1Eating Disorders Teresa Lianne Beck,MD Assistant Professor Family & Preventive MedicineEmory University School of Medicine
2Objectives 2. Understand the epidemiology and populations that 1. Recognize and diagnose eating disorders.2. Understand the epidemiology and populations thatare 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 !
3CASE 118 y.o. female with no significant PMHx, presents with 5 month h/o weight lossJust completed her 1st year of college with a 3.8 GPAShe became a vegetarian after hearing a lecture on cholesterol and heart disease in her biology class, and began reducing the fat in her dietShe is 64 inches tall and has lost 22 pounds to a weight of 95 pounds
4Case 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 dinnerDenies laxative use. BM every 4-5 daysShe runs 4 miles a day, and does 100 sit-up nightlyHer LMP was 6 months agoShe denies ever being sexually active
5Case 1 Constantly feeling cold Dizzy when stands up rapidly Hair is dryFeels bloated after mealsThinks that her thighs and stomach are too big, despite her parents’ protestsDoesn’t believe that she has a problemCase 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
6CASE 2 20 y.o. female presents for evaluation of hematemesis Admits to self-induced vomiting for the past 3 years62 inches tall, 63 kgGorges and vomits 3-5 times per weekUncontrollable eating bingesFeels guiltySmokes 1 pack cigarettes per dayGets drunk weeklyIrregular mensesHas not lost any weight
7Case 337 y.o. AA male who presents to his primary care physician for annual examHis weight is 289 lbs, BMI is 38, his BP is 150/90He does not exerciseHe admits to eating excessive amounts of food and unable to control his binges 4-5 days/weekHe 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.
8Spectrum of disordered eating *An Eating Disorder is about the expression of underlying thoughts and feelings and NOT really about food.Risk factorsBiologicalPsychologicalSocioculturalFamily/interpersonalEating 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 fashionAnorexia Bulimia Binge Eating Eating DisorderNervosa Nervosa Disorder (NOS)Dieting
9EpidemiologyOnset 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, % maleBulimia: 4-20% female, % maleBinge 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.
10Obesity 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.
11Dieting60 % 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.
121999 Youth Risk Behavior Surveillance Survey 7 58 % of students in the United States had exercised to lose weight40 % of students had restricted caloric intake in an attempt to lose weight.
13What’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 thinner40% of them had actually tried to lose weight7% of them scored within the high risk range of an "eating attitude" test that detects or predicts eating disorder behavior.
14Exploring 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 adolescenceSports 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 . (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 .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 . 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  and alcoholism  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 . Adult women with eating disorders appear to have had higher rates of obsessive-compulsive personality traits in childhood . 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 .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
15Recognizing 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)
16Signs/Symptoms of Anorexia Lanugo hairScalp hair lossEarly satietyWeakness, fatigueShort statureOsteopeniaBreast atrophyAtrophic vaginitisPitting edemaCardiac murmursSinus bradyhypothermiaDry skinCold intoleranceBlue hands and feetConstipationBloatingDelayed pubertyPrimary or secondary amenorrheaNerve compressionFaintingOrthostatic hypotensionPatients with eating disorders will come to you for other symptoms and not tell you that they are struggling with an ED.
17Signs/Symptoms of Bulimia Mouth soresPharyngeal traumaDental cariesHeartburn, chest painEsophageal ruptureImpulsivity:StealingAlcohol abuseDrugs/tobaccoMuscle crampsWeaknessBloody diarrheaBleeding or easy bruisingIrregular periodsFaintingSwollen parotid glandsHypotension
18Medical 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.12Major 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.14Personality 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
19Medical Consequences of BED ObesityHTN, CVD, CVAHyperlipidemia, DiabetesRenal, Gallbladder diseaseOsteoarthritisSleep apnea and Respiratory problemsInfertility, complications of pregnancyColon, breast, endometrial, prostate CADepression, suicide, substance abuse
20Evaluation Diagnosis is based on DSM-IV clinical findings Clues in the history and physical examLaboratory studies done to rule out other causes of weight loss and/or complicationsOften is the only way to convince the person he/she needs help
21Anorexia 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 weight3. Body image distortion4. Amenorrhea (3 months)2 sub-types: restricting and purging
22Bulimia 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 gain3. Preoccupation with body weight or shape4. Absence of anorexia nervosa2 sub-types: purging and non-purging
23DSM-IV Research Criteria Binge Eating Disorder1. Recurrent binge eating (at least twice a week for 6 months) *loss of control + *eating very large amounts2. Marked distress with at least three of the following:Eating very rapidlyEating until uncomfortably fullEating when not hungryEating alone due to shame or guiltFeelings of disgust, guilt, depression after overeating3. No recurrent purging, excessive exercise, or fasting4. Absence of anorexia nervosa
24Eating Disorder NOS Other Examples: Those who suffer, but do not meet ALL the diagnostic criteria for another specific eating d/oOther Examples:Chronic dietingGrazingAn individual who repeatedly chews and spits out large amounts of foodLate night eating
25SCOFF 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
26Suggested 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:
27History Requires a high index of suspicion Explore attitudes about weight loss, desired weight, and eating habits24 hour dietary recallDetailed weight and menstrual historyBe direct and ask about dieting, diet pills, bingeing, vomiting, exercise, diuretic, laxative abuseScreen for depression, anxiety, substance abuse, personality disorders, sexual/physical abuse, and suicidalityComplete ROS for medical complications
28Physical Exam - Anorexia Specifically note state of nutrition and hydration, height, weight (w/o clothing) used to calculate BMI, BP and Pulse with orthostatics, hypothermiaSkin (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)
29Bulimia Postural signs (volume depletion) Parotid gland enlargement (chip-munk cheeks), teeth (discoloration, erosion), scars on dorsum of handAbdominal and rectal (bowel sounds, epigastric pain, heme positive stool)Neurologic exam for focal abnormalities suggestive of CNS tumor or seizure disorder (rare)Russell sign
30Binge Eating Disorder PE findings usually are normal Complete head to toe looking for signs commonly associated with complications of obesity (HTN, CVD, DM, DJD)
31Differential Diagnosis of Anorexia Affective disorder- unipolar, bipolarPersonality disorderSchizophreniaAnxiety disorders, including OCDSubstance AbuseOrganic diseaseInfection, including AIDSThyroid diseaseDiabetesCancerMalabsorption
32Differential Diagnosis of Bulimia Organic diseaseInfectionThyroid diseaseDiabetesCancer chemotherapyMalabsorption syndromesGI problems-GERD, IBD, gastroparesis, mass lesionsBrain tumorMigraineEpilepsyAffective disorders- unipolar, bipolarPersonality disordersSchizophreniaAnxiety disorders, including OCDCommon obesity- “compulsive eating”Instrumental vomiting
33Differential Diagnosis of Obesity HypothyroidismHypercortisolismDeficiencies of growth hormone or gonadal steroidsMedicationsLong-term glucocorticoid treatmentImmunosuppression after transplantationCancer chemotherapyIntensive glycemic control with insulin, a sulfonylurea, or a thiazolidinedioneNeuropsychotropic drugs, particularly newer antipsychotic and antiseizure medications
34Laboratory Evaluation Complete Metabolic PanelCBCALKP, LFT’s, amylaseLipidsEKGTFT’sLH, FSH, Prolactin, EstrogenBone Mineral DensityHypoglycemia, 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
35Treatment Options for AN/BN Inpatient hospitalizationOutpatient psychotherapy (CBT)Medication (SSRI’s)Self-help/Support Groups (A/B, OA)Family therapyBibliotherapyNutritional educationStress managementHypnotherapy, guided imagery, reality imaging
36Costs 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
37Costs to SocietyThe 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.
38Costs to the Individual Lost relationshipsWasted talentsSuffering familiesMultiple office visits for medical complaints related to physical and psychological consequences of disordered eating behavior.
39Role of Primary Care Provider Team coordinatorRule out other causes of weight loss and/or complicationsObtain early psychiatric and nutritional consultations and coordinate a multidisciplinary team approach to managementEducate the patient about the medical complications of the illness
40ANOREXIA 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 themLimited efficacyInterdisciplinary care teamMedical providerDietician with experience in EDMental health professional
41MEDICATIONS Overall, disappointing results Effective only for treating comorbid conditions of depression and OCDAnxiolytics may be helpful before meals to suppress the anxiety associated with eatingCase reports in the literature supporting the use of olanzapine
42ANOREXIA Set medical guidelines for outpatient management: weight goal minimum acceptable weightweight goalweight gain of 1-2 lbs. a week for underweight patientsmaintenance of normal electrolytes
43BULIMIA Cognitive behavioral therapy is effective Pharmacotherapy—high success rateFluoxetine—studies reveal up to a 67% reduction in binge eating and a 56% reduction in vomitingTCAsTopiramate—reduced binge eating by 94% and average wt. loss of 6.2 kgOndansetron, 24 mg/day
44Anorexia/BulimiaMonitor weight, postural signs, cardiac rhythm, and electrolytesAddress any metabolic or endocrinologic complications.
45Hospitalization Criteria Loss of more than 40% of ideal weight (or 30% if in 3 months)Rapid progression of weight lossCardiac arrhythmiaPersistent hypokalemia unresponsive to outpatient treatmentSymptoms of poor cerebral perfusion or mentation (syncope, severe dizziness, or listlessness)Psychiatric disturbances beyond patient’s control, severe depressionSuicidal ideation
46Binge 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
47Prognosis 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.
4850% achieve full recovery. 30% experience partial recovery. BulimiaWith treatment50% achieve full recovery.30% experience partial recovery.20% show no improvement.
49Binge Eating DisorderTends 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.
50Taking 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
53How to help yourselfADMIT to yourself that you may have an eating problem or disorder and be in need of helpTELL someone—a friend, family member, family physician, or counselor—about your concernsLEARN 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.
54Helpful Resources Campus Community Emory U. Counseling Center Emory U. Student Health ServicesEmory U. Hospital PsychiatryEmory Women’s CenterStudent Educators on Eating Disorders (SEED)CommunityAtlanta Center for Eating DisordersEating Disorders Information NetworkRidgeview InstituteAnorexia Nervosa and Related DisordersEmory Family & Preventive Medicine
55NationalNational 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)
56Summary 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.
58ReferencesPritts 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.