Anorexia (Greek anorexia) is etymologically loss or loss of appetite. The practitioner confronted with the patient with anorexia must ask and answer four main questions:
– How to diagnose anorexia?
– What are the causes of anorexia?
– What is its severity?
– How to treat the patient?
Here more than elsewhere, the overall care of the patient in his environment is essential.
DIAGNOSTIC:
Examination:
Anorexia translates clinically by loss of appetite or feeding motivation.
In a large majority of cases, it is spontaneously reported by the patient. We can thus observe a reduction in the size or frequency of meals and even their near extinction.
Anorexia can also lead to a selection of food and nutrients or reducing the pleasure associated with food intake.
In mental anorexic patients, the symptoms can often be denied despite clinical evidence of weight loss, contrasting with an increased or normal activity.
It is necessary to distinguish by questioning a lack of desire to eat an early satiety characterized by digestive fullness that occurs after ingestion of a small amount of food. The sitiophobie is characterized by a reduced food intake for fear of digestive disorders while appetite is preserved. This restriction for fear of eating also occurs when odynophagia, when the act of eating is painful regardless of the cause.
The food intake of study is essential, but difficult. The current food intake must be assessed in relation with previous ingesta. Using a dietician is often necessary. One can ask the patient to keep a food diary. Her outfit, despite its complexity, is also part of the management. He can help change behavior, particularly in cases of anorexia or bulimia.The analysis examined the dietary diversity, meal frequency, the possible use of oral nutritional supplements, preferences and aversions, especially if some are recent.
Anorexic patients:
Anorexia is a common symptom of which the population prevalence is about 4%. Outside of mental anorexic patients, some groups of people are particularly affected: the elderly, cancer patients with anorexia can be inaugural.
It is estimated that 5 to 30% of people over 70 autonomous home suffer from some degree of anorexia. This anorexia “physiological” that accompanies aging is related to alterations of taste and smell, but also to disturbances in appetite regulation. Fifteen to 40% of cancer patients have anorexia at the time of the discovery of the diagnosis. If there are associated digestive disorders, the risk of malnutrition is especially high. Generally, anorexia accompanies all malfunctions of the internal homeostasis of the organism.
ETIOLOGY:
The causes of anorexia are many and varied (Box 1). Schematically, anorexia can be either organic (secondary to an underlying disease such as neoplasia, chronic infection) or psychogenic origin (anorexia nervosa, depression).
The care of the patient as a whole is a fundamental approach of anorexia symptoms. Take into account the patient thymie, its framework and living conditions, financial resources, her family and emotional environment. Dependence that can lead to disease, aging and disability are factors that reduce the pleasure of eating and can lead to true secondary anorexia.
Pathologies in question can be infectious, inflammatory or tumor; they can be acute or chronic (Box 1).
Box 1. Major risk factors for anorexia
physiological aging
Somatic organic factors
acute and chronic diseases: cancers, infections, gastrointestinal disorders and liver, organ failure (heart, lung, kidney), endocrine disorders
Physical assault: trauma, burns, surgery, radiotherapy
Medications: antimitotic, antihypertensives, digitalis, diuretics, morphine analgesics, antibiotics, painkillers
Toxic: excessive drinking, drug abuse
psychological and neuropsychological factors
emotional disorders: sadness, boredom, anxiety
Depressed state
cognitive problems: lack of memory, praxis, executive functions
functional factors
Dependence in activities of daily living: eating, meal preparation, shopping
Reduced physical activity
socioeconomic factors
Isolation
low income
The causes are many:
– Organ dysfunction: respiratory insufficiency,
advanced heart, kidney, etc. ;
– Infection, acute or chronic;
– Inflammatory or malignant disease (in particular in case of dysgeusia, dysphagia, vomiting, etc.);
– Medicines inventory is to be done, particularly chemotherapy;
– Trauma.
Anorexia is often more pronounced in the acute phase of the disease. It usually regresses during the healing of the disease in question.
The necessary explorations (imaging, biology) are based on the clinical picture and are similar to those described in Chapter emaciation .
Anorexia is one of the depressive syndrome signs, often diagnosed without difficulty questioning. It must however be careful trap depressive syndrome secondary to organic pathology. Anorexia is then related to both the pathology and depressive syndrome.
Anorexia nervosa is one of the eating disorders. Diagnostic criteria were established (Box 2). It is most often hidden and unacknowledged.
Box 2. Diagnostic criteria of anorexia nervosa adapted from the American Psychiatric Association
emaciation
> 15% of normal weight, up to 50%. Denial of thinness and severity of undernutrition.
BMI <15, severe malnutrition
BMI <12, bringing into play the vital prognosis simply because of malnutrition
Anorexia
Food refusal, anxiety growing. Tri, snacking, and ritual hoarding during meals
Amenorrhea
Primary or secondary, constant if BMI <18
No symptoms of psychotic or melancholic series
Absence of organic pathology, digestive, infl ammatory, endocrine, or pituitary tumor.
Two forms are distinguished
Anorexia restrictive pure: 65 to 75% of cases
bulimic vomiting access with: 25 to 35% of cases
GRAVITY OF ANOREXIA:
Anorexia can be serious when it becomes chronic. Anorexia that lasts beyond 10 days – for example postoperative major surgery – can result in malnutrition. The risk is protein-energy malnutrition with weight loss and its own complications (Electrolyte disturbances with secondary heart disease, susceptibility to infections, etc.) Anorexia should be regarded as serious if the daily food intake is less than one third of needs, either average adult less than 600 to 700 Kcal / day, and for at least 7 to 10 days.
The body mass index should be calculated and compared to normal values (> 18.5 in young adults,> 20-22 in subjects over 70 years). To go further in assessing nutritional status, a simple way is to combine in an index prognostic value of plasma albumin and percentage of weight loss, which the NRI (Nutritional Risk Index) of Buzby realized easily. The index calculation is done by the formula: NRI = 1.519 x albumin (g / L) + (current / conventional weight weight) x 100. This class assessment patients into three groups. Group I (normal nutritional status) consists of patients whose NRI is greater than 97.5%, even if weight loss is then perfectly adaptive. Group II (moderately malnourished) consists of patients whose NRI is between 83.5 and 97.5%. Group III (severely malnourished) consists of patients whose NRI is less than 83.5%. In patients with severe malnutrition, nutritional support should be seen quickly (see also Chapter emaciation).
TREATMENT:
The first treatment of anorexia is that of the underlying pathology. The second treatment is one of the possible protein-malnutrition secondary to dietary restrictions observed when anorexia lasts beyond a week.
The treatment of malnutrition uses nutritional assistance on the one hand and the other orexigenic drugs.
Nutritional assistance:
The use of nutritional assistance is decided primarily on the basis of malnutrition (nutritional index Buzby, prealbumin levels, cholesterol, cells, vitamins, etc.).
The nutritional assistance initially appealed to the enteral route. It should be explained to the patient and family that this assistance does not necessarily cut the appetite and can instead stimulate food intake by making the functional digestive tract. Assisted oral nutrition uses oral supplementation. The principles are described in Box 3. There are many products in small cartons with different textures and a variety of flavors suited to individual preferences (see Chapter emaciation). Energy intake varies between 150 and 300 kcal per serving, protein intake from 12 to 30 g of protein.
Box 3. Rational use of assisted nutrition orally
Explain to the patient the therapeutic objective, encourage in cases of anorexia, reassure the digestive tolerance.
Serve fresh charge (refrigerator temperature).
Serve Remote extra meals (2 hours before or after).
Adjust the flavors and texture to the taste of patients.
Insist that the supplement is consumed when it is served.
Prepare if necessary complement to the patient (open, setting up straw, etc.).
Control consumption of the supplement. If consumption is incomplete, analyze the reasons, try to improve compliance
The use of home enteral nutrition is more complex. It is initiated most often in hospital and care in hospital via a home hospital system.
In all cases, oral nutrition and / or enteral power is supported by the CNAM in a home care package that appeals or not a care provider.
The rate of drug delivery is modified according to the food they must not hinder food intake (vomiting, high quantity of tablets and therefore water to be taken before meals). The schedule and composition of meals are revalued based on the tastes and the patient’s desire. The friendly nature of food intake is essential.
Orexigenic treatments:
Prescription appetite stimulants Treatment depends on the underlying condition, side effects and their risk / benefit ratio.
Corticosteroids may be effective even in small doses: 5 to 10 mg / d of prednisone (Cortancyl®).
Progestins may be used, particularly in cases of cancer or AIDS: medroxyprogesterone Farlutal®) is the most used at the dose of 250 to 500 mg / day. The risk of thromboembolic side effects in particular must be measured. The use of omega 3 or anticytokines is reserved for the field of clinical research. No other treatment should be used for this indication. Antihistamines once used have not demonstrated their effectiveness and should be abandoned in the treatment of anorexia.
CONCLUSION:
Anorexia is a complex symptom occurring during both acute and chronic conditions.
multiple pathophysiological mechanisms and varied causes make it a real challenge in clinical nutrition. A strategy of screening and reporting of anorexic people must be established. It is important once anorexia detected not to let undernutrition settle. We must not forget that anorexia may be isolated in appearance and can be the first symptom of an underlying disease more serious that only a well-conducted medical diagnosis viewpoint will help diagnose and therefore treat fairly early.
