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Eating Disorders

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Title: 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.

8
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

17
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

18
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)

19
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.

26
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.

27
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.
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