Eating Disorders

1
Eating Disorders

• Teresa Lianne Beck,MD
• Assistant Professor
• Family Preventive Medicine
• Emory University School of Medicine

2
Objectives

• 1. Recognize and diagnose eating
  disorders.
• 2. Understand the epidemiology and
  populations that
• are at special risk.
• 3. Understand the underlying causes.
• 4. Become familiar with the DSM-IV
  Criteria.
• 5. Know the psychological and physical
  consequences.
• 6. Be able to treat eating disorders using
  a multimodal
  approach.
• 7. Take Action !

3
CASE 1

• 18 y.o. female with no significant PMHx, presents
  with 5 month h/o weight loss
• Just completed her 1st year of college with a 3.8
  GPA
• She became a vegetarian after hearing a lecture
  on cholesterol and heart disease in her biology
  class, and began reducing the fat in her diet
• She is 64 inches tall and has lost 22 pounds to a
  weight of 95 pounds

4
Case 1

• She drinks 2 cups of coffee and 3 cans of diet
  cola per day
• She eats ½ bagel for breakfast, an apple for
  lunch, and a salad with kidney beans and fruit
  for dinner
• Denies laxative use. BM every 4-5 days
• She runs 4 miles a day, and does 100 sit-up
  nightly
• Her LMP was 6 months ago
• She denies ever being sexually active

5
Case 1

• Constantly feeling cold
• Dizzy when stands up rapidly
• Hair is dry
• Feels bloated after meals
• Thinks that her thighs and stomach are too big,
  despite her parents protests
• Doesnt believe that she has a problem

6
CASE 2

• 20 y.o. female presents for evaluation of
  hematemesis
• Admits to self-induced vomiting for the past 3
  years
• 62 inches tall, 63 kg
• Gorges and vomits 3-5 times per week
• Uncontrollable eating binges
• Feels guilty
• Smokes 1 pack cigarettes per day
• Gets drunk weekly
• Irregular menses
• Has not lost any weight

7
Case 3

• 37 y.o. AA male who presents to his primary care
  physician for annual exam
• His weight is 289 lbs, BMI is 38, his BP is
  150/90
• He does not exercise
• He admits to eating excessive amounts of food and
  unable to control his binges 4-5 days/week
• He eats to point of being uncomfortably full and
  often eats when bored or stressed.
• He admits to feeling ashamed and depressed about
  his inability to control his eating or his
  weight.
• He admits to eating alone, often in his car.

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Spectrum of disordered eating
An Eating Disorder is about the expression of
underlying thoughts and feelings and NOT really
about food.
Risk factors Biological Psychological Sociocultura
l Family/interpersonal
Anorexia Bulimia Binge Eating
Eating Disorder Nervosa
Nervosa Disorder
(NOS) 307.1 307.51
307.50 307.50
Dieting
9
Epidemiology

• Onset of Anorexia is bimodal, puberty (12-15y)
  and late teens to early 20s.
• Bulimia appears during late teens to mid-20s.
• Anorexia 1-2 female, 0.1-0.2 male
• Bulimia 4-20 female, 0.1-0.2 male
• Binge Eating Disorder 3-30 adults (40 male)
• 10 million females and 1 million males are
  affected by eating disorders.
• Most researchers agree these numbers are grossly
  underestimated.

10
Obesity

• 60 Adults in the U.S. are overweight. (BMIgt25)
• 30 Adults are clinically obese (BMIgt30)
• 26 of U.S. children are clinically obese.
• 45 of obese patients have BED.
• Treated as a medical problem requiring change in
  diet and more exercise.

11
Dieting

• 60 of US population is on a diet at any one
  time.
• 95 of those who lose weight will regain within
  5 years.
• 50 billion dollar a year diet industry.
• Dieting has become a normal way of eating.
• 35 of normal dieters will develop some form of
  an eating disorder.

12
1999 Youth Risk Behavior Surveillance Survey 7

• 58 of students in the United States had
  exercised to lose weight
• 40 of students had restricted caloric intake in
  an attempt to lose weight.

13
Whats really scary?

• 80 of women dissatisfied with their body
• In one study, 45 of healthy, normal weight third
  through sixth graders said that they wanted to be
  thinner
• 40 of them had actually tried to lose weight
• 7 of them scored within the high risk range of
  an "eating attitude" test that detects or
  predicts eating disorder behavior.

14
Exploring the Underlying Causes

• Sociocultural factors (mass media, friends,
  occupations, athletics)
• Psychological factors (perfectionist, need for
  control, all or none thinking, low self-esteem,
  difficulty expressing negative emotion,
  difficulty resolving conflict, mood disorders,
  personality disorders, substance abuse, sexual
  trauma)
• Family factors (perfectionist, controlling,
  repress anger, rigid)
• Biological factors (serotonin, genetic
  predisposition)

15
Recognizing the signs and symptoms

• General (skips meals, preoccupation w/food,
  unable to express feelings, worries about others
  opinions, perfectionist, overly critical of self
  and others)
• Anorexia (wt. loss, strict dieting, perceives
  being overweight, denies hunger, rituals,
  excessive exercise)
• Bulimia (visits restroom after meals, eats large
  amounts without gaining wt., eats rapidly, mood
  swings, unexplained disappearance of food, empty
  wrappers)
• Binge Eating d/o (weight gain, eats large amounts
  rapidly, eats in isolation, eats to point of
  being overly full)

16
Signs/Symptoms of Anorexia

• Lanugo hair
• Scalp hair loss
• Early satiety
• Weakness, fatigue
• Short stature
• Osteopenia
• Breast atrophy
• Atrophic vaginitis
• Pitting edema
• Cardiac murmurs
• Sinus brady
• hypothermia

• Dry skin
• Cold intolerance
• Blue hands and feet
• Constipation
• Bloating
• Delayed puberty
• Primary or secondary amenorrhea
• Nerve compression
• Fainting
• Orthostatic hypotension

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Signs/Symptoms of Bulimia

• Mouth sores
• Pharyngeal trauma
• Dental caries
• Heartburn, chest pain
• Esophageal rupture
• Impulsivity
• Stealing
• Alcohol abuse
• Drugs/tobacco

• Muscle cramps
• Weakness
• Bloody diarrhea
• Bleeding or easy bruising
• Irregular periods
• Fainting
• Swollen parotid glands
• Hypotension

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Medical Consequences of AN/BN

• Cardiac (arrhythmia, cardiomyopathy, HF,
  hypotension, DEATH)
• Metabolic (hypokalemia, hyper/hyponatremia,
  metabolic acidosis/alkalosis, hyperlipidemia)
• Endocrine (sick euthyroid, amenorrhea,
  osteoporosis, fractures, growth retardation,
  hypercortisolism, delayed puberty)
• Hematological (anemia, neutropenia, impaired cell
  mediated immunity)
• GI (constipation, dental erosion, esophagitis,
  gastric/esophageal rupture, colonic irritation,
  fatty liver, intestinal atony, gallstones, acute
  pancreatitis)
• Neuro/Psychiatric (depression, anxiety, substance
  abuse, suicide, seizures, myopathy, cortical
  atrophy, peripheral neuropathy)
• Skin (pallor, hypercarotenemia, hair loss,
  lanugo, brittle nails, edema)

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Medical Consequences of BED

• Obesity
• HTN, CVD, CVA
• Hyperlipidemia, Diabetes
• Renal, Gallbladder disease
• Osteoarthritis
• Sleep apnea and Respiratory problems
• Infertility, complications of pregnancy
• Colon, breast, endometrial, prostate CA
• Depression, suicide, substance abuse

20
Evaluation

• Diagnosis is based on DSM-IV clinical findings
• Clues in the history and physical exam
• Laboratory studies done to rule out other causes
  of weight loss and/or complications
• Often is the only way to convince the person
  he/she needs help

21
DSM-IV Criteria

• Anorexia Nervosa
• 1. Refusal to maintain adequate weight (less
  than 85 of IBW or BMIlt17.5)
• 2. Intense fear of gaining weight
• 3. Body image distortion
• 4. Amenorrhea (3 months)
• 2 sub-types restricting and purging

22
DSM-IV Criteria

• Bulimia Nervosa
• 1. Binge eating (twice a week for 3 months)
• 2. Purging (vomiting, laxative, diuretics) and/or
  excessive exercise, or fasting to prevent weight
  gain
• 3. Preoccupation with body weight or shape
• 4. Absence of anorexia nervosa
• 2 sub-types purging and non-purging

23
DSM-IV Research Criteria

• Binge Eating Disorder
• 1. Recurrent binge eating (at least twice a week
  for 6 months) loss of control eating very
  large amounts
• 2. Marked distress with at least three of the
  following
• Eating very rapidly
• Eating until uncomfortably full
• Eating when not hungry
• Eating alone due to shame or guilt
• Feelings of disgust, guilt, depression after
  overeating
• 3. No recurrent purging, excessive exercise, or
  fasting
• 4. Absence of anorexia nervosa

24

• Eating Disorder NOS
• Those who suffer, but do not meet ALL the
  diagnostic criteria for another specific eating
  d/o
• Other Examples
• Chronic dieting
• Grazing
• An individual who repeatedly chews and spits out
  large amounts of food
• Late night eating

25
SCOFF Screen

• S- Do you feel SICK because you feel full?
• C- Do you lose CONTROL over how much you eat?
• O- Have you lost more than ONE stone (13 lbs.)
  recently?
• F- Do you believe yourself to be FAT when others
  say you are thin?
• F-Does FOOD dominate your life?
• 2 or more Yes is a strong indication of an ED.
• Morgan JF, Reid F, Lacey JH. The SCOFF
  questionnaire assessment of a new screening tool
  for eating disorders. BMJ 1999 3191467.

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Suggested Screening Questions for AN/BN

• How many diets have you been on in the past year?
• Do you think you should be dieting?
• Are you dissatisfied with your body size?
• Does your weight affect the way you think about
  yourself?

• Anstine D, Grinenko D. Rapid screening for
  disordered eating in college- aged females in
  the primary care setting. J Adolesc Health
  200026338-42.

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History

• Requires a high index of suspicion
• Explore attitudes about weight loss, desired
  weight, and eating habits
• 24 hour dietary recall
• Detailed weight and menstrual history
• Be direct and ask about dieting, diet pills,
  bingeing, vomiting, exercise, diuretic, laxative
  abuse
• Screen for depression, anxiety, substance abuse,
  personality disorders, sexual/physical abuse, and
  suicidality
• Complete ROS for medical complications

28
Physical Exam - Anorexia

• Specifically note state of nutrition and
  hydration, height, weight (w/o clothing) used to
  calculate BMI, BP and Pulse with orthostatics,
  hypothermia
• Skin (pallor), nails (brittle) and hair (lanugo)
• Chest (rhales), CV (arrhythmia), extremities
  (edema, cyanosis), DTRs (delayed relaxation)
• Abdominal and rectal (bowel sounds, epigastric
  pain, heme positive stool)

29
Bulimia

• Postural signs (volume depletion)
• Parotid gland enlargement (chip-munk cheeks),
  teeth (discoloration, erosion), scars on dorsum
  of hand
• Abdominal and rectal (bowel sounds, epigastric
  pain, heme positive stool)
• Neurologic exam for focal abnormalities
  suggestive of CNS tumor or seizure disorder
  (rare)

30
Binge Eating Disorder

• PE findings usually are normal
• Complete head to toe looking for signs commonly
  associated with complications of obesity (HTN,
  CVD, DM, DJD)

31
Differential Diagnosis of Anorexia

• Affective disorder- unipolar, bipolar
• Personality disorder
• Schizophrenia
• Anxiety disorders, including OCD
• Substance Abuse

• Organic disease
• Infection, including AIDS
• Thyroid disease
• Diabetes
• Cancer
• Malabsorption

32
Differential Diagnosis of Bulimia

• Organic disease
• Infection
• Thyroid disease
• Diabetes
• Cancer chemotherapy
• Malabsorption syndromes
• GI problems-GERD, IBD, gastroparesis, mass
  lesions
• Brain tumor
• Migraine
• Epilepsy

• Affective disorders- unipolar, bipolar
• Personality disorders
• Schizophrenia
• Anxiety disorders, including OCD
• Common obesity- compulsive eating
• Instrumental vomiting

33
Differential Diagnosis of Obesity

• Hypothyroidism
• Hypercortisolism
• Deficiencies of growth hormone or gonadal
  steroids
• Medications
• Long-term glucocorticoid treatment
• Immunosuppression after transplantation
• Cancer chemotherapy
• Intensive glycemic control with insulin, a
  sulfonylurea, or a thiazolidinedione
• Neuropsychotropic drugs, particularly newer
  antipsychotic and antiseizure medications

34
Laboratory Evaluation

• Complete Metabolic Panel
• CBC
• ALKP, LFTs, amylase
• Lipids
• EKG
• TFTs
• LH, FSH, Prolactin, Estrogen
• Bone Mineral Density

35
Treatment Options for AN/BN

• Inpatient hospitalization
• Outpatient psychotherapy (CBT)
• Medication (SSRIs)
• Self-help/Support Groups (A/B, OA)
• Family therapy
• Bibliotherapy
• Nutritional education
• Stress management
• Hypnotherapy, guided imagery, reality imaging

36
Costs To Treat Eating Disorders

• Treatment often requires extensive medical
  monitoring and therapy can extend over two or
  more years.
• Outpatient therapy can extend to 100,000 or
  more.
• Inpatient treatment can be 30,000 a month, and
  many require repeat hospitalizations

37
Costs to Society

• The direct (health care) and indirect (lost
  productivity) costs of obesity in the U.S.
  approximates 10 of the national health care
  budget.
• Amounts to 100 billion per year.

38
Costs to the Individual

• Lost relationships
• Wasted talents
• Suffering families
• Multiple office visits for medical complaints
  related to physical and psychological
  consequences of disordered eating behavior.

39
Role of Primary Care Provider

• Team coordinator
• Rule out other causes of weight loss and/or
  complications
• Obtain early psychiatric and nutritional
  consultations and coordinate a multidisciplinary
  team approach to management
• Educate the patient about the medical
  complications of the illness

40
ANOREXIA

• Cognitive behavioral therapy
• Emphasizes the relationship of thoughts and
  feelings to behavior, learn to recognize and
  change pattern of false beliefs and reactions to
  them
• Limited efficacy
• Interdisciplinary care team
• Medical provider
• Dietician with experience in ED
• Mental health professional

41
MEDICATIONS

• Overall, disappointing results
• Effective only for treating comorbid conditions
  of depression and OCD
• Anxiolytics may be helpful before meals to
  suppress the anxiety associated with eating
• Case reports in the literature supporting the use
  of olanzapine

42
ANOREXIA

• Set medical guidelines for outpatient management
• minimum acceptable weight
• weight goal
• weight gain of 1-2 lbs. a week for underweight
  patients
• maintenance of normal electrolytes

43
BULIMIA

• Cognitive behavioral therapy is effective
• Pharmacotherapyhigh success rate
• Fluoxetinestudies reveal up to a 67 reduction
  in binge eating and a 56 reduction in vomiting
• TCAs
• Topiramatereduced binge eating by 94 and
  average wt. loss of 6.2 kg
• Ondansetron, 24 mg/day

44
Anorexia/Bulimia

• Monitor weight, postural signs, cardiac rhythm,
  and electrolytes
• Address any metabolic or endocrinologic
  complications.

45
Hospitalization Criteria

• Loss of more than 40 of ideal weight (or 30 if
  in 3 months)
• Rapid progression of weight loss
• Cardiac arrhythmia
• Persistent hypokalemia unresponsive to outpatient
  treatment
• Symptoms of poor cerebral perfusion or mentation
  (syncope, severe dizziness, or listlessness)
• Psychiatric disturbances beyond patients
  control, severe depression
• Suicidal ideation

46
Binge Eating Disorder

• Cognitive Behavioral Therapy
• Interpersonal Therapy (deals with depression,
  anxiety, learn to handle stress, express
  feelings, develop strong sense of individuality,
  address sexual issues, past traumatic events)
• Medications (SSRIs Prozac, Zoloft)
• Support Groups (Overeaters Anonymous)
• Monitor and treat medical complications (HTN, DM,
  Hyperlipidemia)

47
Prognosis

• Anorexia
• 5-20 mortality (cardiac arrhythmia's)
• More than 75 will regain weight to near-normal
  levels, with return of menses, but abnormal
  eating habits and psychosocial problems often
  persist.
• 50 become bulimic.

48
Bulimia

• With treatment
• 50 achieve full recovery.
• 30 experience partial recovery.
• 20 show no improvement.

49
Binge Eating Disorder

• Tends to be a chronic condition for those not in
  therapy or support group.
• 50 remission for those treated with CBT.
• Morbidity and mortality are directly related to
  the many diseases associated with obesity.

50
Taking ACTION!

• How can family and friends help?
• How can you help yourself?
• What other resources are available?

51
10 Commandments

1. Its not a diet problem.
2. No one is to blame for the problem. Its no ones
   fault.
3. Understand that he/she needs to eat three meals a
   day, but do not take responsibility for her
   eating. Dont hide food from him/her or push food
   on her. When offering food to others, dont
   exclude him/her.
4. Let him/her know you are willing to provide
   support if she needs it.
5. If you have questions about the ED, ask him/her
   directly. He/She can determine what he/she is
   comfortable sharing.

52
10 Commandments

• Do not share your opinions or judgments on
  his/her size or weight, even if teasing.
• Do not encourage any type of diet.
• Share freely and directly with him/her concerns
  or other feelings you have which regard him/her.
• Understand that he/she is also working on
  communicating more directly.
• Understand that he/she is not cured. He/She will
  be struggling with the ED for quite a while and
  will need continuing work on issues which cause
  and perpetuate it.

S. Sobel. Eating Disorders. CME Resource.
2004-2005.
53
How to help yourself

• ADMIT to yourself that you may have an eating
  problem or disorder and be in need of help
• TELL someonea friend, family member, family
  physician, or counselorabout your concerns
• LEARN that asking for help is a sign of strength
  rather than weakness. Learn to recognize your
  needs and be open about them to yourself and
  others.

54
Helpful Resources

• Campus
• Emory U. Counseling Center
• Emory U. Student Health Services
• Emory U. Hospital Psychiatry
• Emory Womens Center
• Student Educators on Eating Disorders (SEED)

• Community
• Atlanta Center for Eating Disorders
• Eating Disorders Information Network
• Ridgeview Institute
• Anorexia Nervosa and Related Disorders
• Emory Family Preventive Medicine

55
National

• National Association of Anorexia Nervosa and
  Associated Disorders (ANAD)
• Academy for Eating Disorders (AED)
• Anorexia Nervosa and Related Eating Disorders,
  Inc. (ANRED)
• National Eating Disorders Organization (NEDO)
• Eating Disorders Awareness Prevention, Inc.
  (EDAP)
• American Anorexia/Bulimia Association, Inc.
  (AABA)
• Overeaters Anonymous (OA)

56
Summary

• Eating Disorders are extremely common.
• Often underdiagnosed.
• They are the prototypical biopsychosocial
  diseases.
• It has little to do with food and a lot to do
  with underlying thoughts and feelings.
• Dieting is THE BIGGEST risk factor.
• Focus on prevention and early intervention.
• Most effective treatment involves a
  multifactorial approach.
• The earlier treatment begins, the better the
  chance of recovery.

57
THANK YOU!
58
References

• Pritts S, Susman J. Diagnosis of Eating Disorders
  in Primary Care. American Family Physician. 2003
  67 297-304.
• Kreipe RE, Birndorf SA. Eating disorders in
  adolescents and young adults. Med Clin North Am
  2000841027-49.
• Becker AE, Grinspoon SK, Klibanski A, Herzog DB.
  Eating disorders. N Engl J Med 19993401092-8.
• Practice guideline for the treatment of patients
  with eating disorders (revision). American
  Psychiatric Association Work Group on Eating
  Disorders. Am J Psychiatry 2000157(suppl
  1)1-39.