) noted that males in eating disorder treatment programs had feelings of shame and isolation surrounding being a male suffering from what society still viewed as a female disorder. Males are not immune to the medical complications of anorexia nervosa faced by their female counterparts including arrhythmias, osteoporosis, and hepatitis. Sinus bradycardia, as defined by a heart rate less than 60, appears to be the most common medical complication found at initial assessment in a recent retrospective cohort study of 52 adolescent males with AN and an average body mass index (BMI) of 17.4 kg/m2 (Norris et al., 2012). In this study, two-thirds of the males evaluated also had abnormal electrocardiograms as evidenced by rhythm and conduction abnormalities, including QTc prolongation in 9%. However, only 10% of the sample population, of which 19% had binge-purge subtype of anorexia nervosa, had abnormal chemistry panels on initial blood draw and none had any hematologic abnormalities. In addition, osteoporosis was present in the lumbar spine and femoral neck of 8% and 22% of patients respectively, which is a high percentage given the higher BMI of the cohort in this study. Markedly elevated transaminases, which are known to occur in females with anorexia nervosa due to starvation-induced autophagy, has recently been described in two case reports of males with anorexia nervosa (Hunt, Becker, Guimaraes, Stemmer-Rachamimov, & Misdraji, 2012; Smith et al., 2013). In the case report by Smith et al. (2013), transaminases rose to a peak just over 3000 U/L for both aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in a male with a BMI of 12.3 kg/m2 . Interestingly, there was no concomitant hypoglycemia described, though this is known to occur when transaminases rise to greater than three times the upper limit of normal (Gaudiani, Sabel, Mascolo, & Mehler, 2012). Similarly Hunt et al. (2012) describes a case of a 27-year-old male with a BMI of 14 kg/m2 who developed marked transaminase elevations with a peak ALT of nearly 4000 U/L and AST of 2600 U/L. In this particular case, the male subject developed profound hypoglycemia to less than 30 mg/dL, though it was not reported the length the hypoglycemia persisted. Both males had resolution
Severe Anorexia Nervosa in Males
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Downloaded by [York University Libraries] at 20:49 30 December 2014
of transaminitis with refeeding and weight restoration. Clearly, there needs to be further research on the medical complications of anorexia nervosa specific to males, especially those with lower BMIs and thus more severe disease presentations. The ACUTE Center for Eating Disorders at Denver Health Medical Center treats some of the most medically compromised and severe cases of anorexia nervosa and bulimia and provides medical stabilization services. Herein we report a series of 14 male patients admitted with severe anorexia nervosa. Each of the male patients presented for medical stabilization before they were able to transfer for follow-up treatment at traditional eating disorder programs across the United States.
METHOD Patients The ACUTE Center at Denver Health Medical Center is a ten-bed medical stabilization unit for medically compromised eating-disordered patients, housed within a 477-bed public safety net Level I trauma center. ACUTE only accepts patients whose weight have fallen well below 70% of ideal body weight, which the center defines for men as 106 pounds for the first five feet in stature, plus six pounds for every subsequent inch. Multidisciplinary expertise in the eating-disorder-specific manifestations of internal medicine, along with nutrition, physical/occupational/speech therapy, nursing, and psychiatry, facilitate the initiation of judicious nutritional rehabilitation and medically safe weight restoration with a goal of two to three pounds of weight gain per week. Patients are usually then discharged to an inpatient eating-disorder program, once they have met both the accepting program’s definition of medical stability and are beyond the risk period for the development of the refeeding syndrome.
Study Design Male patients admitted to ACUTE for medical stabilization of their severe anorexia nervosa between October 1, 2008 and December 31, 2012 were eligible for the study. Only the index admission for each patient during the study period was included due to the inherent dependencies among multiple admissions. Patients were excluded if they were hospitalized for less than 48 hours or were hospitalized for non-anorexia nervosa reasons (i.e., did not require medical stabilization). Patient demographics, anthropometric measurements, and caloric intake were obtained from chart reviews. Laboratory test results and medications were queried from our electronic data repository (Decision Support Solutions; Siemens, Malvern, PA). The lowest finger-stick blood glucose level
212
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Downloaded by [York University Libraries] at 20:49 30 December 2014
was obtained by chart review for each day on each patient and the lowest Z-score was identified in each patient’s bone density dual-energy X-ray absorptiometry (DEXA) scan. Admission daily caloric intake was based on the first day the patient was on the ACUTE unit for a full 24-hour period and received nutrition. The discharge daily caloric intake was based on the patient’s last full 24-hour period in the ACUTE unit, that is, the day before the patient was discharged. Hypophosphatemia was defined as a serum value less than 2.7 mg/dL. At our institution, institutional review board approval is not required for a retrospective, descriptive study of this nature in which standard clinical practices are performed based on unit protocols.
Statistical Analysis Univariate statistics, including frequencies (percentages), means ± standard deviations, and medians (interquartile ranges [IQR]), were used to describe the sample. The distributions of the continuous variables were determined by the Anderson-Darling test. Resting energy expenditure obtained by two different methodologies was compared using the paired t-test. All analyses were done using SAS software version 9.2 (SAS Institute, Carey, NC).
RESULTS During the 51 months of the study period, there were 177 admissions to ACUTE for 142 distinct patients. Among these patients with severe anorexia nervosa, 15 were males (10.6%) who had a total of 17 hospitalizations (9.6% of admissions). Only one patient had multiple hospitalizations during the 4.25 years and he was admitted three times. One male was excluded from the dataset because he was admitted for non-anorexia nervosa reasons. Therefore, 14 male patients were included in this study. The male patients with anorexia nervosa had a mean age of 24 ± 5 years. One patient required an air-ambulance transfer from a hospital medical unit outside of Colorado and the others arrived by commercial air from their respective states. The mean duration of illness was 5 years (IQR: 2–8 years). Ten of the patients were purely restrictive and four had binge-purge anorexia nervosa. Of note, these patients all had severe degrees of anorexia nervosa with body mass indexes ranging from 11.5 to 15.9 kg/m2 . The other relevant patient characteristics are shown in Table 1. Vital signs were notable on admission with an average heart rate of 67 ± 14 beats per minute (range 49–95) and a systolic blood pressure of 103 ± 9 mmHg. Two patients were hypothermic on admission (
Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Severe Anorexia Nervosa in Males: Clinical Presentations and Medical Treatment ab
cd
Allison L. Sabel , Elissa Rosen
& Philip S. Mehler
cd
a
Department of Patient Safety and Quality, Denver Health Medical Center, Denver, Colorado, USA b
Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA c
Click for updates
Department of Internal Medicine, Denver Health Medical Center, Denver, Colorado, USA d
Department of Medicine, University of Colorado, Aurora, Colorado, USA Published online: 11 Mar 2014.
To cite this article: Allison L. Sabel, Elissa Rosen & Philip S. Mehler (2014) Severe Anorexia Nervosa in Males: Clinical Presentations and Medical Treatment, Eating Disorders: The Journal of Treatment & Prevention, 22:3, 209-220, DOI: 10.1080/10640266.2014.890459 To link to this article: http://dx.doi.org/10.1080/10640266.2014.890459
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [York University Libraries] at 20:49 30 December 2014
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Eating Disorders, 22:209–220, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.890459
Severe Anorexia Nervosa in Males: Clinical Presentations and Medical Treatment
Downloaded by [York University Libraries] at 20:49 30 December 2014
ALLISON L. SABEL Department of Patient Safety and Quality, Denver Health Medical Center, Denver; and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
ELISSA ROSEN and PHILIP S. MEHLER Department of Internal Medicine, Denver Health Medical Center, Denver; and Department of Medicine, University of Colorado, Aurora, Colorado, USA
The clinical presentation and medical complications of severe anorexia nervosa among males were examined to further the understanding of this increasingly prevalent condition. Fourteen males were admitted to a medical stabilization unit over the study period. Males with severe anorexia nervosa were found to have a multitude of significant medical and laboratory abnormalities, which are in need of treatment via judicious, nutritional rehabilitation and weight restoration to prevent additional morbidity and to facilitate transfer and admission to traditional eating disorder programs.
Anorexia nervosa (AN) is thought of as an almost exclusively female eating disorder. In the past, ratios of 20:1 were quoted as the female to male prevalence. However, more recent studies indicate that males may account for 10–25% of anorexia and bulimia cases (Hudson, Hiripi, Pope, & Kessler, 2007; Weltzin, 2005). The National Institute of Mental Health recently reported that upwards of one million males struggle with eating disorders. Thus, more males are currently seeking help with their anorexia nervosa. Despite the growing prevalence of eating disorders amongst the male population, there is a paucity of literature surrounding the clinical presentation and medical complications faced by this cohort. As the recent Address correspondence to Philip S. Mehler, Department of Internal Medicine, Denver Health Medical Center, 777 Bannock Street, MC0278, Denver, CO 80204, USA. E-mail: [email protected] 209
Downloaded by [York University Libraries] at 20:49 30 December 2014
210
A. L. Sabel et al.
retrospective cohort study by Gueguen et al. (2012) suggests, there may in fact be a higher short term (less than 3 year) post treatment mortality in males compared to females. Therefore, a greater understanding of the differences in anorexia nervosa between genders may help to tailor more specific psychological and medical treatments for males, and, thus, reduce morbidity and mortality. Current literature does demonstrate a difference in the clinical presentation of eating disorders in males versus females and a delay in diagnosis. Males are more likely to present at a later age, to have premorbid obesity, and to over exercise (Gueguen et al., 2012; Norris et al., 2012). The delay in diagnosis is in part due to continued gender stereotypes surrounding eating disorders—primarily the belief that it is a female predominant illness. In fact, Robinson, Mountford, and Sperlinger (2013) noted that males in eating disorder treatment programs had feelings of shame and isolation surrounding being a male suffering from what society still viewed as a female disorder. Males are not immune to the medical complications of anorexia nervosa faced by their female counterparts including arrhythmias, osteoporosis, and hepatitis. Sinus bradycardia, as defined by a heart rate less than 60, appears to be the most common medical complication found at initial assessment in a recent retrospective cohort study of 52 adolescent males with AN and an average body mass index (BMI) of 17.4 kg/m2 (Norris et al., 2012). In this study, two-thirds of the males evaluated also had abnormal electrocardiograms as evidenced by rhythm and conduction abnormalities, including QTc prolongation in 9%. However, only 10% of the sample population, of which 19% had binge-purge subtype of anorexia nervosa, had abnormal chemistry panels on initial blood draw and none had any hematologic abnormalities. In addition, osteoporosis was present in the lumbar spine and femoral neck of 8% and 22% of patients respectively, which is a high percentage given the higher BMI of the cohort in this study. Markedly elevated transaminases, which are known to occur in females with anorexia nervosa due to starvation-induced autophagy, has recently been described in two case reports of males with anorexia nervosa (Hunt, Becker, Guimaraes, Stemmer-Rachamimov, & Misdraji, 2012; Smith et al., 2013). In the case report by Smith et al. (2013), transaminases rose to a peak just over 3000 U/L for both aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in a male with a BMI of 12.3 kg/m2 . Interestingly, there was no concomitant hypoglycemia described, though this is known to occur when transaminases rise to greater than three times the upper limit of normal (Gaudiani, Sabel, Mascolo, & Mehler, 2012). Similarly Hunt et al. (2012) describes a case of a 27-year-old male with a BMI of 14 kg/m2 who developed marked transaminase elevations with a peak ALT of nearly 4000 U/L and AST of 2600 U/L. In this particular case, the male subject developed profound hypoglycemia to less than 30 mg/dL, though it was not reported the length the hypoglycemia persisted. Both males had resolution
Severe Anorexia Nervosa in Males
211
Downloaded by [York University Libraries] at 20:49 30 December 2014
of transaminitis with refeeding and weight restoration. Clearly, there needs to be further research on the medical complications of anorexia nervosa specific to males, especially those with lower BMIs and thus more severe disease presentations. The ACUTE Center for Eating Disorders at Denver Health Medical Center treats some of the most medically compromised and severe cases of anorexia nervosa and bulimia and provides medical stabilization services. Herein we report a series of 14 male patients admitted with severe anorexia nervosa. Each of the male patients presented for medical stabilization before they were able to transfer for follow-up treatment at traditional eating disorder programs across the United States.
METHOD Patients The ACUTE Center at Denver Health Medical Center is a ten-bed medical stabilization unit for medically compromised eating-disordered patients, housed within a 477-bed public safety net Level I trauma center. ACUTE only accepts patients whose weight have fallen well below 70% of ideal body weight, which the center defines for men as 106 pounds for the first five feet in stature, plus six pounds for every subsequent inch. Multidisciplinary expertise in the eating-disorder-specific manifestations of internal medicine, along with nutrition, physical/occupational/speech therapy, nursing, and psychiatry, facilitate the initiation of judicious nutritional rehabilitation and medically safe weight restoration with a goal of two to three pounds of weight gain per week. Patients are usually then discharged to an inpatient eating-disorder program, once they have met both the accepting program’s definition of medical stability and are beyond the risk period for the development of the refeeding syndrome.
Study Design Male patients admitted to ACUTE for medical stabilization of their severe anorexia nervosa between October 1, 2008 and December 31, 2012 were eligible for the study. Only the index admission for each patient during the study period was included due to the inherent dependencies among multiple admissions. Patients were excluded if they were hospitalized for less than 48 hours or were hospitalized for non-anorexia nervosa reasons (i.e., did not require medical stabilization). Patient demographics, anthropometric measurements, and caloric intake were obtained from chart reviews. Laboratory test results and medications were queried from our electronic data repository (Decision Support Solutions; Siemens, Malvern, PA). The lowest finger-stick blood glucose level
212
A. L. Sabel et al.
Downloaded by [York University Libraries] at 20:49 30 December 2014
was obtained by chart review for each day on each patient and the lowest Z-score was identified in each patient’s bone density dual-energy X-ray absorptiometry (DEXA) scan. Admission daily caloric intake was based on the first day the patient was on the ACUTE unit for a full 24-hour period and received nutrition. The discharge daily caloric intake was based on the patient’s last full 24-hour period in the ACUTE unit, that is, the day before the patient was discharged. Hypophosphatemia was defined as a serum value less than 2.7 mg/dL. At our institution, institutional review board approval is not required for a retrospective, descriptive study of this nature in which standard clinical practices are performed based on unit protocols.
Statistical Analysis Univariate statistics, including frequencies (percentages), means ± standard deviations, and medians (interquartile ranges [IQR]), were used to describe the sample. The distributions of the continuous variables were determined by the Anderson-Darling test. Resting energy expenditure obtained by two different methodologies was compared using the paired t-test. All analyses were done using SAS software version 9.2 (SAS Institute, Carey, NC).
RESULTS During the 51 months of the study period, there were 177 admissions to ACUTE for 142 distinct patients. Among these patients with severe anorexia nervosa, 15 were males (10.6%) who had a total of 17 hospitalizations (9.6% of admissions). Only one patient had multiple hospitalizations during the 4.25 years and he was admitted three times. One male was excluded from the dataset because he was admitted for non-anorexia nervosa reasons. Therefore, 14 male patients were included in this study. The male patients with anorexia nervosa had a mean age of 24 ± 5 years. One patient required an air-ambulance transfer from a hospital medical unit outside of Colorado and the others arrived by commercial air from their respective states. The mean duration of illness was 5 years (IQR: 2–8 years). Ten of the patients were purely restrictive and four had binge-purge anorexia nervosa. Of note, these patients all had severe degrees of anorexia nervosa with body mass indexes ranging from 11.5 to 15.9 kg/m2 . The other relevant patient characteristics are shown in Table 1. Vital signs were notable on admission with an average heart rate of 67 ± 14 beats per minute (range 49–95) and a systolic blood pressure of 103 ± 9 mmHg. Two patients were hypothermic on admission (
