Eating DisordersEating Disorders

Darwin Deen, MD, MSDarwin Deen, MD, MS

Department of Family Department of Family Medicine and Medicine and

Community HealthCommunity Health

References -References - Material for These Slides Was Material for These Slides Was Taken From the Following Sources: Taken From the Following Sources:

1.1. Rock CL Nutritional and Medical Assessment and Rock CL Nutritional and Medical Assessment and Management of Eating Disorders. Nutr Clin Care Management of Eating Disorders. Nutr Clin Care 1999:2(6)332-343.1999:2(6)332-343.

2.2. Baker CW Brownell KD Binge Eating Disorder: Baker CW Brownell KD Binge Eating Disorder: Identification and Management. Nutr Clin Care Identification and Management. Nutr Clin Care 1999:2(6)344-353.1999:2(6)344-353.

3.3. Klapper F, et al Psychiatric Management of Eating Klapper F, et al Psychiatric Management of Eating Disorders. Nutr Clin Care 1999:2(6)354-360.Disorders. Nutr Clin Care 1999:2(6)354-360.

4.4. Eating Disorders and Obesity: A Comprehensive Eating Disorders and Obesity: A Comprehensive Handbook. Brownell KD, Fairburn CG eds. 1995 Handbook. Brownell KD, Fairburn CG eds. 1995 Guilford Press, New York.Guilford Press, New York.

5.5. The Management of Eating Disorders and The Management of Eating Disorders and Obesity. Goldstein DJ ed. 1999 Humana Press, Obesity. Goldstein DJ ed. 1999 Humana Press, Totowa, NJTotowa, NJ

Why We Need to Know:Why We Need to Know: Eating disorder prevalence is estimated at 3-Eating disorder prevalence is estimated at 3-

7% in teenagers7% in teenagers Disorders of eating exist across a continuumDisorders of eating exist across a continuum Those who develop eating disorders during Those who develop eating disorders during

adolescence may die or live with the sequelaadolescence may die or live with the sequela Obesity has become an epidemic in the 21Obesity has become an epidemic in the 21stst

centurycentury Dieting (and fear of fatness) is associated Dieting (and fear of fatness) is associated

with the development of eating disorderswith the development of eating disorders

Historical OverviewHistorical Overview

William Hammond published the William Hammond published the first review of patients with first review of patients with anorexia in 1879.anorexia in 1879.

Patients with this syndrome were Patients with this syndrome were described throughout the middle described throughout the middle ages.ages.

Cultural obsession with thinness & Cultural obsession with thinness & weight in women has been linked weight in women has been linked to increasing prevalence.to increasing prevalence.

Factors Associated With Factors Associated With Increased Risk for Eating Increased Risk for Eating DisordersDisorders

Female genderFemale gender Dieting behaviorDieting behavior Middle or upper-class socioeconomic Middle or upper-class socioeconomic

backgroundbackground Personality disorderPersonality disorder Family dysfunctionFamily dysfunction Profession or pursuit that stresses Profession or pursuit that stresses

thinnessthinness Diseases for which management involves Diseases for which management involves

emphasis on diet regulationemphasis on diet regulation

Epidemiology of AnorexiaEpidemiology of Anorexia

Onset typically during adolescenceOnset typically during adolescence More than three times as common More than three times as common

in femalesin females Lifetime prevalence of .5 - 2%Lifetime prevalence of .5 - 2% Subclinical variants occur in up to Subclinical variants occur in up to

10% of adolescent females10% of adolescent females Psychiatric comorbidityPsychiatric comorbidity

DSM-IV Diagnostic CriteriaDSM-IV Diagnostic Criteria

Anorexia nervosa:Anorexia nervosa: Refusal to maintain body weight at or above minimally Refusal to maintain body weight at or above minimally

normal weight for age and heightnormal weight for age and height Intense fear of gaining weight or becoming fat, even Intense fear of gaining weight or becoming fat, even

though underweight.though underweight. Disturbance in the way in which one’s body weight or Disturbance in the way in which one’s body weight or

shape is experienced, undue influence of body weight shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness or shape on self evaluation, or denial of the seriousness of current low body weight.of current low body weight.

Secondary AmenorrheaSecondary Amenorrhea Two types: restricting and binge eating/purgingTwo types: restricting and binge eating/purging

Medical Complications of Anorexia Medical Complications of Anorexia NervosaNervosa

Metabolic abnormalitiesMetabolic abnormalities Gastrointestinal and renal Gastrointestinal and renal Cardiac and pulmonaryCardiac and pulmonary Hematological and immunological Hematological and immunological DentalDental Fluid and electrolyteFluid and electrolyte CNS and endocrineCNS and endocrine

Endocrine Changes in Anorexia Endocrine Changes in Anorexia NervosaNervosa

Impaired LHRH secretion leading to Impaired LHRH secretion leading to LH, LH, FSH, and estradiolFSH, and estradiol

Amenorrhea 2Amenorrhea 2° hypogonadotropic ° hypogonadotropic hypogonadismhypogonadism

Delayed TSH response to TRHDelayed TSH response to TRH Peripheral conversion of TPeripheral conversion of T44 T T33 leading to leading to

normal Tnormal T44 and low T and low T33 levels levels Conversion of TConversion of T44 to r T to r T33

GH, GH, cortisol, normal prolactin cortisol, normal prolactin Insulin and fasting glucose and abnormal Insulin and fasting glucose and abnormal

glucose toleranceglucose tolerance

Other Physiologic Changes in ANOther Physiologic Changes in AN

Clinical hypothyroidism: dry skin, Clinical hypothyroidism: dry skin, constipation, hypothermia, constipation, hypothermia, bradycardia, delayed deep tendon bradycardia, delayed deep tendon reflexesreflexes

Bradycardia & hypotensionBradycardia & hypotension EKG changes: low voltage, prolonged EKG changes: low voltage, prolonged

QT interval, & S-T segment depressionQT interval, & S-T segment depression Delayed gastric emptying and Delayed gastric emptying and

prolonged transit timeprolonged transit time

Medical and Nutritional Medical and Nutritional Management of Anorexia NervosaManagement of Anorexia Nervosa

Multidisciplinary approachMultidisciplinary approach Weight restoration is a key goalWeight restoration is a key goal Cognitive restructuring around Cognitive restructuring around

food beliefsfood beliefs Hospitalization may be indicated if Hospitalization may be indicated if

patient is <75% of recommended patient is <75% of recommended weight-for-heightweight-for-height

Pharmacologic Therapy for Pharmacologic Therapy for ANAN

Many medications have been tried in AN Many medications have been tried in AN

including neuroleptics, appetitie stimulants, including neuroleptics, appetitie stimulants,

prokinetic agents, and antidepressants.prokinetic agents, and antidepressants.

Most have little or no efficacy when Most have little or no efficacy when

compared to placebo.compared to placebo.

Serotonin-specific agents have shown Serotonin-specific agents have shown

promise in patients after weight restoration.promise in patients after weight restoration.

Epidemiology of Bulemia Epidemiology of Bulemia NervosaNervosa

Term bulemarexia coined in 1976Term bulemarexia coined in 1976 Prevalence estimates of 4-9% of Prevalence estimates of 4-9% of

young womenyoung women One study showed that 80% of One study showed that 80% of

college women have bingedcollege women have binged Prevalence related to social weight Prevalence related to social weight

normsnorms Different theories of etiologyDifferent theories of etiology

DSM-IV Diagnostic CriteriaDSM-IV Diagnostic Criteria

Bulimia nervosaBulimia nervosa-- Recurrent episodes of Recurrent episodes of

binge eating binge eating characterized by:characterized by: Eating in a discrete Eating in a discrete

period of time, an period of time, an amount of food that is amount of food that is definitely larger than definitely larger than most people would most people would eat during a similar eat during a similar period of time and period of time and circumstances.circumstances.

A sense of lack of A sense of lack of control over eating control over eating during the episode.during the episode.

Recurrent inappropriate Recurrent inappropriate compensatory behavior in compensatory behavior in order to prevent weight order to prevent weight gain.gain.

Binge eating and Binge eating and inappropriate behavior inappropriate behavior both occur, on average, both occur, on average, at at least 2/week X3 at at least 2/week X3 months.months.

Self evaluation is unduly Self evaluation is unduly influenced by body shape influenced by body shape and weight.and weight.

The disturbance does not The disturbance does not occur exclusively during occur exclusively during episodes of AN.episodes of AN.

Medical Complications of Medical Complications of Bulemia NervosaBulemia Nervosa

RenalRenal GastrointestinalGastrointestinal ElectrolyteElectrolyte Laxative abuse complicationsLaxative abuse complications Hematologic abnormalitiesHematologic abnormalities Neurologic abnormalitiesNeurologic abnormalities Endocrine & dental abnormalitiesEndocrine & dental abnormalities

Medical and Nutritional Medical and Nutritional Management of Bulemia Management of Bulemia NervosaNervosa

Medical management to monitor Medical management to monitor electrolytes, vital signs, and weightelectrolytes, vital signs, and weight

Pharmacotherapy with antidepressant Pharmacotherapy with antidepressant medicationmedication

Nutrition education about body weight Nutrition education about body weight regulation & consequences of bulemic regulation & consequences of bulemic behaviorbehavior

Cognitive-behavioral therapy to address Cognitive-behavioral therapy to address normalizing meal pattern and change normalizing meal pattern and change attitudes and behaviorsattitudes and behaviors

DSM-IV Diagnostic CriteriaDSM-IV Diagnostic Criteria Eating disorders not Eating disorders not

otherwise specified otherwise specified (EDNOS)(EDNOS)

For females, all of the criteria for For females, all of the criteria for AN are met except that the AN are met except that the individual has regular menses.individual has regular menses.

All of the criteria for AN are met All of the criteria for AN are met except that, despite significant except that, despite significant weight loss, the individuals weight loss, the individuals current weight is in the normal current weight is in the normal range.range.

All of the criteria for BN are met All of the criteria for BN are met except that the binge eating and except that the binge eating and inappropriate compensatory inappropriate compensatory mechanisms occur at a frequency mechanisms occur at a frequency of <2/week or for a duration of of <2/week or for a duration of <3months.<3months.

The regular use of The regular use of inappropriate compensatory inappropriate compensatory behavior by an individual of behavior by an individual of normal body weight after normal body weight after eating small amounts of foodeating small amounts of food

Repeatedly chewing and Repeatedly chewing and spitting out, but not spitting out, but not swallowing, large amounts of swallowing, large amounts of food.food.

Binge eating disorder: Binge eating disorder: recurrent episodes of binge recurrent episodes of binge eating in the absence of the eating in the absence of the regular use of inappropriate regular use of inappropriate compensatory behaviors compensatory behaviors characteristic of BNcharacteristic of BN

Binge Eating DisorderBinge Eating Disorder BED is a new diagnosis that refers to a BED is a new diagnosis that refers to a

pattern of recurrent binge eating episodes pattern of recurrent binge eating episodes without the compensatory behaviors seen without the compensatory behaviors seen in bulemia.in bulemia.

Binge eating episodes are characterized Binge eating episodes are characterized by both large amounts of food consumed by both large amounts of food consumed and feelings of loss of control.and feelings of loss of control.

Prevalence estimates in population studies Prevalence estimates in population studies are 0.5-2%. In patients seeking weight loss are 0.5-2%. In patients seeking weight loss treatment it may be as high as 20%.treatment it may be as high as 20%.

DSM-IV Diagnostic CriteriaDSM-IV Diagnostic Criteria

Binge eating disorder (BED)Binge eating disorder (BED) Recurrent episodes of binge eating .Recurrent episodes of binge eating . The binge eating episodes are associated with 3 or more of The binge eating episodes are associated with 3 or more of

the following: eating much more rapidly than normal, the following: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amount eating until feeling uncomfortably full, eating large amount of food when not feeling hungry, eating alone because of of food when not feeling hungry, eating alone because of being embarrassed by how much one is eating or feeling being embarrassed by how much one is eating or feeling disgusted with oneself, depressed or very guilty after disgusted with oneself, depressed or very guilty after overeating.overeating.

Marked distress regarding binge eating is presentMarked distress regarding binge eating is present The binge eating occurs, on average, at least 2/week X6 The binge eating occurs, on average, at least 2/week X6

monthsmonths The binge eating is not associated with the regular use of The binge eating is not associated with the regular use of

inappropriate compensatory behaviors.inappropriate compensatory behaviors.

Medical and Nutritional Medical and Nutritional Management of Binge Eating Management of Binge Eating DisorderDisorder

Primary Care clinicians role is to Primary Care clinicians role is to identify patients and assist them in identify patients and assist them in seeking treatment.seeking treatment.

Patients may be reluctant to reveal Patients may be reluctant to reveal their abnormal eating pattern and their abnormal eating pattern and may be unfamiliar with the fact may be unfamiliar with the fact that effective treatments exist.that effective treatments exist.

Cognitive Behavioral Therapy Cognitive Behavioral Therapy for BEDfor BED

Three Phases of Treatment:Three Phases of Treatment: Phase 1 Treatment InitiationPhase 1 Treatment Initiation

GoalsGoals– Educate r.e. BEDEducate r.e. BED– Disrupt disordered eating patternsDisrupt disordered eating patterns– Regain control over eatingRegain control over eating– Initiate exercise programInitiate exercise program

ToolsTools– Self-monitoring: foods, beverages, thoughts, Self-monitoring: foods, beverages, thoughts,

feelings before during & after eating, & bingesfeelings before during & after eating, & binges– Identification & practice of alternative behaviorsIdentification & practice of alternative behaviors– Goals setting Goals setting – Stimulus control techniquesStimulus control techniques

Cognitive Behavioral Therapy Cognitive Behavioral Therapy for BEDfor BED

Phase 2 Cognitive RestructuringPhase 2 Cognitive Restructuring GoalsGoals

– Identification and modification of maladaptive Identification and modification of maladaptive thoughts and beliefsthoughts and beliefs

– Learn and practice problem-solving skillsLearn and practice problem-solving skills Phase 3 Termination and Maintenance of Phase 3 Termination and Maintenance of

ChangeChange GoalsGoals

– Promote body acceptancePromote body acceptance Identify positive role modelsIdentify positive role models Encourage body enjoymentEncourage body enjoyment Decrease social avoidance Decrease social avoidance

– Develop a maintenance planDevelop a maintenance plan Anticipate future difficultiesAnticipate future difficulties Identify high-risk situationsIdentify high-risk situations Develop restart plan in case of relapseDevelop restart plan in case of relapse

What to Ask Patients*What to Ask Patients*

Do you eat regular meals and snacks Do you eat regular meals and snacks during a typical day?during a typical day?

Do you feel distressed in any way about Do you feel distressed in any way about your eating pattern?your eating pattern?

Do you ever feel that your eating is very Do you ever feel that your eating is very chaotic or out of control?chaotic or out of control?

Do you ever eat large quantities of food Do you ever eat large quantities of food and feel that it is difficult to stop?and feel that it is difficult to stop?

If yes, how often does this happen?If yes, how often does this happen?– * From Ref #2* From Ref #2

Follow-up Questions*Follow-up Questions* Inquire about the nature of binge eatingInquire about the nature of binge eating

Do you ever eat large amounts of food even when not Do you ever eat large amounts of food even when not physically hungry?physically hungry?

Do you ever eat alone because of being embarrassed Do you ever eat alone because of being embarrassed by how much you are eating?by how much you are eating?

Do you ever feel disgusted, depressed or very guilty Do you ever feel disgusted, depressed or very guilty after overeating?after overeating?

Inquire about compensatory behaviorsInquire about compensatory behaviors Do you ever make yourself vomit or take laxatives?Do you ever make yourself vomit or take laxatives? Do you use diet pills or any other diet aids?Do you use diet pills or any other diet aids?

Inquire about any prior treatment for eating Inquire about any prior treatment for eating problems and interest in current treatmentproblems and interest in current treatment

CBT for BEDCBT for BED

Cognitive Behavioral TherapyCognitive Behavioral Therapy Short-term, directed type of therapyShort-term, directed type of therapy Addresses behaviors and beliefsAddresses behaviors and beliefs Uses self-monitoring “homework”Uses self-monitoring “homework” Focuses on normalizing both eating Focuses on normalizing both eating

behavior and dysfunctional thoughts behavior and dysfunctional thoughts about food, shape, and weightabout food, shape, and weight

Treatment Issues in Treatment Issues in BEDBED

Should weight loss be a goal of Should weight loss be a goal of therapytherapy

Treatment modalities:Treatment modalities: Physical activityPhysical activity Self-helpSelf-help Nutritional CounselingNutritional Counseling CBTCBT Individual or Group TherapyIndividual or Group Therapy AntidepressantAntidepressant

Resources for More Resources for More Information Information Ref2Ref2

American Anorexia Bulemia Assn., Inc. American Anorexia Bulemia Assn., Inc. www.aabainc.orgwww.aabainc.org

Eating Disorders Awareness and Eating Disorders Awareness and Prevention, Inc. Prevention, Inc. www.edap.orgwww.edap.org

National Eating Disorders Organization National Eating Disorders Organization www.laureate.com/nedo/nedointro.aspwww.laureate.com/nedo/nedointro.asp

Overeaters Anonymous Overeaters Anonymous www.overeatersanonymous.orgwww.overeatersanonymous.org

Academy for Eating Disorders Academy for Eating Disorders www.acadeatdis.orgwww.acadeatdis.org

Anorexia Nervosa & Related Eating Anorexia Nervosa & Related Eating Disorders, Inc. Disorders, Inc. www.www.anredanred.com.com