Eating Disorders & Weight

Related Disorders
videos

 Documentary thin:
http://www.youtube.com/watch?v=W7fLaOF
EmL4
 http://www.youtube.com/watch?v=-
pEkCbqN4uo
Exams

 Grades are posted on blackboard

 Next exam: 7/24

 Introduction
 Physical attractiveness is
important in most cultures
 Desired features can vary across
cultures
 In U.S., waist-to-hip-ratio (WHR) of
0.7 is associated with good health
 However, 80% of 18+ women have
WHR >= 0.9
 This is a 40 percent increase since
2002, and it keeps increasing
The biggest loser…
 Cultural Pressure: Thin Is In…
 Considerable social pressure to maintain
slim appearance
 45% of women and 25% of men are on diets to
control their weight.
 Americans spend over $30 billion per year to
lose or control weight.
 Over 70% of American girls have dieted by age
10.
 About 1/3 of high school girls and 16% of boys
show some signs of an eating disorder.
Eating disorders in South Korea
 Like other countries in Asia, increases in rates of
eating disorders (ED) have been observed in South
Korea: 8.5 % of those surveyed evidenced abnormal
eating pathology

 Overall, reports of EDs from Korea are very similar

in presentation to cases observed in the West

 Body dissatisfaction and internalization of the thin

ideal may, in fact, be more widespread in Korea
than in the West
The rise of eating disorders in Asia: a review (Pike & Dunne, 2015)
Increased emphasis over time on thin = beauty
 …but Americans are moving further into obesity

 ~65% of adults in the U.S.

are either overweight or
obese.
 Up to 1 in 3 children under
age 18 are overweight or
obese.

LINK
Eating Disorders

 Main diagnostic categories & symptoms

 Anorexia, Bulimia, NOS, BED

 Review of the main theories of development

& treatment options
Anorexia Nervosa: DSM criteria
A. Restriction of energy intake relative to
requirements, leading to significantly low body
weight

B. Intense fear of gaining weight /becoming fat

even though underweight

C. Distorted body image

Anorexia: Subtypes
Types:
 Restricting type: Dieting, fasting, or
excessive exercise to maintain low weight.
No binging or purging.
 Binge eating/purging type:
 Binge:
▪ Eat more than most would in a discrete time period
 Purge:
▪ use vomiting, laxatives, diuretics, enemas to
minimize caloric impact
Anorexia Nervosa
 Other symptoms
 Electrolyte imbalances
▪ Causes heart problems: irregular, low beats, failure
▪ Hypotension (low blood pressure)
 Gastrointestinal problems
▪ Stomach expansion
▪ Kidney failure
 Immune system problems
Anorexia Nervosa
 Other symptoms (cont.)
 Loss of bone mass/strength
 Dermatologic problems
▪ Dry skin, brittle nails, hair loss
▪ Lanugo – fine, soft body hair
 Neurological problems—decreased electrolytes
affect nervous system. Potassium and sodium
electrolytes essential for neural transmission
 Structural brain changes—enlarged ventricles
Anorexia: Course

 Usually begins in adolescence (ages 15-19)

 Mean age of onset: 17 yrs
 Onset often associated w/ stressful life
event (such as leaving home for college)
AN: Prevalence & Demographics
 Prevalence: 1% in the U.S.
 Rates are rising around the world
 95% are female
 Rates for men are increasing
 Most prevalent in industrialized societies but changing
 Typically in high SES but may also be changing
 Increased risk among 1st-degree relatives
 5-8% Death Rate (not including suicide).
 If add suicide death rate is over 10%, making it the most lethal
psychiatric diagnosis
Anorexia: Comorbidity
 60% have major depressive disorder (Agras,
2001)

 Lifetime prevalence of 20%-65% w/ anxiety

disorder (Kaye et al., 2004)

 50% may have personality disorder, usually

OCPD or Borderline PD (BPD)
 Documentary THIN http://www.youtube.com/watch?
v=W7fLaOFEmL4
 Bulimia Nervosa

A. Recurrent Binges:
 Eating more than most would in a discrete time period
▪ binge—eating a day or 2 worth of food in a ~2 hour period
 Sense of lack of control over eating

B. Compensatory behaviors to prevent weight gain

 Purging (vomiting), excessive exercise, laxatives, diuretics

C. Binges & compensatory behaviors minimum 1x/week for 3 mos.

D. Self-esteem tied to weight/shape
E. Symptoms do not occur exclusively during episodes of anorexia.
 Binge
 Usually high fat, high calorie foods, but may also
be large amounts of healthy foods

 Average objective binge: 1900 calories (8 cups)

 Often restrict between binges and binge on

foods trying to restrict
Purges

 Moderately severe:
few times/week

 Most severe: several times/day

or after any food is eaten

 e.g., vomit, laxative, diuretic,

exercise, fasting
Triggers for binges/purges

 Evenings

 Triggers: emotions, tempting food,

interpersonal stressors, body image
dissatisfaction, skipping meals/getting too
hungry
 Medical Complications of
Bulimia Nervosa

o From binging:
o Stomach/esophagus rupture, slow heart rate

o From laxative and diuretic abuse:

o Dehydration

o From vomiting:
o Sore throat
o Electrolyte imbalances (can cause heart problems)
o Dental erosion
o Swelling of salivary glands
Bulimia Nervosa

 Prevalence: 0.5-3%, more common in women

 15% of women admit to some purging behavior
 More common in Euro vs African-Americans
 Onset: ages 15-29

 Comorbidity:
 BN: depression, anxiety, personality disorders,
substance abuse
Bulimia: Comorbidity

 20% have MDD (Agras, 2001)

 Anxiety disorders common at similar rate to
that in anorexia (except PTSD which is 3x
more prevalent in bulimia than anorexia;
Kaye et al., 2004)
 Substance Abuse: 25% (Agras, 2001)
 Fear of obesity and distorted body image lead to…

Starvation

Preoccupation with food

Harder attempts at thinness

Increased anxiety & depression

Greater feelings of fear & loss of control

Medical problems
Commonalities between AN & BN

 Preoccupation with food / weight

 Heightened suicide risk
 Commonly comorbid w/ substance abuse &
depression
 May see self as overweight regardless of
actual weight
Differences between AN & BN
 Key difference is weight status
 AN – very underweight
 BN – underweight to overweight
 Restricting differences
 AN – “successful”; BN – unsuccessful
 Denial differences
 AN—denial of hunger and disorder
 BN—admit hunger, may see behavior = abnormal

 BN tend to be more concerned w/ being

attractive to others; more mood swings, PD
Binge Eating Disorder
 Recurrent binges associated with 3+ of:
 Unusually rapid eating
 Eating large amounts w/o hunger
 Eating until uncomfortably full
 Eating alone because of embarrassment
 Depression/self-disgust/guilt post binge

 Significant distress about binges

 Average 1x/week, 3 months
 No inappropriate compensatory behavior
 Lifetime prev: 2.8% (Hudson et al., 2007)
 “Other specified Feeding or Eating
Disorder” (AKA ED-NOS)
Per DSM-IV, ED-not otherwise specified (NOS) was most commonly
diagnosed Eating Disorder. Examples include:
 Symptoms of AN but weight is in the normal range despite
significant weight loss.
 Symptoms of BN but binges and compensatory behaviors are less
frequent than 1x/week, the total duration is less than 3 months, OR
the individual engages in inappropriate compensatory behaviors
after eating small amounts of food
Etiology
General View on Etiology

 Multidimensional risk profile

 Like diathesis-stress, person may have multiple
risk factors which increases odds of developing
AN or BN

 Review considers EDs in general, except

where noted
Psychodynamic Theory

 Disturbed mother-child interaction = ego

deficiency (no independence/self control) &
perceptual disturbance
 Result of ineffective parenting (not
attending to child’s needs) leads to kids who
feel ineffectual
 ED pts may be alexithymic (difficulty perceiving
own emotions) and confuse anxiety for hunger
 Cognitive Factors

 Cognitive distortions around

body weight and self worth &
dysfunctional cognitive styles
 Dichotomous thinking/all or
nothing
 Obsession with importance of
physical appearance
 “Good girls” eager to please
 Poor awareness of body cues like
emotional states and hunger
 Low mood
 Negative body image
Link to Depression (MDD)??

 1. MDD rates are higher in ED vs. non-ED

 2. Close relatives of people with ED have
higher MDD rates vs. no ED relatives.
 3. Commonalities around neurotransmitter
dysfunction across MDD and EDs
 4. Some effect of antidepressants
for both
Stop here!!
Biological Factors

 Genetic factors: moderate heritability

 Bulimia MZ 23%, DZ 9%
 Anorexia MZ 70%, DZ 20%
 Overall eating disorders are 6x more likely in
relatives of ED patients

 Low Serotonin activity

 May account for overlap between depression and
eating disorders
 May influence cravings for high carbohydrate foods
Biological Factors

 Weight set point

 Body has “weight thermostat”
▪ Set point = your body’s ideal weight
▪ May act via hypothalamus

 When weight falls below set point, biological

mechanisms get the body back to set point
▪ If food intake , metabolism 
▪ If food intake , fat storage  (to prevent starvation)
▪ If food intake , fat storage (prevent future starvation)
 Biological Factors

 Hypothalamus
 Regulates appetite
 Works to maintain set point

 Restricting AN might shut down/ignore

signals
 Binge-purgers may battle with signals
General Psychological Factors
 Personality Characteristics
(particularly with AN)
 Neuroticism (anxious/depressed)
 Prefer orderliness, predictability
 Show conformity, deference
 Avoid risk
 Excessively perfectionistic
 Struggle for control / overachieve

 AN often resistant to treatment,

disagree w/ statements about own
health
 Social Factors

 Cultural Influence
 Media and cultural influence on “ideal”
woman = thin
 More common in mid, upper class white
women
 Asian, Arab women in western culture > own
culture

 Self-Ideal Body Image Discordance

 Society’s views on thinness are pressure
on females that often causes them to
develop highly intrusive & pervasive
perceptual biases re: how “fat” they are
Ad Campaigns - *viewer discretion
Treatment
Anorexia Nervosa
 Primary goal is weight gain
 Hospitalization & supportive nursing care
 Eliminate causal / maintaining factors
 For adolescents, family based therapy is first line tx
 Family structure, communication, negot. adolescent dev. issues. Also
CBT—self-monitoring, changing eating behavs/beliefs re:food.
 For adults, high drop out rates, but CBT is promising (~80%
show some improvement)
 Self-monitoring, change eating behavs, beliefs re: food and wt
 Interpersonal therapy less effective than CBT
 Inpatient, day hosp, residential: not many studies examining
efficacy
 Medications are not particularly helpful
AN Treatment
 May involve refeeding during hospitalization
(orally if pt is compliant or through a NGI tube if
not)
 Nutritionists should be involved in all treatment for
anorexia. Also an MD to monitor for medical
problems and monitor wt.

 OVERALL VERDICT  not so good; chronic

problem, and unclear that treatment helps more
than spontaneous recovery
 Bulimia: Treatment
 More likely to seek treatment voluntarily
 Remission rates
 Only 6% of those with bulimia receive mental health tx.
 60% of those w/ bulimia in full or partial remission 10
years after tx.

 Chronic course of residual symptoms

 restrictive eating, preoccupations w/ eating and food, etc.
Bulimia Nervosa (also BED)
 Primary goal is changing eating patterns
 Cognitive-behavioral therapy is fist line (alone or w/
medications, 12-24 sessions)

 Interpersonal therapy
 Focuses on relationship problems, not eating; less quick
but comparable to CBT at follow-up

 Antidepressants help 25 – 50% of patients (but often

relapse when discontinued)
 EFFICACY: 40% high response, 40% some response, 20%
no response – CBT beats meds solo here, but high relapse
rate
 Those w/ daily purging and those who do not respond w/I 8-
10 wks should be referred to more intensive tx.
CBT for Bulimia

 3 “phases”
 1. Education about bulimia; orientation to
CBT
▪ Treatment structure & goals
▪ Self-monitoring
▪ Normalize and stabilize eating patterns
CBT for Bulimia

 2. Increased cognitive focus

 Identify & evaluate thoughts
(related to shape, weight, & eating)
 Behavioral experiments to test beliefs

 3. Relapse prevention strategies

 What ifs?
 Identify, plan for high risk situations
Evidence for Efficacy
 Agras et al. (2000), N = 220
100

80

60
CBT
40 IPT
20

0
Recovered Remitted
The results indicate both a clinical and statistical
advantage for CBT over IPT at the end of treatment.
Mechanisms: Why does CBT work?
 Reduction in dietary restraint as early as Week 4
mediated posttreatment improvement in both binge
eating and vomiting
Web Controversy

 Pro-Anorexia/Thinspiration Web Sites

 Sites created by anorexic patients who want to
stay the way the are
▪ poetry, tips for dieting, pictures of very thin bodies
▪ Have also included tips for hiding your disorder from
family/therapists
 Should these be
restricted?
Obesity

 Not included in DSM-5 despite evidence that

strong behavioral and psychological factors but
being considered
 Right now is considered as a medical problem.
 Defined as being 20% or more over the ideal
weight based on life insurance stats for person’s
age, build, sex, and height.
 40% above normal is a marker of severe
overweight (Brownell, 1995)
 Obesity: Stats
 30% of adults in US significantly overweight or obese
(Cassell & Gleaves, 2006)
 Prevalence almost tripled from 1991 (12%)
 Accounted for >164,000 deaths in US alone in 2000 (Flegal
et al., 2005)
 In kids and adolescents, rates of being overweight has
tripled in last 25 yrs (Critser, 2003)
 Obesity most expensive health problem in U.S. w/ costs
exceeding $117 billion per yr (exceeds costs for smoking
and alcohol abuse)
 HBO documentary
http://www.youtube.com/watch?v=-pEkCbqN4uo
Causes
 Spread of modernization (Henderson &
Brownell, 2004)
 inactive, sedentary lifestyle and eating high-fat,
energy-dense diet (Levine, 2005)
 Pima Indian women who moved to Arizona
consumed 41% of total calories in fat and weighed
44 lbs more than Pima women who stayed in
Mexico (Ravussin et al., 1994)
 Immigrants to US more than doubled their
prevalence of obesity from 8% to 19% after 15 yrs
or more of living in US (Goel et al., 2004)
 https://www.nytimes.com/2017/12/11/health/
obesity-mexico-nafta.html
Causes (continued)
 Genes
 Influence number of fat cells person has,
likelihood of fat storage, and activity levels
(Cope, Fernandez, & Allison, 2004)
 Thought to account for 30% of cause of
obesity (Bouchard, 2002)
Causes (continued)
 Emotional eating:
 Obesity linked to low self-esteem and depression
(Miller & Downey, 1999)
 Obese individuals say they eat when bored, when
experiencing strong emotions
 Sedentary activities: tv, video games, internet,
driving to work, not exercising
 Eating during sedentary activities.
 Pay less attention to how much eating and what
eating and eat more
 Also commercials suggest should eat and will even
if not hungry
Treatment
 Only moderately successful
 Many times people will try self-directed
weight loss (diet & exercise on own). Usually
not very successful.
 Then many will try a commercial self-help
program, like Jenny Craig, Wt. Watchers. 80% of
people not successful on them in long run. Usually
b/c people don’t stick to the program.
Treatment
 Most successful are professionally directed
behavioral modification programs. Especially if
attend group maintenance sessions in year
following wt loss.
 Programs usually consist of low-calorie diet (900-
1200 cal/day) often times liquid meal replacement
and exercise programs. After 3-4 months put on
low-calorie balanced diet.
 As many as 50% regain lost weight in first year following tx
(Wadden & Osei, 2002)
Treatment

 Medication
 FDA has approved 2 drugs that reduce internal
cues signaling hunger (Meridia & Xenical).
 Those on meds for more than 1 yr = weight loss of
7-8%.
 Best when combined w/ changing eating and
exercise.
Treatment
 Bariatric surgery
 Stomach stapled to create small pouch at base of esophagus,
which limits food intake. Stomach holds only 1 oz of food.
 Gastric bypass is alternative. Creates bypass of part of small
intestine and make stomach smaller which limits food and
absorption of calories.
▪ Only for extreme obesity
▪ Pts lose 30-50% of body wt postoperatively
▪ Usually must have at least 1 obesity-related health condition like heart
disease or diabetes.
▪ 15-20% experience severe complications and require rehospitalization
and additional surgery in first few yrs after surgery.
Treatment: Bariatric surgery cont
 Requires dietary changes:
 Temporary:
▪ only liquids, then pureed foods for 3-4 wks, then soft foods, then
normal foods.
 Long term:
▪ Eat and drink slowly.
▪ Low fat, low sugar.
▪ Eat protein first.
▪ Chew foods until very small or may have blockages.
▪ Sip liquids only while eating or will fill up stomach. Drink liquids
between meals.
 Can get anemia (30%), low calcium(30%), etc because
not absorbing nutrients enough.
 May have “dumping syndrome”: food moves too
quickly thru stomach and intestines.
 Have nausea, weakness, sweating, faintness, and diarrhea
soon after eating. Certain foods may make this worse, such as
high in sugar.