NFS 5033: Exam 1
What is neophobia?
"fear of new" or to reject new foods -preschoolers may have to be introduced to a food up to 16 x before acceptance Culture teaches children things like : what can be eaten, what should be avoided, what flavors should not be combined, time of day when food is to be eaten
What is the DSM-V Diagnostic Criteria for Other Specified Eating Disorder? *category applies to presentation in which symptoms characteristic of an ED cause clinically significant distress or impairment in social, occupational, or other important areas but don't meet full criteria for any other disorder
-*Atypical AN (all criteria for AN are met, except that despite sig. wt loss, individual's wt is within or above normal range -Bulimia *of low frequency and/or limited duration (all criteria of BN met, except that binge eating/inappropriate compensatory behavior occur, on avg, less than once a week and/or less than 3 mo) -Binge Eating *of low frequency and/or limited duration (all criteria of BED met, except that binging occurs, on avg, less than once a week and/or less than 3mo) -Purging Disorder* (recurrent purging to influence wt or body shape in the ABSENCE of binging) -Night Eating Syndrome* (recurrent ep of night eating after dinner or waking up; there IS awareness and recall of eating; not influenced by sleep-wake cycle or social norms)
What were the 4 subcategories of eating disorders used in the DSM-IV?
-Anorexia -Bulimia -Eating Disorder Not Otherwise Specified -Binge Eating Disorder
What are the 4 classifications of eating disorders in the DSM-V? ?
-Anorexia (Restricting, Binging-purging types) -Bulimia -Binge Eating Disorder -Other Specified Eating Disorder
What is the activity of the vagus nerve in BN / AN pts?
-BN : pt may have a hyperactive vagus nerve -AN : pt may have a hypo-reactive vagus nerve
Which *satiation signals *decrease appetite?
-Cholecystokinin (CKK) -Incretin hormones (Glucagon-Like Peptide or GLP-1, Glucose-depedent Insulinotropic, Polypeptide or GIP) -Vagus nerve
What is the Cori Cycle or Lactic Acid System? in tissues with insufficient oxygen (muscle during high-intensity) or tissues that lack mitochondria
-Prevents accumulation of lactic acid in muscles -Cycles lactate from muscle to liver where it undergoes gluconeogenesis -During fasting, Cori Cycle will continue for several weeks -When running out of Glycogen, the Cori cycle comes into play -Lactate is produced here by anaerobic glycolysis in Muscle when the oxygen supply decreases (high-intensity exercise) If Lactic acid accumulates in blood it will lower the pH of blood and this is associated with fatigue
What happens with weight loss during fasting?
-adipose tissue lost is 85% fat by wt -liver glycogen and muscle contribute to intracellular water loss -loss is roughly proportional to body wt and lean body mass -after 2 weeks: extracellular fluid loss almost ceases -after 3 weeks: continued wt loss adipose and lean tissue = 300g/day
What is "thinness"? What BMI is considered underweight?
-age-sex- and ethnicity-adjusted BMI that falls below the 10th percentile -a BMI of <18.5 is underweight
What are the physiological abnormalities in menstrual cycle in AN?
-basal levels of LH, FSH, and estrogen are decreased -24-hour LH secretion pattern is abnormal -wt restoration usually returns LH normal
What type of treatment/therapy is effective for treatment of AN, BN and BED?
-behavioral therapy -interpersonal therapy -family therapy
What are the metabolic consequences of Fasting for 12-24 hours?
-blood glucose levels fall, reduced transport of glucose into muscle/fat, glycogen synthesis is inhibited... low insulin + high glucagon = increased gluconeogenesis -mobilization of free fatty acids from adipose and AA from muscle (150g CHO/day will abolish ketosis)
What did the Minnesota Starvation Experiment show regarding dieting/caloric restriction ?
-caloric restriction can lead to overeating, even binge eating
What is "disinhibition"?
-chronic dieters do NOT compensate for consuming an "off limits" food by reducing the intake --> they become "disinhibited" and overeat / eat MORE -it doesn't matter whether or not the food eaten was actually high in calories/fat, the dieter only had to perceive the food as forbidden Nondieters or dieters who haven't broken their self-imposed restrictions don't overeat subsequently
What is the major determining factor on ketone body production?
-circulating concentration of free fatty acids and the rate of delivery of FFA to liver
What is the GOAL os the Genetics of AN Collaborative Study? (identification of genetic variants that affect risk for AN)
-define the regions of genome containing variations that have a substantial impact on risk of AN
Thyroid hormone consequences in AN ?
-delayed TSH response -AN reduces T4 --> T3 in periphery -hypothyroidism
What 3 core beliefs can be used to help better understand ED features?
-dietary restraint -body checking + avoidance -preoccupation with thoughts of shape, wt, eating
What were the conclusions from the Project EAT-III findings?
-disordered eating behaviors are not just an adolescent problem -prevalent among young adults -tracking suggests the early eating disorders lead on ongoing use -need for early prevention -need for ongoing prevention and treatment interventions throughout adolescent and young adulthood
Genes that determine fatness affect.... ? (3)
-energy intake -energy expenditure -partitioning (where calories are stored)
If CBT-BN is going to have a lasting impact on binge eating/purging (one aspect of the disorder that pts want to change), then what does treatment need to address? 3 things
-extreme dieting -over-evaluation of shape and weight -any tendency for eating to change in response to adverse events and negative moods
What macronutrient do males/females prefer in *pre-puberty?
-female: carbohydrate (may be due to increase in NPY) -male: protein (may be due to growth hormone releasing factor)
What are the 3 hypothalamus controls of fat ingestion/deposition? *neurochemical activity peaks during middle-to-late part of natural feeding cycle
-galanin (GA; neuropeptide with highest [ ] in hypothalamus; stimulates feeding behavior) -opioid peptides -corticosterone or aldosterone
What are the 3 neurochemicals that stimulate eating of carbohydrates? *neurochemical activity peaks during initial hours of eating cycle
-gamma-aminobutyric acid (GABA) -norepinephrine -peptide neuropeptide Y (NPY) *these increase carb utilization and promotes fat storage bc they increase blood glucose quickly *corticosterone increases and increase carb stores
Differential Diagnosis of AN in adolescence?
-general medical condition -major depressive disorder -schizophrenia -social phobia -obsessive-compulsive disorder -body dysmorphic disorder
What happens to luteinizing hormone (LH) during normal ovulation? What happens to follicle-stimulating hormone (FSH) during normal ovulation?
-glycoprotein -acute rise of LH (triggers ovulation) FSH: -initiates follicular growth -regulates development, growth, pubertal maturation, reproductive processes of human body
What is the difference between *hunger, *appetite, *satiety, and *aversion?
-hunger: drives ingestion of calories -appetite: physiological and/or psychological impulse that triggers desire for food -satiety: inhibits ingestion of calories -aversion: physiological and/or psychological sensation that inhibits desire for food
symptoms of hypothyroidism?
-hypothermia -bradycardia -constipation -dry skin -reversible with refeeding
What did the Genome-wide association study discover?
-identified a specific genetic risk factor Early B-cell Factor 1 (EBF1) suggested as a variant dysregulation of leptin signaling that may play a role in AN -circulating leptin levels in AN is very low --> decline can lead to changes in brain activity involved in regulatory, emotional and cognitive appetite control
What is the restraint theory ?
-imposing dietary restraint or "diet boundaries" can lead to frustration and stress (cycles of under- and over- eating can impair normal hunger/satiety cues) -strict dieting is causally connected to AN and BN -moderate caloric restriction doesn't cause binging in obese adults
Characteristics of dopaminergic genes?
-increased dopaminergic activity may be involved in many major symptoms related to AN (repulsion to food, wt loss, hyperactivity, amenorrhea, distortion of body image)
What is the striatum? Function? Importance in EDs?
-inside part of cerebrum; regulation of movement pathways and involved in cognitive control -activated by reward, aversive, novel, unexpected or intense stimuli, cues related to such events -reports that recovered AN pt have an increase in ventral striatum dopamine receptor
Which *adipose signals *decrease appetite?
-insulin (beta cells of pancreas) -leptin (adipokine) -amylin (co-secreted with insulin)
Characteristics of serotonergic genes?
-involved in wt regulation, specifically eating behavior -implicated in development of ED -serotonin can be synthesized from tryptophan
Etiology and pathogenesis in BN in adolescents?
-less known compared to AN -usually presents later than AN (late teens) -entry point often dieting -often pleased with themselves in early stages -normal eating patterns become disrupted -vacillation between binging/fasting
What is the relationship between appetite and physical activity?
-loose coupling of appetite and physical activity... physical activity doesn't automatically increase eating (eating may be unchanged or may decline) -reduced physical activity may result in lack of down regulation of energy intake (sedentary routine doesn't necessarily include a reduced intake and can lead to positive energy balance, most of which is stored as fat)
Consequences of Anorexia similar to Classic starvation ?
-low TEE and RMR -elevated B-hydroxybutyric acid & FFA -bradycardia (often have resting heart rate below 6 beats/min) -orthostatic hypotension (dizzy) -delayed gastric emptying -impaired temp regulation to cold
What are the metabolic consequences of Fasting for 2-3 days?
-low insulin, high glucagon -increased lipolysis -increased ketone body production -increased protein catabolism
Etiology and pathogenesis of adolescent AN?
-multifactorial etiology -social factors, psychological predisposition, and biological vulnerability -entry point often dieting -features include: dread of not being in control and distorted perception of their body -superficially strong and defiant -devoid of self-confidence, paralyzed by helplessness and terrified by her lack of self-control
Differential diagnosis with adolescent BN ?
-neurological or general medical conditions -major depressive disorder -personality disorders
Formation of ketone bodies during starvation?
-normally, circulating ketone bodies are so low they are almost undetectable -after release of ketone bodies into blood, acetoacetate & beta-hydroxybutyric form Acetone -ketogenesis is at max capacity by about 3 days of fasting -all tissues with mitochondria oxidize ketone bodies -after 3-4 days of fasting, acetone appears in small amounts in breath (sweet odor) -ketone body oxidation provides 30-40% of body's total energy used in 4-7 days of fasting
What are significant feeding/eating problem considerations in childhood? These should be considered when determining whether a child has a clinically significant eating problem
-nutritional adequacy of diet -disturbances on wt, growth, and physical development/function -disturbance on social + emotional development -disturbances on interaction with caregiver/family
What are biological responses that are satiety signals?
-oral stimulation -stomach distention and gastric emptying -hormones -plasma nutrients
Electrolyte abnormalities with Anorexia & Bulimia?
-poor fluid intake, vomiting, laxative abuse, diuretic abuse Purging: Metabolic Alkalosis -pH of blood is elevated above normal as a result of decreased hydrogen ion [ ], leading to increased bicarbonate -vomiting results in loss of HCl with the stomach content, which raises pH of blood Hypokalemia: weakness, lethargy, cardiac arrhythmias Hypophosphatemia: poor dietary intake and presents problem with refeeding (refeeding with CHO can result in reduced fat metabolism and increased metabolism of glucose, which causes an increased use of phosphate to make ATP thus leading to hypophosphatemia)
What is the relationship between leptin and body weight?
-positive correlation between leptin and body fat (leptin levels are higher in obese compared to lean people) -leptin increases with overfeeding and decreases with fasting -women have higher [ ] than men, even when corrected for body fat %
What were the key overall findings in the Project EAT-III Teens + young adults?
-prevalence of dieting and disordered eating high and remained constant -behaviors tended to track within individuals -risk tended to be consistent for older girls and boys transitioning from middle adolescence to middle young adulthood
What is galanin?
-promotes food intake, especially fat -inhibits insulin release -in AN, levels are lower
What is the role of growth hormone releasing factor in maintenance of protein balance? *appetite for protein increases over active feeding cycle
-promotes protein synthesis and growth -increases ingestion of food (especially protein)
What does the CBT for BN propose?
-proposes that binge eating is largely a result of their form of dietary restraint (Pathway A - E) -Figure on slide 17
What is the transdiagnostic cognitive behavioral therapy ? Trans-CBT
-pt with AN, BN and EDNOS (prior) have many features in common --> suggests that there is a case for viewing EDs as a single diagnostic category instead of individual disorders -essentially a combination of BN and Restricting-type AN
What is the DSM-V Diagnostic Criteria for BN?
-recurrent binging episodes characterized by both: eating in discrete period, an amount of food larger than most people AND a sense of lack of control over eating -recurrent inappropriate compensatory behavior to prevent wt gain (vomiting, laxatives, diuretics, enemas, fasting, excessive exercise, meds) -binge eating and inappropriate compensatory behaviors occur, on avg, at least once a week for 3 mo -self-evaluation is influenced by body shape/wt -disturbance doesn't occur exclusively during episodes of AN
Criteria for BN in adolescents?
-recurrent ep of binge eating -recurrent inappropriate compensatory behavior to prevent wt gain -binge eating/compensatory behaviors both occur, on avg, at least once a week for 3 mo -self-evaluation unduly influenced by body shape and wt -disturbance doesn't occur exclusively during ep of AN (purging type, non-purging)
Criteria for Binge Eating Disorder in adolescent ?
-recurrent ep of binge eating (eating in a discrete period of time, an amount of food that is larger than what most people would eat; AND lack of control over eating ) 3 or more of the following... -eating much more rapidly than normal -eating until feeling uncomfortably full -eating large amts of food when not physically hungry -eating alone bc of feeling embarrassed -feeling disgusted with oneself, depressed, or very guilty -distress regarding binge eating is present -binge eating occurs, on avg, at least once a week for 3 mo -binge is not associated with recurrent use of inappropriate compensatory behavior as BN *For females, all criteria for AN are met except that individual has regular menses
What is the DSM-V Diagnostic Criteria for Binge Eating Disorder (BED)?
-recurrent ep of binge eating; ep is characterized by both: eating in discrete period, an amount that is larger than most ppl AND a sense of lack of control over eating -binging is associated with 3 or more of the following: Eating more rapidly than normal; Eating until uncomfortably full; Eating large amts when not physically hungry; Eating alone due to embarrassment; Feeling disgusted, depressed, or guilty after overeating -marked distress regarding binge ep is present -occurs, on avg. at least once a week for 3 mo -binging NOT associated w/ regular use of inappropriate compensatory behavior as in BN & does NOT occur exclusively during course of BN or AN
What is NPY associated with in the maintenance of carb balance? Secreted by what?
-regulating energy balance; memory/learning; epilepsy -main effect is *increase food intake and decreased physical activity -secreted by hypothalamus; one of most abundant in CNS
AN criteria in adolescents?
-restriction of energy intake relative to requirements, leading to a significantly low body wt in context of age, sex, developmental trajectory, and physical health -intense fear of gaining weight or becoming fat, or persistant behavior that interferes with weight gain -disturbance in the way in which one's body wt or shape is experienced, undue influence of the body weight or shape on self-evaluation, or denial of the seriousness of current low body wt
What is the DSM-V Diagnostic Criteria for AN?
-restriction of energy intake relative to requirements, leading to significantly low body wt -intense fear of gaining wt or becoming "fat" -disturbances in way in which one's body wt or shape is experienced, or denial of seriousness of current low body wt (sig. low wt = wt less than minimally normal or expected)
Associated features and disorders involved in adolescent AN?
-severe weight loss contributes to depressive symptoms -depressed mood, social withdrawal, irritability, insomnia -obsessive-compulsive features -concerns about eating in public, feelings of ineffectiveness, inflexible thinking, limited social spontaneity, overly restrained initiative and emotional expression -weight loss = impressive achievement, extraordinary self-discipline -weight gain = unacceptable failure of self-control
What macronutrient do males/females prefer in *post-puberty?
-sharp increase in fat preference (associated w/ body wt gain) -galanin and opioids increase due to increase in gonadal sterols -increase in fat appetite in females is related to action of estrogen/progesterone (require fat deposition for reproduction prep)
Consequences of eating calorically dilute foods ?
-short-term: lead to high intake of bulky, low-energy-dense food (dec. caloric intake) -long term: malnutrition and eventually increased hunger (binge eating) Goal in ED treatment: normalize food choices so that unadulterated foods are most frequently chosen
Definition of starvation*, fast/total fast, cachexia?
-starvation: prolonged inadequate intake of protein, energy or both -fast/total fast: exclusion of all food -cachexia: wasting resulting from metabolic stress
What are food characteristics that are satiety signals?
-taste -volume and weight -energy density -osmolarity -macronutrient distribution
Treatment for adolescent eating disorders?
-team approach -with children and adolescents, need family involved -intense work often needed -often long in duration -frustration common (pt, family, provider) -poor prognosis, especially compared to other diagnostic groups -high incidence of drop out
Associated features/disorders with adolescent BN?
-typically within normal wt range -dysphoria usually precedes a binge and is relieved by it -vomiting used by 80-90% -increased frequency of depressive symptoms or mood disorders -other disorders: major depression (75%), anxiety (43%), substance-related (49%), personality (50-75%) -tendency toward more impulsive and high risk behaviors *more common in younger patients throat/teeth damage from vomiting electrolyte imbalance fingers have "Russell's sign" due to biting fingers when vomiting
What are the 2 ways in which malnutrition may impact taste?
-zinc deficiency is known to cause lack of taste -tryptophan & phenylalanine deficiency can cause bitter taste Zinc, tryptophan and phenylalanine are found in PROTEIN (people with ED commonly avoid meats, reportedly due to "Lack of taste") --> Decreased protein intake --> depleted nutrition status --> decreased taste for protein
How is smell and taste impaired in AN and BN?
AN: May not like the taste of high fat foods (also bad smell receptor) BN: Hypersensitivity to flavors (tend to rate lower-fat and lower-sugar solutions as more intensely flavored than normal)
What is palatability?
Acceptability of food -promotes the selection, intake, absorption, and digestion of foods *High-fat foods are more energy-dense and have higher palatability as well as lower satiating ability *Low-energy-dense food are usually less palatable and more satiating
Screening for adolescent eating disorder?
Ask questions... -How do you feel about your body? -How would you describe your bingeing? How much food/what time period? -How often do you vomit? how many times in an episode? -Any changes in attention, concentration or task completion? -Describe your mood? -Any thoughts or intent to hurt yourself or commit suicide?
GI symptoms in BN? AN?
BN: -hyperactive vagus nerve -more likely to develop GI problems such as nausea, vomiting, indigestion, diarrhea AN: -hypo-reactive vagus nerve -gastric emptying, gastric distention, constipation *In many people with ED, normal fullness is thought to be bloating or constipation
When does ketosis become dangerous? What does it result in?
Dangerous in: -dieters on low or no CHO diet -pt with DM -prolonged fasting Results in: -excretion of ketone bodies in urine/breath when plasma lvl rises -loss of cal -large urinary losses of water & electrolytes -blood pH changes -death
Definitions: Dietary restraint Dietary restriction Dietary rules Food avoidance Debting Delayed eating Driven exercising Excessive exercising
Dietary restraint: attempting to limit the amount eaten Dietary restriction: true under eating in a physiological sense Dietary rules: highly specific dietary goals Food avoidance: purposeful avoidance of certain foods (generally perceived as fattening) Debting: creating of an energy deficit or "debt" to accommodate subsequent eating Delayed eating: postponing eating as a means of wt control Driven exercising: a particular form of excessive exercising in which there is a subjective sense of being driven or compelled to exercise Excessive exercising: exercisig to an undue extent
Through evolution, what foods do humans prefer?
Energy dense, high-fat, high-sugar foods
What are considered "Healthy" dieting behaviors? "Unhealthy"?
Healthy: -portion control -restriction or avoiding fat -limiting snacks -avoiding sweets/sweetened drinks Unhealthy: -skipping meals -fasting -vomitting -laxatives -smoking
Early food preferences in infants? 3-5 y/o? 12 y/o? TASTE is key
Infants -seek out a sweet taste -mother's milk is sweet, has calming effect -when infants are given something biter they tend to stick out their tongues /reject 3-5 y/o -lean towards sweetness as well as familiarity when making food choices 12 y/o -like sweet taste and sugar consumption peak
What is the relationship between BMI and dieting?
NOT linear -10% of underweight are dieting -70-80% of overwt or obese ppl are not dieting HOWEVER - dieting is strongly related to BMI! -overwt women are 4x more likely to diet -obese women 6x more likely
How is CCK altered in BN? AN?
Secreted in SI in response to presence of nutrients; suppresses food intake & signals feeling of fullness (limits meal size) BN: may not sense satisfaction, person eats large quantities of food faster than brain is able to signal satisfaction (purging, laxatives, chewing/spitting out food may lower CCK secretion) AN: over sensitized to CCK so that they feel full after only a few bites of food
What is the #1 reason for eating a specific food ?
Taste
What is the major GI nerve and conveys information to the brain via the Serotonergic system?
Vagus nerve
What was Project EAT-III?
a 2011 publication on the prevalence and tracking eating disorders over 10 years (dieting, binge eating, unhealthy and extreme wt control behaviors)
What is an endophenotype?
a psychiatric concept and special kind of biomarker; used to divide behavioral symptoms into more stable phenotypes with a clear genetic connection
What is the "Activity Based Anorexia"?
a study of the pathophysiological processes in AN using animals -semi-starvation hyperactivity model -limited access to food during first 2 hours of eating time for rodents for 5 days -as seen in AN pt, certain rat/mouse strains showed diverse behavioral responses and hyperactivity
What is ghrelin?
appetite stimulating hormone -produced by endocrine cells in stomach + GI tract -increases with fasting/before meals; decreases within 1 hr after food intake
What is the effect of excess norepinephrine, NPY or corticosterone??
causes an overconsumption of carbohydrates, increases body fat and body wt
What is the specific classification of "*Binging/Purging type" AN?
during last 3 mo, individual has engaged in recurrent ep of binging or purging (vomiting or laxatives, diuretics, enemas)
What is the specific classification of "*Restricting type" AN?
during the last 3 mo, the individual has not engaged in recurrent ep of binging or purging behavior (vomiting or laxatives, diuretics or enemas). describes presentations in which wt loss is accomplished primarily through dieting, fasting and/or excessive exercise
What is "normal eating" in childhood?
feeding or eating consistent with the child's growing, developing, and functioning at an appropriate developmental level
What is "disordered eating" in childhood?
feeding/eating patterns or behaviors that result in disruption to expected growth, development, and/or functioning
What is the role of dopamine in the maintenance of fat balance?
inhibits fat intake and increased body wt (amphetamines release dopamine; they're appetite suppressants) *antipsychotic medication antagonizes dopamine and promotes obesity
What is the relationship between leptin and AN? Overweight/BN?
leptin levels correspond with % body fat -AN pt have low Leptin bc body fat % is low -overweight BN pt have elevated leptin levels -when obese individuals lose wt by calorie restriction, leptin levels fall
Which biological system has an influence on eating behaviors?
neuroendocrine system
the Largest groups of people dieting are those that are _________ weight?
normal weight
What happens to protein/energy metabolism during fasting for... -overnight fast -1-3 days -7-10 days -2-3 weeks
overnight: decreased insulin with mild muscle proteolysis 1-3 days: increased BCAA leucine, isoleucine & valine 7-10 days: whole body N loss 10-12g/day; 1-2kg loss of lean body mass; lethal if continued 2-3 weeks: 50% of protein loss; REE decreases (2 weeks = 15%, 3-4 weeks = 25-35%)
What is "counter-regulation"?
planning to eat something that is "diet-breaking" -dieter cognitively abandons the self-diet rules and restrictions and overeats
What are the satiation signals?
proportional to what is being consumed and help to determine meal size -CCK Incretin hormones (GLP-1, GIP)
What is adiponectin? (weight gain)
secreted from adipose tissue; inversely related to amount of adipose tissue -increases after food restriction and weight loss diets
What is sensory-specific satiety?
sensation past the period when food is physically in contact of pressure and stretch receptors (reduces the perceived pleasantness of food as it is eaten) NOTE: high protein foods appear to be most satiating; fats are the least satiating; carbs are in between
Which hormone levels help differentiate between constitutionally thin females and AN ?
serum leptin levels -restrained eating is associated with a LOW leptin level
What is neuroendocrinology?
study of glands and neural input regulating functions; glands monitor input received and respond to maintain system -hypothalamus: feedback loop; controls appetite for carb/protein/fat -modulates metabolism
What is the "meal size"? What is it effected By?
the balance between (+) and (-) feedback from food eaten (eating stops when + and - are equal) - mouth and nose are (+) , food stimuli are (-) -effected by: insulin and leptin, both decrease meal size by increasing neg. feedback from SI (mediated by SI)
What is chemoreception?
the process by which organisms respond to chemical stimuli in their environments that depends primarily on the senses of taste and smell (Olfactory/Gustatory) Long acting, the peaks are drawn out longer
What is the MAJOR difference between AN and BN?
the relative balance of the under- and overeating and the effect on body weight... AN: more successful attempts to restrict eating (under eating predominates and the pt remains significantly underwt and has the features) BN: body wt is usually unremarkable, overeating and under eating cancel each other out
What is rumination disorder?
where regurgitation, re-chewing, and or re-swallowing foods occurs
What is the treatment cornerstone of AN?
wt restoration