Jack Sprat and His Wife: Disordered Eating and the Continuum From Anorexia Through Obesity Stephen...

Jack Sprat and His Wife:Disordered Eating and the Continuum From Anorexia

Through Obesity

Stephen Sondike, MD

Medical Director, Disordered Eating Center

Of Charleston (DECC)

Section Head, Adolescent Medicine

Charleston Area Medical Center

Associate Professor of Pediatrics

West Virginia University School of Medicine

Jack Sprat could eat no fat.

His wife could eat no lean.

And so between them both, you

see, They licked the platter clean

Anorexia Nervosa

Anorexia Nervosa

Female athlete Triad

Anorexia Nervosa


EDNOS

Anorexia Nervosa


EDNOS

Bulimia Nervosa

Anorexia Nervosa


EDNOS

Bulimia Nervosa

“non-purging” BN

Anorexia Nervosa


EDNOS

Bulimia Nervosa


Binge eating disorder

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

A case in point: Pt RS

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

Age 11: 160 lbs (pt report)

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

Age 13: (3/3/09)Wt: 39.8 kg

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

6/17/09 : wt 51 kgMom reports pt

caught exercising and vomiting in bathroom

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

8/18/09 : wt 56.6 kg“binging and purging

constantly”

Anorexia Nervosa


EDNOS

Bulimia Nervosa

Binge eating

disorder

overweight

10/15/09 : wt 70.7 kgNo purging.

Eating powdered scandishakes from

the sink

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

10/21/10 : wt 99.7kg

Anorexia Nervosa


EDNOS

Bulimia Nervosa



overweight

7/7/11:hospital admission for abdominal pain. Wt 72.5 kg

Crossing Over

• 28 % of patients with AN (n = 108) had pre-morbid body weight of 115 % IBW or greater1 .

• Up to 30% of obese patients may have BED2

• Overweight patients commonly use diet pills/laxatives/purging to try to lose weight (18% F, 8% M )3

• People with BN are 3 times more likely to be obese as a child4

1Crisp et. al. (1980) 2Streigal-Moore et al. (2004)3Neumark-Sztainer et al. (2006)4 Fairburn et al. (1997)

Dieting behavior in children adolescents is common

• 60% of female students trying to lose wt.• 29% of male students trying to lose wt.• 21% of females use diet pills• 7 % of females have tried vomiting

Source YRBSS 2003

“Dieting” and Weight Status

• Parental dieting and “fat talk” is associated with disordered eating, decreased body satisfaction and increased weight status in children

• Personal history of dieting is associated with higher BMI and increased weight gain since the onset of “dieting”

“Diabulimia”• Up to 50% of women with Type 1 Diabetes

binge eat.• Up to 30% of women with T1DM intentionally

withhold or reduce prescribed insulin to control weight

• Most DM patients had lost significant weight prior to diagnosis and gain weight past baseline with treatment.

• The standard treatment of T1DM are behaviors that are intrinsic to eating disorders.

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Adolescent Obesity is Increasing

• NHANES III

– 22-23% of American Children are above the 85th percentile for BMI.

– 10.5% are above the 95th percentile for BMI.

– Adolescent obesity is associated with significant morbidity and mortality in both the short and long term.

NIDDM is Epidemic• Between 1982 and 1994: 10-fold increase in new

diagnosis in pediatric populations1

• Type 2 Diabetes represents up to 50% of new pediatric Diabetes diagnoses

• Impaired glucose tolerance in 25% of obese children and 21% of obese adolescents2

1 Pinhaus-Hamiel et al, J Pediatr. 1996 May;128(5 Pt 1):608-15. 2 Sinha et.al. NEJM 2002 Mar; 346(11):802-10

Pediatric Hypertension is Increasing

• Concordant increase in SBP and BMI in middle school students between 1986 and 19961

• In children aged 8-17 over the past 15 years– 1.4 mm/hg in SBP– 3.3 mm/hg2 in DSP

Sources: 1Leupker, 19992Muntner, JAMA, 2004

Bogalusa Heart Study

• Atherosclerosis begins at an early age– Coronary artery and aortic plaques found as

early as age 5

• Atherosclerotic plaques in childhood associated with traditional risk factors

Metabolic Syndrome(as defined by Reaven)

• Hyperinsulinemia

• Obesity

• Hypertension

• Dyslipidemia

Metabolic Syndrome in Youth • At least 3 of the following:

– Abdominal obesity– Low HDL– Hypertriglyceridemia– Hypertension– Impaired Glucose Tolerance

• 30% of overweight Hispanic children with FHx of NIDDM meet criteria for Metabolic syndrome.1

• 37.8% of moderately obese and 49.7% of severely obese subjects meet criteria for metabolic syndrome2

1Cruz et. al. J Clin Endocrinol Metab. 2004 Jan;89(1):108-13.2 Weiss et al. NEJM. 2004 June ; 350 (23) 2362-2374

Prevalence of eating disorders

• Anorexia Nervosa

– Females 0.5-1%– Males 5-10 % of all cases (female:male 9-1)

• Binge Eating Disorder: (among college students)– Females 2.8%– Males 1.9%– (Spitzer 1993)

• Bulimia Nervosa

– Females 1-3%– Males 0.1-0.3 %

EDNOS

up to 20 % of adolescents

Prevalence of Eating Disorders

• Eating disorders have been steadily increasing since the 1950s

• Changing demographics– More males– More minorities– More worldwide– Younger and younger

• Hospitalizations for ED for children younger that 12 have increased 119% from 1999-2006

• Supersizing• Marketing high sugar foods to children• Unhealthy foods marketed as good for you• Nintendo and X-Box, Social media

– Thumb exercises

• Healthy foods are more expensive• Elevators and Moving sidewalks• The 4 N’s

– ‘Net – Nickelodeon– Nintendo – Nabisco

America is an Obesogenic Society. . .

1140 Kcal75g fat

• Supersizing• Marketing high sugar foods to children• Unhealthy foods marketed as good for you• Nintendo and X-Box, Social media

– Thumb exercises

• Healthy foods are more expensive• Elevators and Moving sidewalks• The 4 N’s

– ‘Net – Nickelodeon– Nintendo – Nabisco

America is an Obesogenic Society. . .

. . . In a Culture which Stigmatizes Obesity

• Thin is ideal, the thinner the better

• Abundance of quick weight loss schemes

• Overweight = negative personality traits

. . . in a Culture which Stigmatizes Obesity

• Thin is ideal, the thinner the better

• Abundance of quick weight loss schemes

• Overweight = negative personality traits

Evaluating Adiposity

• BMI = wt (Kg)/ht (m)2

– Limited by inability to differentiate LBM from adiposity

• Skinfold measurements– limited by operator dependence

• Water Submersion– you can’t afford it

• Air Dispacement (BodPod), TOBEC, DEXA, MRI/CT– Ditto

• Bioimpedence- Dependant on hydration status• Visual test

HIPAA HIPAA

SAME BMI

Anorexia Nervosa-Diagnostic Criteria (DSM IV)

• Weight of less than 85% expected• Intense fear of becoming fat• Disturbance in the perception of ones

weight• Amenorrhea in post menarchal females

– Absence of 3 consecutive cycles– RESTRICTING TYPE– BINGE/PURGE TYPE

Female Athlete Triad• Disordered Eating• Amenorrhea• Osteopenia

– Results when caloric intake is insufficient for the increased need associated with vigorous exercise

– May be of normal weight but manage like an anorexic

Bulimia Nervosa-Diagnostic Criteria (DSM IV)

• Recurrent episodes of Binge Eating, characterized by both of the following:– Eating, in a discreet period of time, more than

most people would eat during a similar time period under similar circumstances

– A sense of lack of control during such episodes

• Recurrent inappropriate compensatory behaviors to prevent weight gain– ie. Laxatives, vomiting, exercise, fasting

Bulimia Nervosa-Diagnostic Criteria (DSM IV)

• At least twice/week for 3 months• Self-image unduly influenced by weight• The disturbance does not occur solely

during episodes of AN

BED - Diagnostic Criteria (DSM IV-Appendix B)

• Recurrent episodes of Binge Eating, characterized by both of the following:– Eating, in a discreet period of time, more than most

people would eat during a similar time period under similar circumstances

– A sense of lack of control during such episodes• The binge eating is associated with three or more

of the following:– Eating much more rapidly than normal– Eating until uncomfortably full– Eating large amounts when not hungry– Eating alone due to embarrassment– Feeling disgust or guilt about eating

BED - Diagnostic Criteria (DSM IV- Appendix B)

– Marked Distress towards Binge eating– Twice weekly for 6 months– Not associated with compensatory behavior or

does not occur exclusively during AN or BN

Eating Disorder not Otherwise Specified (EDNOS)

• Disorders of eating that do not fit full the criteria for AN or BN

• Common examples:– All criteria for AN except regular menses– All criteria for AN except wt. >85% expected– All criteria for BN except does not occur

twice/week, or for 3 months– Purging without bingingThe DSM 5 will swallow a lot of this up in the

other diagnoses (www.dsm5.org)

Elevated Body Weight

Usual Body Weight

(Lean or Obese)

Reduced Body Weight

24 hr energy expenditure

Physical activity energy expenditure

Thermic effect of eating

T-3

Sympathetic tone

Parasympathetic tone

24 hr energy expenditure

Energy expenditure physical activity

Thermic effect of eating

T-3

Sympathetic tone

Parasympathetic tone

Perpetuating factors (cont.)

Hormonal And Neural Control of Appetite-

Serotonin

• Increases satiety

• Decreased in low weight AN but increased from normal in long term recovered AN

• Possibly lower in BN; Binge on tryptophan?• Decreased in obese and correlated with

carbohydrate cravings

Hormonal And Neural Control of Appetite-

NorEpi and Dopamine

• Norepi is Orexigenic: Altered in low-weight AN but normal in recovery

• BN- NorEpi low baseline but increased in in response to meals

• Dopamine is associated with eating pleasure-Certain obese patients have an allele which is associates with reduced D2 receptors

Hormonal And Neural Control of Appetite -Cholecystikinin (CCK)-

• induces satiety• AN low in low weight and normal in

recovered (expected response)• BN inadequate rise after meals• Obese No specific effect

Hormonal And Neural Control of Appetite -Cortisol

• Secreted in response to stress- may increase appetite– Elevated in those with disordered eating

• Higher cortisol is associated with higher ED attitudes and behaviors regardless of BMI status

• Likely an adaptive response to starvation which perpetuates the behaviors.

– Lawson et. Al; Eur J Endocrinol. 2011 Feb;164(2):253-61.

Hormonal And Neural Control of Appetite –Peptide YY

• Secreted in the intestine in response to food intake– Strong anorexic effect– Appear to be high in disordered eating and

malnutrition and associated with drive for thinness

– Low in obese subjects.

Hormonal And Neural Control of Appetite

Ghrelin – abnormally increased in BN-possibly decreased sensitivity in AN.

NPY and PPY- Very potent appetite stimulators

No specific differences

adiponectin; agouti related protein; leptin; resistin; others-further study needed

The Dichotomy

• Obese = you should be unhappy about you weight

• you are only successful in the program if you lose weight (you are “non-compliant” if you can’t/won’t)– Losing weight will improve your life– You may want to eliminate certain

macronutrients (ie fat, carbs etc.)

“Follow this diet, Mr. Figby, and I want to see two-

thirds of you back here for a

check-up”

The Dichotomy

• Anorexia Nervosa = You are healthy at any size– Body weight does (or should) not reflect happiness– You should be comfortable with all types of food and

dismiss “food phobias”– “It’s donut day in the AN ward”

“Health at Every Size”

• Accepting and respecting the natural diversity of body sizes and shapes.

• Eating in a flexible manner that values pleasure and honors internal cues of hunger, satiety, and appetite.

• Exercising for pleasure and the joy of physical movement rather than to lose weight.

I don’t stop eating when

I’m full.

The meal is not over when

I’m full.

The meal is over when I hate myself!

Dietary treatment goals

• Attain skills for a lifetime of weight management– self monitoring of eating, physical

activity and weight– social and emotional support

• Realistic weight goal (may differ from that initially expressed by the teen or parents)

Psychological Treatment• Cognitive Behavoral Therapy (CBT)

– the mainstay of treatment for disordered eating

– Demonstrated effectiveness in BN and BED.

Emphasizes the interrelationships between thoughts, feelings, and behaviors as they relate to a situation.

– Structured, collaborative, time limited approach to increasing capacity to identify, challenge, and modify problem thoughts and behaviors

Family Based Therapy (Mauldsley Method)Demonstrated effective, and superior to CBT in younger patients with AN

Pharmacotherapy in ED• High dose SSRI (60 mg. Fluoxetine) has been

shown in studies to decrease binge-purge cycles in bulimia

• No medication has been shown to be more effective than placebo for AN, but studies have only been done on those patients with very low weight.

• SSRIs may be effective for treating comorbidities (OCD, major depression, PTSD)

• To nourish the brain, you must nourish the body

Pharmacotherapy in ObesityApproved:

• Sibutramine (Meridia)• Orlistat (Xenical)

Off label:• Fluoxitine (Prozac)• Topirimate (Topamax)

Dangerous:• Ephedrine

– Ephedrine/Caffeine (off the market)

Pulling it together:

• Your goal weight is whatever your weight happens to be when living a healthy lifestyle

• Even if you can’t lose/gain weight you are not a bad person or a failure, you just have a problem you need to work on which is NOT YOUR FAULT

• Model good, healthy behaviors• Have realistic goals

Do:• Be sensitive and contemplative about

addressing weight issues with kids and families

• Associate excess adiposity with health risks and comfort issues rather than self worth and cosmetic issues

• Practice anticipatory guidance about unhealthy weight loss behaviors

• Encourage and congratulate even small behavior changes, even if they don’t bring immediate “results”

Don’t

• Tell an adolescent that they “need to lose 50 pounds”

• Use sensitive terms like “obese” “fat” “chunky”

• Criticize a patient who is not meeting a weight goal

• Suggest a restriction without suggesting a substitution

Disordered Eating center of Charleston

• Multidisciplinary, multicampus team• Stephen B. Sondike MD, Medical Director

Jessica Luzier, PhD, Clinical Director

Jamie Oliver, RD, Dietician

Morgantown Contacts:

Pamela Murray, MD

J. Scott Mizes, PhD

THANKS!

Jack Sprat and His Wife: Disordered Eating and the Continuum From Anorexia Through Obesity Stephen...

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