Part I – Eating Disorders: General Trends/Issues Early Eating Disorders Anorexia Nervosa Bulimia...
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Transcript of Part I – Eating Disorders: General Trends/Issues Early Eating Disorders Anorexia Nervosa Bulimia...
Part I – Eating Disorders:
General Trends/IssuesEarly Eating Disorders
Anorexia NervosaBulimia Nervosa
Prevalence/PatternsPrevalence
Increases in prevalence over past 4 years; changing norms regarding size and shape of women*Historically confined to middle to upper SESIn college-age American women, 10 % or more have some symptoms of an eating disorderEstimated to occur in 0.5% to 3% of all teenagersAmong athletes and performers, range from 15% to 60%.
Gender & Age Differences90-95% of affected individuals are femaleLittle is known about nature of disorder in malesLess frequently occurs before adolescence or after age 25
*Prorated Trend of Women’s Actual Body Weights Compared with the Trend for Playboy Centerfolds &
Miss America Contestants
General Risk FactorsSelf-Ideal Body Image Discordance
General sociocultural norms idealizing extremes of thinness in women in Western cultures
This pressure may lead to development of intrusive and pervasive perceptual biases regarding how fat they are
Lead women to believe that men prefer more slender shapes than they in fact do
Related to decreases in self-esteem usually apparent during mid-adolescence in girls
While women’s actual weight has been increasing over past four decades, the weight of cultural beauty icons has decreased at the same rate
Barbie DollInteresting Facts
In 1945 Ruth and Elliot Handler form Mattel. In 1957 Ruth conceives of a three dimensional adult-like doll. The body is based on German doll called "Lilli" which is sold as a sex toy for men. If Barbie was human sized, she would stand 5 foot 6 inches tall, weigh 110 pounds, and have a 39 inch bust, 18 inch waist and 33 inch hips.
General Risk FactorsDevelopmental Risk Factors
Continuum of “eating pathology” from pickiness and dieting to clinical syndromes
Early eating habits: stability of problem eating in young children (e.g., pickiness, binging, pica (eating non-food items))
Drive for thinness: key motivational factor underlying dieting and body image (e.g., “losing weight will make them like me more”)
Dieting: between grades 5-8, 1/3 students diet and 45% want to lose weight
Biological Resistance to weight changeBodies will resist, and try to compensate, for marked variation from one’s “set point” (individual norm)Physiological compensations include enhanced hunger drive and slowing of metabolism at decreased caloric intake
Early Eating DisordersFeeding Disorder of Infancy or Early Childhood
Sudden or marked deceleration of weight gain in an infant or young child and a consequent slowing of emotional and social development.Relatively common (up to 1/3 of infants affected); more often found in high-risk families, where abuse or neglect may be presentOutcome depends on timing and level of intervention
Failure to ThriveWeight below 5th percentile for age, and/or deceleration in rate of weight gain from birth to present of at least 2 standard deviationsBeen associated with poor attachment, poverty, family disorganization, limited social supportOutcome highly related to child’s home environment
Early Eating DisordersPica
Ingestion of inedible substances for period at least 1 monthAffects mostly very young kids and those with MRCauses: poor stimulation and supervision in the home; in some cases of MR also genetic/biological factorsSeverity often related to degree of environmental deprivation and intellectual impairmentMost clinical interventions emphasize operant conditioning
Shaping and reinforcement of appropriate eating behavior
Anorexia NervosaCore Characteristics
Refusal to maintain body weight at or above a minimally normal weight for age and height (less than 85%)Intense fear of gaining weight of becoming fat, even though under-weightDisturbance in experience of body weight or shape by self-evaluation, or denial of seriousness of current low weightAmenorrhea (absence of 3 consecutive menstrual cycles)
Two Types:Restricting TypeBinge-Eating/Purging Type
Anorexia NervosaAssociated Features
Comorbid ConditionsDepressionOCD & extreme self-control (in restricting types)Substance abuse disorders (in binge-eating/purging type)Personality disorders (esp. anxious-fearful)
Behavioral PatternsIsolation from peers; social awkwardnessSevere dietary restriction, excessive exercise (RT)Misuse of laxatives, diuretics, enemas, self-induced vomiting (B-E/PT)
Anorexia NervosaSpecific Risk Factors
Personality CharacteristicsEmotionally reserved and cognitively inhibitedPreference for routine, order, and predictable environments; poor adaptationShow heightened conformity and deference to othersAvoid risk and react to stressful events with strong feelings of distressFocus excessively on perfectionismMaturity fears
Family PatternsMothers described as: excessively dominant, intrusive, overbearing, and less affectionate, discouragement of autonomyFathers described as: emotionally absentFamilies described as: limited tolerance of disharmonious affect or tension, poor conflict resolution skills, preoccupation with desirability of thinness, dieting, and good physical appearance
Anorexia NervosaTreatment Goals
Stabilize PatientRestoring hormonal function and bone densityMaximize chances for full and lasting recovery
Treatment ComponentsHospitalization
Renourish and reestablish weight to ensure survival
Psychological Treatment (Out/Inpatient)Family therapyCognitive-behavioral therapyNutritional counseling
Anorexia NervosaPrognosis: Long-term Physical Effects
Heart diseaseMost common medical cause of death in people with severe anorexia. Heart develops dangerous rhythms, blood flow is reduced and blood pressure may drop, heart muscles starve, losing sizeCholesterol levels tend to rise
Electrolyte ImbalancesAnemiaReproductive and Hormonal Abnormalities
Low levels of reproductive hormones& changes in thyroid hormones
Neurological ProblemsNerve damage and seizures, disordered thinking, loss of feeling, or other nerve problems in the hands or feet. Structural changes and abnormal activity during anorexic states; some damage may be permanent.
Anorexia NervosaPrognosis
At this time, no treatment for anorexia is completely effective. Many remain very thin and displayed characteristics of the disorder, including perfectionism and drive for thinness, that keep them at risk for recurrence of the eating disorder. Recovery can take between 4 and nearly 7 years. Comorbid disorders increase for poor outcome.
Risk of DeathDeath rates ranging from 4% to 20%. The risk for early death is twice as high in bulimic anorexics as it is in the anorexic-restrictor types.Increased suicide rates.
Bulimia NervosaCore Characteristics
Recurrent episodes of binge eatingEating in a discrete period of time (i.e. 2hrs) an amount of food that is definitely larger than most people would in similar circumstances A sense of lack of control over eating during the episode
Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or medications, fasting, or excessive exerciseBoth behaviors occur on average at least twice a week for 3 mosSelf-evaluation unduly influenced by body shape and weightTwo Types:
Purging TypeNon-purging type
Bulimia NervosaAssociated Features
Comorbid ConditionsAnxiety disorders (esp. GAD)Substance use disordersPersonality disorders (esp. Cluster B – emotional, dramatic, emotional, erratic)
Behavioral PatternsPurging types show greater physical and psychological dysfunctionPreoccupation with efforts to conceal disorder and master impulse to bingeBinge episodes usually involve intake of about 1000 calories approx. 14 times per week
Bulimia NervosaSpecific Risk Factors
Personality CharacteristicsLong-standing pattern of excessive perfectionismNegative self-evaluationMaturity fearsImpulsivity
Family PatternsHigh parental expectationsOther family members dietingHigher criticism by family members about shape, weight, or eatingDecreased allowance for autonomy
Bulimia NervosaTreatment
AntidepressantsCognitive-Behavioral Therapy
Clearly superior to medication
Emphasis on normalizing eating patternsTemporal regularitySocial eating
Focus on distorted cognitive patternsDichotomous thinking
Bulimia NervosaPrognosis
Less major health problems associated with bulimia, where normal weight is maintainedIn general, the outlook is better for bulimia than for anorexia. Mortality rate about 1% for those in treatment; 20% have life-long patterns of disorder
Physical EffectsTeeth erosion, cavities, and gum problemsLoss of fluid and low potassium levelsAcute stomach distress, rupture of the esophagus, or food pipe
Boys and Body ImageGrowing awareness regarding the pressure men and boys are under to appear muscular.
Many males are becoming insecure about their physical appearance as advertising images raise the standard and idealize well-built men.
Alarming increase in obsessive weight training and the use of anabolic steroids and dietary supplements that promise bigger muscles or more stamina for lifting.
Number of boys affected is increasing and that many cases may not be reported, since males are reluctant to acknowledge any illness primarily associated with females.
Part II - Obesity:
An EpidemicCurrent Treatments
A New Approach: BCT
Obesity Trends* Among U.S. AdultsBRFSS, 1985
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1986
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1987
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1988
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1989
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1990
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1991
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1992
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1993
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1994
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1995
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1996
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1997
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1998
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 1999
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 2000
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. AdultsBRFSS, 2001
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
A National CrisisThe rates of overweight and obese
individuals have been steadily climbing.
Rates of obesity alone have doubled in the last decade.
1998, the World Health Organization labeled Obesity “an Epidemic.”
65% of the population are now either overweight or obese (2004).
The trend is continuing with no end in sight.
Who is Overweight or Obese?
Height-Weight Tables >120% desirable weight
BMI (kg of body weight / height (in meters) squared)Normal < 25 kg/m2
Overweight 25-30Class I Obesity 30-34.99 Class II Obesity 35-39.99 Class III Obesity >40
Percent Fat >25% males; >32% females
Waist Circumference >40 in. males; >35 in. females
Physical & Emotional Burdens
Risk of major chronic diseases increases with increases in BMI and central obesity:
Metabolic SyndromeCardiovascular Diseases
Type 2 DiabetesCancers
OsteoarthritisSleep Apnea
Gall bladder DiseasePsychological Disorders
Social and Employee Discrimination
$100 billion dollars spent annually on obesity-related health care utilization.$329.2 billion dollars spent in 2002 on CVD-related illness.$50 billion dollars spent annually on diet related products.
The Financial Burden
The Ultimate CostDirect link between Obesity and Years of Life Lost (Fontaine et al, 2003)
Young adults with morbid obesity had a 22% reduction in life span.Ethnic differences in optimal BMI
23 to 25 for Caucasian (men and women) 23 to 30 was optimal for African American (men and women).
Obesity-related illness accounts for >280k deaths annually (Manson, 2003)
Obesity mortality is positively correlated with CVD mortality
950,000 people die each year from cardiovascular disease (CDC, 2003)
US Cardiovascular Disease Rates
400
420
440
460
480
500
520
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0
Years
MenWomen
Dea
ths
in t
he
Th
ousa
nd
s
Cardiovascular disease mortality trends for males and females in the United States, 1979-2000. Reprinted from the American Heart Association.
Explanation
Biological
Psychological
Social
Engel, 1977, 1980; Schwartz, 1982