Eating Disorders Mini-Med School Samra Blanchard, MD Division Chair, Pediatric Gastroenterology Associate Professor of Pediatrics

Facts from eating disorders foundation 80% of women who answered a People magazine survey responded that images of women on television and in the movies make them feel insecure. Two out of five women and one out five men would trade three to five years of their life to achieve their weight goals. In 1970, the average age a girl started dieting was 14; by 1990 the average had dropped to 8. One out of three women and one out of four men are on a diet at any given time. Four out of five US women are dissatisfied with their appearance. A study found that adolescent girls were more fearful of gaining weight than getting cancer, nuclear war or losing their parents

What is an eating disorder? Eating disorders are syndromes resulting from extreme emotions, attitudes, and behaviors surrounding weight and food issues. They involve serious and complex emotional and physical addictions and distress or excessive concern about body shape or weight. Eating disorders include a range of behaviors like obsession with food, weight and appearance, to the degree that a person's health, relationships and daily activities are adversely affected. Presentation varies, but eating disorders often occur with severe medical or psychiatric co-morbidity.

Prevalance of Eating Disorders It is estimated that eight million Americans have an eating disorder – seven million women and one million men One in 200 American women suffers from anorexia Two to three in 100 American women suffers from bulimia Estimates of female-to-male ratio range from 6 : 1 to 10 : 1. The most common age at onset for anorexia nervosa is the mid-teens The onset of bulimia nervosa is usually in adolescence but may be as late as early adulthood

Eating Disorders Etiology- Multifactorial

Psychological Factors that can contribute to Eating Disorders: Low self-esteem Feelings of inadequacy or lack of control in life Depression, anxiety, anger, or loneliness Interpersonal Factors that Can Contribute to Eating Disorders: Troubled family and personal relationships Difficulty expressing emotions and feelings History of being teased or ridiculed based on size or weight History of physical or sexual abuse

Social Factors that can contribute to Eating Disorders: Societal pressures to be slender Movies, magazines, and other media show excessively slim starlets and models creating an unhealthy image of what young women should look like, which adds to the internal pressure for perfectionism.

Genetic Factors First-degree female relatives and monozygotic twin offspring of patients with anorexia nervosa have higher rates of anorexia nervosa and bulimia nervosa. Families of patients with bulimia nervosa have higher rates of substance abuse, particularly alcoholism, affective disorders, and obesity. Traits such as impulsivity, negative affect, perfectionism, and low self-esteem are risk factors that may largely be genetically determined. Research ongoing on role of endorphins in anorexia and bulimia.

Classification Diagnostic and Statistical Manual of Mental Disorders, 4 th ed, text revision (DSM IV-TR ) Anorexia nervosa Bulimia Eating disorder not otherwise specified (ED- NOS) – Binge-eating disorder – Night-eating syndrome – Purging disorder

Anorexia Nervosa: DSM IV-TR Criteria Refusal to maintain body weight at or above a minimally normal weight for age and height. Intense fear of gaining weight or becoming fat, even though underweight. Disturbance in the way one's body weight or shape are experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight. Amenorrhea (at least three consecutive cycles) in postmenarchal girls and women.

Anorexia Nervosa- Types Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (self- induced vomiting or misuse of laxatives, diuretics, or enemas). Binge-eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Anorexia in Greek: an (provation, lack of) orexis (appetite) Not necessarily only lack of appetite Obsession/dreaming of food Not a new illness - first described in 1686 Relentless pursuit of thinness “Being thin means being in control”

Anorexia Weight: significantly underweight Eating habits: takes in few calories, may have odd food rituals Body image: obsessed with weight and appearance and believes she/he is fat when really underweight Physical symptoms: low blood pressure, low heart rate, hair loss, weakness, fatigue, nutritional deficiencies, cessation of menstruation Emotional symptoms: depression, anxiety, obsessive- compulsive behaviors, denial of problem, fear of gaining weight Relationships: can be withdrawn, may refuse to eat in front of others

Bulimia Nervosa- DSM IV-TR criteria Recurrent episodes of binge eating characterized by both: – Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances – A sense of lack of control over eating during the episode, defined by a feeling that one cannot stop eating or control what or how much one is eating Recurrent inappropriate compensatory behavior to prevent weight gain – Self-induced vomiting – Misuse of laxatives, diuretics, enemas, or other medications – Fasting – Excessive exercise

Bulimia Nervosa- DSM IV-TR criteria The binge eating and inappropriate compensatory behavior both occur, on average, at least twice a week for 3 months. Self evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Bulimia Nervosa- Types Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Non-purging type: During the current episode of bulimia nervosa, the person has used inappropriate compensatory behavior but has not regularly engaged in self-induced vomiting or misuse of laxatives, diuretics, or enemas.

Bulimia is derived from Latin: “hunger of an ox” First described in Romans Medically described in 1903 Frequency and intensity of binging separates bulimics from anorexics Purging or other compensatory behaviors often serve to ease the guilt and anxiety over eating Compared to anorexics, bulimics are not easily identified

Bulimia Weight: varies, usually normal weight or overweight Eating habits: binges by eating large amounts of food in a short period of time, then purges by vomiting and/or abusing laxatives Body image: obsessed with appearance Physical symptoms: changes in weight, sores in the mouth, dental problems, weakness, fatigue, sore throat Emotional symptoms: anxiety, depression, self- destructive behavior, feelings of guilt Relationships: may be withdrawn but able to develop relationships with others

Binge-Eating Disorders Weight: usually overweight Eating habits: binges by eating large amounts of food in a short period of time; may restrict food in between binges Body image: Focused on weight and appearance Physical symptoms: excessive weight gain, high BP, joint pain, fatigue Emotional symptoms: Depression, feeling of guilt or self-hatred Relationships: may be withdrawn or overly sensitive

Screening Tools- SCOFF questionnaire Do you make yourself Sick because you fell uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (14 lbs or 6.35kg) in a three-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life?

Screening Tools- Eating disorder screen for primary care (ESP) Are you satisfied with your eating patterns? Do you ever eat in secret? Does your weight affect the way you feel about yourself? Have any members of your family suffered with an eating disorder? Do you currently suffer with or have you ever suffered in the past with an eating disorder?

Treatment of Eating Disorders Prevention – Media literacy – Education Medically unstable – Hospitalization for nutritional rehabilitation and correction of electrolyte abnormalities – Treat co-morbid psychiatric disorders Medically stable – Outpatient treatment

Outpatient treatment Psychodynamic Cognitive behavioral Disease addiction Nutritional education Medication

Access to treatment Only 1 in 10 people with eating disorders receive treatment About 80% of the girls/women who have accessed care for their eating disorders do not get the intensity of treatment they need to stay in recovery – they are often sent home weeks earlier than the recommended stay Treatment of an eating disorder in the US ranges from $500 per day to $2,000 per day. The average cost for a month of inpatient treatment is $30,000. It is estimated that individuals with eating disorders need anywhere from 3 – 6 months of inpatient care. Health insurance companies for several reasons do not typically cover the cost of treating eating disorders.