1. Eating Disorders Teresa Lianne Beck,MD Assistant Professor
Family & Preventive Medicine
Emory University School of Medicine

2. Objectives 2. Understand the epidemiology and populations that
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
Doesn’t believe that she has a problem
Case illustrates many classic features—weight loss can often be attributed to a specific event such as an illness or a comment by family or teacher

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
Sociocultural
Family/interpersonal
Eating disorders are among the most common psychiatric problems that affect young women,1 and these conditions impose a high burden of morbidity and mortality. Unfortunately, the diagnosis of eating disorders can be elusive, and more than one half of all cases go undetected.2 The family physician's office is an ideal setting to identify eating disorders and initiate treatment in a timely fashion
Anorexia Bulimia Binge Eating Eating Disorder
Nervosa Nervosa Disorder (NOS)
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, % male
Bulimia: 4-20% female, % 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. (BMI>25)
30% Adults are clinically obese (BMI>30)
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. What’s 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)
-- a history of dieting was the most important predictor of a new eating disorder in adolescent children
--Childhood preoccupation with a thin body and social pressure about weight are associated with the development of binge eating disorders in adolescence
Sports and artistic endeavors in which leanness is emphasized (eg, ballet, running, or wrestling) and sports in which scoring is partly subjective (eg, skating or gymnastics) are associated with a higher incidence of eating disorders. Young women with restrictive eating disorders and amenorrhea have been referred to as having the "female athlete triad," which consists of an eating disorder, amenorrhea, and osteoporosis [17]. (See "Amenorrhea and infertility associated with exercise").
Studies that have examined the possible association of eating disorders and sexual abuse have been conflicting. One report found no specific relationship between sexual abuse and the development of an eating disorder; rates of sexual abuse among bulimic patients were higher than among healthy controls, but were not significantly different from rates of abuse among other psychiatric patients [18].
A role for genetics in the pathogenesis of eating disorders is supported by studies that found that young women whose first degree relatives have eating disorders were at a six- to ten-fold increased risk for developing an eating disorder [19]. In addition, monozygotic twins have a higher rate of concordance for eating disorders compared with dizygotic twins [18,20]. There is also a higher prevalence of affective disorders [21] and alcoholism [22] in first-degree relatives of patients with eating disorders.
Psychiatric problems are common in patients with eating disorders. They have a high rate of affective disorders, anxiety disorders, obsessive-compulsive disorder, and personality disorders [21]. Adult women with eating disorders appear to have had higher rates of obsessive-compulsive personality traits in childhood [23]. Patients with eating disorders also have a higher reported rate of substance abuse. Alcohol problems are more prevalent among those with bulimia nervosa than among patients with restrictive anorexia nervosa [22].
There is no strong empirical data to support one particular family prototype that enhances the development of eating disorders. However, family characteristics associated with the development of eating disorders may include high parental expectations regarding achievement and appearance (as perceived by the teen), families who have difficulties managing conflict, poor communication style (particularly related to feelings), enmeshment and, less frequently, estrangement between family members, devaluation of the mother or the maternal role, and marital tension. Families struggling with an eating disorder often have difficulties responding positively to the changing physical and emotional needs of their adolescent. Family stress of any kind can be a significant factor in the development of an eating disorder.
Eating disorders are particularly common in young women with type 1 diabetes mellitus. Up to one third of women with type 1 diabetes may have eating disorders

15. Recognizing the signs and symptoms
General (skips meals, preoccupation w/food, unable to express feelings, worries about other’s 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
Patients with eating disorders will come to you for other symptoms and not tell you that they are struggling with an ED.

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)
Psychiatric comorbidity is extremely common; illnesses such as affective disorders, obsessive-compulsive disorder, somatization disorder, and substance abuse must be considered when patients present with such symptoms.12
Major depression is the most common comorbid condition among patients with anorexia, with a lifetime risk as high as 80 percent.5 Anxiety disorders, especially social phobia, also are common.5 Obsessive-compulsive disorder has a prevalence of 30 percent among patients with eating disorders.13 Substance abuse prevalence is estimated at 12 to 18 percent in patients with anorexia and 30 to 70 percent in patients with bulimia.14
Personality disorders (Axis II diagnoses) also are common, with comorbidity rates reported at 21 to 97 percent.15 The wide range is related to the complexity of evaluating these diagnoses. Patients with bulimia are more likely to have a cluster B diagnosis (dramatic/ erratic), whereas patients with anorexia are more likely to have a cluster C diagnosis (avoidant/anxious).15

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. Anorexia Nervosa DSM-IV Criteria 2 sub-types: restricting and purging
1. Refusal to maintain adequate weight: (less than 85% of IBW or BMI<17.5)
2. Intense fear of gaining weight
3. Body image distortion
4. Amenorrhea (3 months)
2 sub-types: restricting and purging

22. Bulimia Nervosa DSM-IV Criteria
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 Other Examples:
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; 319:1467.
Yes answer to 2 or more questions was associated with a sensitivity of 100% and a specificity of 87.5% for an eating disorder

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?
Positive response to any of these questions warrants further evaluation.
Anstine D, Grinenko D. Rapid screening for disordered eating in college- aged females in the primary care setting. J Adolesc Health 2000;26:

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), DTR’s (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)
Russell sign

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, LFT’s, amylase
Lipids
EKG
TFT’s
LH, FSH, Prolactin, Estrogen
Bone Mineral Density
Hypoglycemia, leukopenia, elevated liver enzymes, euthyroid sick syndrome (low TSH level, normal T3, T4 levels) Hypochloremic, hypokalemic, or metabolic alkalosis (from vomiting), hypokalemia (from laxatives or diuretics), elevated salivary amylase (might also be present in binging/purging subtype of anorexia)
Low voltage; prolonged QT interval, bradycardia

35. Treatment Options for AN/BN
Inpatient hospitalization
Outpatient psychotherapy (CBT)
Medication (SSRI’s)
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 Interdisciplinary care team
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: weight goal
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
Pharmacotherapy—high success rate
Fluoxetine—studies reveal up to a 67% reduction in binge eating and a 56% reduction in vomiting
TCAs
Topiramate—reduced 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 patient’s 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 (SSRI’s: Prozac, Zoloft)
Support Groups (Overeaters Anonymous)
Monitor and treat medical complications (HTN, DM, Hyperlipidemia)
The relative benefits of medications and cognitive-behavioral therapy have been assessed and compared. Study results indicate that cognitive-behavioral therapy is superior to medication alone and that the combination of cognitive-behavioral therapy and medication is more effective than the use of medication alone.37

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. 50% achieve full recovery. 30% experience partial recovery.
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” It’s not a diet problem.
No one is to blame for the problem. It’s no one’s fault.
Understand that he/she needs to eat three meals a day, but do not take responsibility for her eating. Don’t hide food from him/her or push food on her. When offering food to others, don’t exclude him/her.
Let him/her know you are willing to provide support if she needs it.
If you have questions about the ED, ask him/her directly. He/She can determine what he/she is comfortable sharing.
It is complicated and has to do with a person’s ability to identify and communicate feelings, her fear of conflict and sense of self-worth.

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

53. How to help yourself
ADMIT to yourself that you may have an eating problem or disorder and be in need of help
TELL someone—a friend, family member, family physician, or counselor—about 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 Community Emory U. Counseling Center
Emory U. Student Health Services
Emory U. Hospital Psychiatry
Emory Women’s 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.
Must be considered in the DDx of all patient’s complaints, especially young women who present with the multitude of physical and psychological consequences, signs and symptoms of eating disorders.

57. THANK YOU!

58. References
Pritts S, Susman J. Diagnosis of Eating Disorders in Primary Care. American Family Physician. 2003; 67:
Kreipe RE, Birndorf SA. Eating disorders in adolescents and young adults. Med Clin North Am 2000;84:
Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Engl J Med 1999;340:
Practice guideline for the treatment of patients with eating disorders (revision). American Psychiatric Association Work Group on Eating Disorders. Am J Psychiatry 2000;157(suppl 1):1-39.