Eating Disorders

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

2. Objectives 1. Recognize and diagnose eating disorders. 2. Understand the epidemiology and populations that are at special risk. 3. Understand the underlying causes. 4. Become familiar with the DSM-IV Criteria. 5. Know the psychological and physical consequences. 6. Be able to treat eating disorders using a multimodal approach. 7. Take Action !

3. CASE 1 • 18 y.o. female with no significant PMHx, presents with 5 month h/o weight loss • Just completed her 1st year of college with a 3.8 GPA • She became a vegetarian after hearing a lecture on cholesterol and heart disease in her biology class, and began reducing the fat in her diet • She is 64 inches tall and has lost 22 pounds to a weight of 95 pounds

4. Case 1 • She drinks 2 cups of coffee and 3 cans of diet cola per day • She eats ½ bagel for breakfast, an apple for lunch, and a salad with kidney beans and fruit for dinner • Denies laxative use. BM every 4-5 days • She runs 4 miles a day, and does 100 sit-up nightly • Her LMP was 6 months ago • She denies ever being sexually active

5. Case 1 • Constantly feeling cold • Dizzy when stands up rapidly • Hair is dry • Feels bloated after meals • Thinks that her thighs and stomach are too big, despite her parents’ protests • 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. 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 Anorexia Bulimia Binge Eating Eating Disorder Nervosa Nervosa Disorder (NOS) 307.1 307.51 307.50 307.50 Dieting

9. Epidemiology • Onset of Anorexia is bimodal, puberty (12-15y) and late teens to early 20s. • Bulimia appears during late teens to mid-20s. • Anorexia: 1-2% female, 0.1-0.2% male • Bulimia: 4-20% female, 0.1-0.2% male • Binge Eating Disorder: 3-30% adults (40% male) • 10 million females and 1 million males are affected by eating disorders. • Most researchers agree these numbers are grossly underestimated.

10. Obesity • 60% Adults in the U.S. are overweight. (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)

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. 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 Short stature Osteopenia Breast atrophy Atrophic vaginitis Pitting edema Cardiac murmurs Sinus brady hypothermia Signs/Symptoms of Anorexia

17. 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 Signs/Symptoms of Bulimia

18. Medical Consequences of AN/BN • Cardiac(arrhythmia, cardiomyopathy, HF, hypotension, DEATH) • Metabolic(hypokalemia, hyper/hyponatremia, metabolic acidosis/alkalosis, hyperlipidemia) • Endocrine (sick euthyroid, amenorrhea, osteoporosis, fractures, growth retardation, hypercortisolism, delayed puberty) • Hematological(anemia, neutropenia, impaired cell mediated immunity) • GI(constipation, dental erosion, esophagitis, gastric/esophageal rupture, colonic irritation, fatty liver, intestinal atony, gallstones, acute pancreatitis) • Neuro/Psychiatric(depression, anxiety, substance abuse, suicide, seizures, myopathy, cortical atrophy, peripheral neuropathy) • Skin(pallor, hypercarotenemia, hair loss, lanugo, brittle nails, edema)

19. Medical Consequences of BED • Obesity • HTN, CVD, CVA • Hyperlipidemia, Diabetes • Renal, Gallbladder disease • Osteoarthritis • Sleep apnea and Respiratory problems • Infertility, complications of pregnancy • Colon, breast, endometrial, prostate CA • Depression, suicide, substance abuse

20. Evaluation • Diagnosis is based on DSM-IV clinical findings • Clues in the history and physical exam • Laboratory studies done to rule out other causes of weight loss and/or complications • Often is the only way to convince the person he/she needs help

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

22. DSM-IV Criteria Bulimia Nervosa • 1. Binge eating (twice a week for 3 months) • 2. Purging (vomiting, laxative, diuretics) and/or excessive exercise, or fasting to prevent weight gain • 3. Preoccupation with body weight or shape • 4. Absence of anorexia nervosa • 2 sub-types: purging and non-purging

23. DSM-IV Research Criteria Binge Eating Disorder • 1. Recurrent binge eating (at least twice a week for 6 months) *loss of control + *eating very large amounts • 2. Marked distress with at least three of the following: • Eating very rapidly • Eating until uncomfortably full • Eating when not hungry • Eating alone due to shame or guilt • Feelings of disgust, guilt, depression after overeating • 3. No recurrent purging, excessive exercise, or fasting • 4. Absence of anorexia nervosa

24. Eating Disorder NOS • Those who suffer, but do not meetALLthe 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 FOODdominate 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.

26. Suggested Screening Questions for AN/BN • How many diets have you been on in the past year? • Do you think you should be dieting? • Are you dissatisfied with your body size? • Does your weight affect the way you think about yourself? • Anstine D, Grinenko D. Rapid screening for disordered eating in college- aged females in the primary care setting. J Adolesc Health 2000;26:338-42.

27. History • Requires a high index of suspicion • Explore attitudes about weight loss, desired weight, and eating habits • 24 hour dietary recall • Detailed weight and menstrual history • Be direct and ask about dieting, diet pills, bingeing, vomiting, exercise, diuretic, laxative abuse • Screen for depression, anxiety, substance abuse, personality disorders, sexual/physical abuse, and suicidality • Complete ROS for medical complications

28. Physical Exam - Anorexia • Specifically note state of nutrition and hydration, height, weight (w/o clothing) used to calculate BMI, BP and Pulse with orthostatics, hypothermia • Skin (pallor), nails (brittle) and hair (lanugo) • Chest (rhales), CV (arrhythmia), extremities (edema, cyanosis), 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)

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 • 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-GERD, IBD, gastroparesis, mass lesions • Brain tumor • Migraine • Epilepsy

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

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 • Emphasizes the relationship of thoughts and feelings to behavior, learn to recognize and change pattern of false beliefs and reactions to them • Limited efficacy • Interdisciplinary care team • Medical provider • Dietician with experience in ED • Mental health professional

41. MEDICATIONS • Overall, disappointing results • Effective only for treating comorbid conditions of depression and OCD • Anxiolytics may be helpful before meals to suppress the anxiety associated with eating • Case reports in the literature supporting the use of olanzapine

42. ANOREXIA • Set medical guidelines for outpatient management: • minimum acceptable weight • weight goal • weight gain of 1-2 lbs. a week for underweight patients • maintenance of normal electrolytes

43. BULIMIA • Cognitive behavioral therapy is effective • 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)

47. Prognosis • Anorexia • 5-20% mortality (cardiac arrhythmia's) • More than 75% will regain weight to near-normal levels, with return of menses, but abnormal eating habits and psychosocial problems often persist. • 50% become bulimic.

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

49. Binge Eating Disorder • Tends to be a chronic condition for those not in therapy or support group. • 50% remission for those treated with CBT. • Morbidity and mortality are directly related to the many diseases associated with obesity.

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