1. ELFT Training Packages for Primary Care ‘Eating Disorders’ Responsible Clinician for contact: Frank Röhricht Associate Medical Director

2. Learning 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 diagnostic 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 1 st 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

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

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. (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 High percentage of population is on a “diet” at any one time. 95 % of those who lose weight will regain within 5 years. billion pound industry. Dieting has become a “normal” way of eating. 35% of “normal dieters” will develop some form of an eating disorder.

12. 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.

13. 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)

14. HISTORY Diet restriction – number of calories Purging behaviours – vomiting, laxatives, diuretics Excessive exercise Menstruation ‘fear of fatness’ (‘do you worry excessively about your weight?’) Any previous treatment Co morbidity, risks of DSH, pregnancy

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. Physical Symptoms of Anorexia Dry skin Cold intolerance Blue hands and feet Constipation Bloating Delayed puberty Primary or secondary amenorrhea Nerve compression Fainting Orthostatic hypotension Lanugo hair Scalp hair loss Early satiety Weakness, fatigue Osteopenia Breast atrophy Atrophic vaginitis Pitting edema Cardiac murmurs Sinus brady hypothermia

17. Physical Symptoms of Bulimia Mouth sores Pharyngeal trauma Dental caries Heartburn, chest pain Oesophageal rupture Impulsivity: –Alcohol abuse –Drugs/tobacco Muscle cramps Weakness Bloody diarrhea Bleeding or easy bruising Irregular periods Fainting Swollen parotid glands Hypotension

18. PHYSICAL FINDINGS BMI is w/h2 – height in metres and weight in kilos Pulse and BP (lying and standing) and temperature Muscle strength (stand up from squat without using arms) Blood tests (esp U&E, Mg+, phosphate, FBC,LFT)

19. Potential Medical Consequences AN/BN Cardiac (arrhythmia, cardiomyopathy, HF, hypotension,) Metabolic (hypokalemia, hyper/hyponatremia, metabolic acidosis/alkalosis, hyperlipidemia) Endocrine (sick euthyroid, amenorrhea, osteoporosis, fractures, growth retardation, hypercortisolism, delayed puberty) Hematological (anemia, neutropenia, impaired 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)

20. Potential Medical Consequences of BED Obesity –Cardiovascular disease –Hyperlipidemia, Diabetes –Renal, Gallbladder disease –Osteoarthritis –Sleep apnea and Respiratory problems –Infertility, complications of pregnancy –Colon, breast, endometrial, prostate CA –Depression, suicide, substance abuse

21. Evaluation Diagnosis is based on ICD/DSM 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

22. DSM-IV Criteria Anorexia Nervosa 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

23. 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

24. 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

25. 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

26. 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.

27. 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 2000;26:338-42. Anstine D, Grinenko D. Rapid screening for disordered eating in college- aged females in the primary care setting. J Adolesc Health 2000;26:338-42.

28. 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

29. 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)

30. 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)

31. Binge Eating Disorder PE findings usually are normal Complete head to toe looking for signs commonly associated with complications of obesity

32. 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

33. Differential Diagnosis of Bulimia Affective disorders- unipolar, bipolar Personality disorders Schizophrenia Anxiety disorders, including OCD Common obesity- “compulsive eating” Instrumental vomiting Organic disease –Infection –Thyroid disease –Diabetes –Cancer chemotherapy –Malabsorption syndromes –GI problems, IBS, gastroparesis, mass lesions –Brain tumor –Migraine, Epilepsy

34. 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

35. Laboratory Evaluation Glucose LFT’s, amylase Lipids EKG TFT’s LH, FSH, Prolactin, Estrogen (?) Bone Mineral Density

36. Treatment Options for AN/BN Inpatient hospitalization Outpatient psychotherapy (CBT and other) Medication (SSRI’s) Self-help/Support Groups (A/B, OA) Family therapy Bibliotherapy Nutritional education Stress management Hypnotherapy, guided imagery, reality imaging

37. REFERRALS PATHWAY – Immediate ED or A&E BMI under 12 and weight loss > 1 kg per week BP < 80/60, postural drop, pulse <40 (ECG shows prolonged QT interval) Unable to get up from squat without using arms T < 34.5 C Severely abnormal U&E – eg K+ <3

38. Urgent Referral necessary if: BMI below 14 Weight loss 7kg in 4 weeks BP < 90/70 Unable to get up from chair without arms T<35C Oedema Abnormal U&E, Mg+, FBC (lowered), LFTs (raised), albumin

39. Costs To Treat Eating Disorders Treatment often requires extensive medical monitoring and therapy can extend over two or more years. Outpatient therapy can be prolonged and expensive many patients require repeat hospitalizations

40. 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.

41. 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

42. 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

43. Psychological Therapies Guided self-help CBT CAT No longer couple therapy Psychodynamic therapy Family therapy Group psychotherapy

44. 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 antipsychotics (e.g. Olanzapine)

45. Notes on NICE for A.N. Psychological therapies incl CAT, CBT, IPT and family interventions – with the aim of encouraging wt gain and healthy eating Most people with A.N. should be treated as out pt Family members should be considered in all cases because of the effects of AN on the family Medication is not the primary tx of AN

46. A.N. Caution should be used when treating comorbid mental health problems – depression may resolve with wt gain alone – QT prolongation In most pts with AN an average weekly wt gain of 0.5 – 1kg in in pts, and 0.5 kg in out pt settings should be the aim Feeding against pt will is tx of last resort under MHA

47. Notes on NICE on B.N. Pts should be advised to reduce laxative use and informed that laxatives do not signif reduce calorie intake Pts who vomit need regular dental reviews, avoid brushing after vomiting, rinse with non- acidic mouthwash, limit acidic foods Self-help programme, CBT-BN or IPT (which needs 8-12 mths) SSRIs (esp fluoxetene) reduce binging and purging – work rapidly There is a limited role for in pt tx

48. BINGE EATING DISORDER Self help programme, CBT-BED, or IPT, or modified DBT All psychological interventions have a limited effect on body wt Trial of SSRI

49. 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

50. 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

51. Anorexia/Bulimia Monitor weight, postural signs, cardiac rhythm, and electrolytes Address any metabolic or endocrinologic complications.

52. Criteria for Hospitalization 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

53. 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)

54. 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.

55. Bulimia With treatment – 50% achieve full recovery. – 30% experience partial recovery. – 20% show no improvement.

56. 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.

57. Taking ACTION! How can family and friends help? How can you help yourself? What other resources are available?

58. “10 Commandments” 1.It’s not a diet problem. 2.No one is to blame for the problem. It’s no one’s fault. 3.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. 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.

59. “10 Commandments” 6.Do not share your opinions or judgments on his/her size or weight, even if teasing. 7.Do not encourage any type of diet. 8.Share freely and directly with him/her concerns or other feelings you have which regard him/her. 9.Understand that he/she is also working on communicating more directly. 10.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.

60. 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.

61. Summary, Take home messages: 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.