The Alliance for Eating Disorders Awareness

Joann Hendelman, Ph.D., R.N., FAED, CEDS-SClinical Director

Johanna S. KandelFounder/CEO

Eating Disorders 101: How to Screen, Assess, and Diagnose Students with Eating Disorders

Eating Disorders Stats…

More than 30 Million Americans are currently battling

eating disorders

25% of college-aged students have eating disorders (NIMH 2012).

College administrators report a 24.3% rise in eating disorder behavior among college students (2010 National Survey of Counseling Center Directors).

91% of women on college campuses have attempted to control their weight through excessive dieting (ANAD)

At least three quarters (75%) of college students are dissatisfied with their weight (Soet, J. and T. Sevig, 2006)

Less than 20% who screened positive for EDs report receiving treatment on college campuses (Stanford 2013)

College Students and Eating Disorders

ACHA’s 2010 National College Health Assessment

44% of college women are dieting to lose weight

27% of college men are dieting to lose weight 61% of college women are exercising to lose

weight 45% of college men are exercising to lose

weight

College Students and Eating Disorders

“The mortality rate for those with anorexia nervosa is estimated at 5% per decade… making it one of the leading contributors to excess mortality of any of the psychiatric disorders. Research tells us that anorexia is a brain disease

with severe metabolic effects on the entire body. While the symptoms are behavioral, this illness has a biological

core, with genetic components, changes in brain activity and neural pathways

currently under study.”

Thomas Insel, M.D., Director, National Institute of Mental Health, Bethesda, MD, April 2007

Heritability in Anorexia and Bulimia

50 to 80% of cause is genetic AN & BN share common genes AN & BN run in families

“We think genes load the gun by creating behavioral susceptibility such as

perfectionism or the drive for thinness. Environment then pulls the trigger.”

– Walter H. Kaye, M.D.

Genetics

Contributing Factors Genetics Traumatic experiences Family difficulties Onset of mental illness History of substance abuse History of dieting Sports/activities where weight regulation is demanded Physical illness that causes weight loss Perfectionism Vegetarianism

Eating disorders display substantial co-morbidity with other mental health disorders.

While eating disorders often coexist with other mental health disorders, eating disorders often go undiagnosed and untreated.

A low number of sufferers obtain treatment for their eating disorder hence inaccurate measures of incidence (Only 1 in 10).

Eating disorders frequently impair the sufferer's home, work, personal, and social life.

Binge Eating Disorder is more common than anorexia or bulimia and is commonly associated with severe obesity.

Researchers found a surprisingly high rate of anorexia and bulimia among men, representing approximately one fourth of all the cases of each disorder.

Eating disorders DO NOT discriminate

between age, gender, race and class –

NO ONE IS IMMUNE

New Trends…

Men Women in Midlife Young Children

“Which of these trends has the highest percent increase?”

Women in Midlife Triggers

Desire to remain young in a society that does not let you grow old gracefully.

Divorce Rate in the U.S. (50%)MenopauseEmpty Nest SyndromeLoss (i.e. spouse, parent, child)Eating Disorders that were not

treated years prior

Males and Eating Disorders

• Recent research indicates that 1 in 4 people with eating disorders is male

• Rate of men with BED is similar to women

• Greater tendency to use compulsive exercise rather than purging for weight control.

• Preferred body image is muscular. • Increasing evidence as concerned

about body image as women.

Eating Disorders in Children

10% of eating disorders clients are < 10 years of age.

119% increase in hospitalizations in children < 12 yrs.

Nearly HALF of 3- to 6-year-old girls reported they worry about being fat (Tantleff-Dunn, 2009)

Children maturing earlier and earlier

Being teased by peers

Society’s obsession with thinness

OBESITY EDUCATION

.

Anorexia Nervosa:(Self-Starvation)

A self-imposed starvation resulting from a distorted body image and an

intense fear of gaining weight.

Demographics of Anorexia

1% of suburban female teens Bimodal peak of onset:

12-13 years old17 years old

50% restrictors (limit food and exercise)

50% bulimic subtype:also purge

Anorexia Nervosa:(Self-Starvation)

Restricting type - dieting, fastingand/or excessive exercise

Binge-eating/purging type - vomiting,

misuse of laxatives, enemas and/ordiuretics; carries greater medical

risk.

Review of Symptoms:Anorexia

Sizeable weight change Disturbed body image Cold

intolerance/hypothermia

Constipation Loss of muscle mass Depressive symptoms Anxiety Cognitive impairment

Dizziness/fainting Loss/delay menses

(Amenorrhea) Orthostatic

hypotension Self mutilation Sleep disturbance Brittle nails Thinning/dull hair

Physical Findings:Anorexia

Emaciation Bradycardia Hypothermia Lanugo hair Dry skin Carotenemia

Hyperkeratosis Edema Anemia Cyanotic

extremities Hypotension Gastroparesis

Anorexia: The Dangerous Reality

MortalityAnorexia Nervosa has the

highest mortality rate among all psychiatric disorders.

10 – 20 % will die○Death from cardiac arrest, suicide,

starvation, other medical complications

Bulimia Nervosa(Binge-Purge)

“A disorder in which an individual engages in episodes

of bingeing and purging.”

Demographics:Bulimia

21% of college-aged women Peak onset: college age Duration before presentation: 5

years Normal weight range

30% hx of obesity20% hx anorexia

Bulimia Nervosa(Binge-Purge)

75% - 85% of individuals with Bulimia are normal

weight to overweight

Review of Symptoms:Bulimia

Average weight w/ weight fluctuation

Disturbed body image

Depressive symptoms

Anxiety

Dizziness and fainting

Fatigue

Chipmunk facies

Abdominal pain

Self mutilation

Feelings of shame and guilt

Sleep disturbance

Bloating/heartburn

Bowel paralysis

Physical Findings:Bulimia

Normal or Overweight

Hypertensive Parotid

enlargement Dental erosions Russell's sign -

scars on knuckles Boerhaave

Syndrome

Edema Extremity

weakness Esophagitis Electrolyte

imbalance Sore throat Dehydration

Binge Eating Disorder(Bingeing)

“Recurrent episodes ofbinge eating without the

purging behavior ofBulimia Nervosa.”

Binge Eating Disorder

Recurrent episodes of binge eating with: Eating in discrete period of time an amount of food larger than most

people would eat A sense of lack of control over eating during the episode (a feeling

that one cannot stop eating or control what or how much one is eating)

The binge eating occurs at least once a week for three (3) months.

The binge eating episodes are associated with: eating much more rapidly than normal eating until feeling uncomfortably full eating large amounts of food when not feeling physically hungry eating alone because of feeling embarrassed by how much one is

eating feeling disgusted with oneself, depressed, or very guilty afterwards

Binge Eating Disorder : Physical Findings

Overweight or obesity

Gallbladder disease

Increased BP

Increased cholesterol

Heart disease

Type II diabetes

Lipid abnormalities

Osteoarthritis

Sleep apnea

Obesity

30-50% of hospital based obese population have BED

20-30% of patients seeking medical weight loss treatment have BED

Treatment issues of obesity with consideration of eating disorders (obesity prevention)Following involvement in an obesity prevention program,

30% of children aged 6-14 displayed one or more behaviors that could be associated with the development of an eating disorder (Science Daily, 2012)

Eating Disorders Not Otherwise Specified

Significant eating disorder that does not exactly meet

criteria for AN or BN

Avoidance/RestrictiveFood Intake Disorder

Persistent disturbance in eating leading toWeight loss/inadequate growthSignificant nutritional deficiencyDependence on tube feeding/nutritional

supplementsImpaired psycho-social functioning/inability to eat

with others

ExclusionsLack of food, cultural practiceOther medical/psychological issuesIrrational fear of weight & shape = eating disorder

Other Types of Eating Disorders

Orthorexia Muscle Dysmorphia Drunkorexia PICA Diabulimia

Orthorexia

Coined in 1997 by Steven Bratman, MD Defined as an obsession with "healthy or

righteous eating.” It often begins with someone's simple and

genuine desire to live a healthy lifestyle. The severe restrictive nature of orthorexia

could easily morph into anorexia. Can result after major illness

Muscle Dysmorphia

Obsess/worry about being small, underdeveloped, and/or underweight.

Many are obsessed with having the perfect physique and are addicted to lifting weights.

Muscle-bound, but believe their muscles are inadequate.

Steroid abuse, unnecessary plastic surgery, and even suicide.

Drunkorexia A non medical term, for the

practice of swapping food calories for those in alcohol.

Statistics suggest that 30% of 18-24 year olds skip food in order to drink more.

Also known as a mixture of alcoholism, bulimia and anorexia

Prominent among young college women who skip meals so they can get drunk at night and not worry about the calories

PICA (as an Eating Disorder)

Pica is disorder in which a person has a strong desire to eat, lick, or chew non-food items in lieu of eating caloric foods.

Persistent eating of nonnutritive substances for a period of at least 1 month. The eating of nonnutritive substances is inappropriate to the developmental level.

Diabulimia:Type 1 Diabetes

"Diabulimia" is used to describe people with diabetes that manipulate their intake of insulin in order to temporarily alter their weight.

"Diabulimia" is extremely seriousDoubled rate of physical toll taken on the body

than diabetes or an eating disorder alone. Manipulation of ketone levels may result in

dehydration, kidney dysfunction, and blindness.

40% mortality rate.

Warning!!!

Do NOT ask your patient if

they are manipulating their insulin in order to lose weight. You do not

want to teach them a ‘trick!’

Screening Questions Do you feel big/small in your body? When/what did you last eat? What did you eat

yesterday? Do you have forbidden foods? What is your ideal body weight? How often do you

weigh yourself? Have you lost/gained weight within the last 3 months? What has your weight range been?

Do you make yourself sick (i.e. purge) when you feel uncomfortably full?

Do you binge? What constitutes a binge for you? Do you eat when you’re hungry and stop when you are

full? Do you worry you have lost control over how much you eat?

Would you say that food/ food thoughts dominate your life?

What is your exercise regimen? Be mindful when screening not to ignore males!!

Evaluation of patients with eating disorders

History:

Weight/diet history

Menstrual history & pattern

Body image disturbance

Eating habits Binge eating &

purging behaviors

Current & past medications

Substance abuse

Exercise regimen Compensatory behaviors:

laxative, diuretic, diet pills/stimulants, ipecac use

Suicidal ideationsPsychiatric history○ including - family history

of disordered eating, addictive disorders, depression, anxiety, etc.

Sexual history

Evaluation Continued

Systems:Vitals○ Body temperature○ Heart rate○ Blood pressure○ Height & weight

Heart:Cardiac arrhythmiasHeart palpitationsChest pain

Heent:PerimyolysisDental cariesChipped teethMouth soresSialadenosis

Physical exam:

Evaluation Continued

EndocrineAmenorrhea/irregular

mensesLoss of libidoDecreased bone density OsteoporosisInfertility Poor glucose control &

diabetic ketoacidosis (in diabetics)

Physical exam:

SkinDry skinBrittle nailsCarotenemia PigmentationHair loss/thinningLanugo hairRussell’s signPoor wound

healing

Evaluation Continued

Labs/Studies

EKG CBC w/ diff Full thyroid panel (T², T³, T, TSH) Urinalysis; specific gravity, sodium Bone density scan Complete metabolic profile Full chemistry amylase Serum magnesium/glucose/electrolytes Amenorrhea evaluation

Evaluation Continued

Special Circumstances (e.g. clients <15% IBW)Chest x-rayComplement 324 hour creatinine clearanceUric acidBrain scanEchocardiogramSkin testing for immune functioningDXA scan (amenorrhea 6+ months)Estradiol level (or testosterone in males)ANA, amylase, lipase, LH, FSH, prolactinUGI+/-SBFT

Laboratory Clues

Low Glucose = Poor nutrition High Glucose = Insulin omission Low Potassium = Vomiting, laxatives, etc Low Chloride = Vomiting High Chloride = Laxatives High Blood Bicarbonate = Vomiting Low Blood Bicarbonate = Laxatives High Blood Urea Nitrogen = Dehydration

Laboratory Clues

High Creatinine = Dehydration Low Calcium = Poor nutrition at expense of

bone Low Phosphate = Poor nutrition or refeeding Low Magnesium = Poor nutrition or laxatives High Amaylase = Vomiting, pancreatitis High Lipase = Pancreatitis High Total Bilirubin = Liver dysfunction High Total Protein/Albumin = Malnutrition

Occasional Lab Findings

HormonesLow Estradiol (Females)Low Testosterone (Males)

Lipids: anything goesHigh Cholesterol = Short term starvationLow Cholesterol = Long term starvation

“Sick euthyroid” Low T4, normal TSH

Electrocardiogram

Usually normal Bradycardia or other arrhythmias Signs of hypokalemia Low voltage changes Prolonged QTc – Greater than 440 Occasional ST-segment depression

Criteria for Hospitalization

Weight more than 25% below IBW Bradycardia < 50 BPM Temperature < 96 degrees F (< 35.6

C) Hypotension < 80/50 mm Hg Orthostasis > 20 BMP Hypokalemia < 3 Renal failure ECG abnormalities Failure in outpatient intervention Suicidality

Role of the Practitioner

Selling patients treatment they don’t want for a

problem they don’t think they have

Do’s

Offer empathy Roll with the

resistance Avoid

accusations/arguing/ pressuring

Ask open ended questions

Listen reflectively Affirm/validate Summarize

Motivational Interviewing:

Don’ts

Do not believe all patient reports are accurate

Do not tell an underweight person with ED’s to “just eat” or they are “lucky” to be thin

Do not tell an overweight person to just stop eating

Do not expect this will go away with time

DON’T DELAY with early onset ED symptoms

Clinic Culture

WeighingOffice staff must be trained to use standardized

protocols to record consistent, reliable measurements

Scale should be located in a private area

Client should be weighed backwards to avoid revealing their true weight to them (Blind weights)

Be aware that clients may drink extra fluids (water-loading), put weight in pockets/rocks in underwear, and/or wear layers of extra clothing before being weighed

Weighing

Never leave chart unattended – and do not vocalize number or share whether it’s up/down

Comments about weight should be minimized and made discretely

Clinic Culture

Clinic Culture When words have unintentional meanings

“Healthy” Fat Gained weight Out of Control

“Look Better” Fat Gained weight Out of Control

“You look very nice today” Fat Gained weight Out of Control

Clinic Culture They Said What???

“If you have an eating disorder, then why aren’t you skinnier?”

“So what? An eating disorder? I’ve had one of those…This is all your choice. Some people have real problems.”

“You’re a guy, and guys don’t get eating disorders.”“No you don’t have an eating disorder…you’re not

that skinny and your teeth are not yellow.”“I had an eating disorder when I was younger, but I

weighed much less than you do now.”“You can starve yourself, and binge and purge as

much as you want as long as you take vitamins, and don’t hit your head when you pass out. You’ll grow out of this stage eventually.”

Hostile Recovery Environment

We are In A Hostile Recovery Environment

Pervasive on college campuses

Glamorization/encouragement of the illness

Thinness = control, popularity, success, relational connection

Fat = out of control, shunned, failure, relational rejection

Readily available and legal drug of choice

War on Obesity

Questions?For more information, please call:

The Alliance for Eating Disorders Awareness

(866) 662-1235www.allianceforeatingdisorders.com