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

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 !

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

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

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

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

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.

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) 307.1 307.51 307.50 307.50 Dieting

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.

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.

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.

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.

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.

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

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)

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.

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

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

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

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

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

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

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

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

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

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;26:338-42.

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

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)

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

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)

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

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

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

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

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

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

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.

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.

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

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

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

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

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

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

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

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

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.

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

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.

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

“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.

“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.

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.

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

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)

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.

THANK YOU!

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 2000;84:1027-49. Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Engl J Med 1999;340:1092-8. 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.