Nina K. Schlachter, D.O Ephrat L. Lipton, LCSW, BCD Christine Engstrom, MS, RD, LD  “Anorexia nervosa and bulimia nervosa have been considered to be influenced by cultural forces; as these forces change, the disorders themselves are altered.  Awareness of the impact of sociocultural forces is critical to enhancing the understanding of the etiology and pathogenesis and to informing models of care.” Dorian and Garfinkel (1999) p. 187 Eating Disorders As They Pertain To:  Race/Culture/Ethnicity  Socioeconomic Status  Gender/Gender Identity  Sexual Orientation  Age  Comorbidity with Substance Abuse Eating Disorders are Becoming Global Eating disorders are on the rise in:  Arabic, Asian, Latin, African cultures  Diverse populations in the US including African Americans, Mexican Americans, Native Americans Afifi-Soweid, et al (2002)  954 Lebanese collage students  53% Male  47% Female Afifi-Soweid, et al (2002)  70% were trying to lose body weight  49% of those were normal to low body weight  52% were currently engaging in disordered eating behaviors Lee and Lee (2000) ED reports increasing in Japan, Hong Kong, Singapore, Taiwan and Korea Increased reports in urbanized regions of low-income Asian countries such as:      China India Philippines Malaysia Thailand  Girls in Asian countries exhibit similar fat concerns as western female  Fat concern has increased among Chinese females since late 1990’s (Efron, 1997; Feldman, et al, 1988; Gunewardene,et al, 2001; Lee, et al, 2002; Lee and Lee, 2000) American Psychiatric Association (2000) Japan:  The only non-western country with figures of ED comparable to those in the US (May even be under diagnosed)  Until recently, nearly all ED research was focused on young, white, females  Recent studies report a clear rise in ED among nonwhite women  Prevalence of binge eating in people of color comparable to Caucasians American Psychiatric Association (2000) In the US:  ED appear to be as common in young Hispanic women and Native Americans as Caucasians  Mexican American females are reported to be the fastest rising group of individuals struggling with ED  In the Southeast, ED are more common among African American women than anywhere else in the country Gard and Freeman (1996) Extensive review of the literature from 1970 to mid 90’s Looked at stereotype that high SES correlates with increased incidence of ED  Extensive research fails to support the stereotype  8 major studies failed to show a positive relationship between SES and ED  Evidence supporting this stereotype based on small, uncontrolled case studies Who gets services? Hoek (1993)  70% of people with ED visit general practitioner within a year  Of these, about 50% are anorectic, and most are referred out  Only 50% of bulimia cases are referred out Freeman and Gard (1996)  83 homeless people  19.1% suffered from ED  4x more suffered from BN than AN The World Bank reports that ED are on the rise in low income communities Lee and Lee (2000) Young females in low income rural China were concerned with dieting and being fat, despite the fact that they were normal to under weight Rogers, et al (1997) “Among young women who meet the diagnostic criteria for an ED, SES does not appear to be a significant factor.”  State-wide survey of public schools in Minnesota  17,571 adolescent girls between grades 7-12  Broad based community sample to avoid selection bias  High SES was related to body shape and size, unhealthy dieting, poor body image  No relationship was found between diagnostic ED and SES Streigel-Moore, et al (2000)  Children of less educated parents had more severe ED  Parental unemployment and mother only employment were risk factors for high EAT scores Moorhead, et al (2003) “Our study found no association between socioeconomic characteristics and ED”  22 year longitudinal study 1977-1999  Beginning in kindergarten  74 full participants Barry, et al (2002)  Men comprise a substantial proportion of the BED population  Women are only 1 ½ x more likely to have BED than men  Men report less dissatisfaction with body image and less drive for thinness  In men, binge eating associated with negative emotions (anger and depression)  In women, binge eating is linked to failed diet attempts and poor body image  Females who binge are prone to extreme dieting and wt. compensatory behaviors  Men with BED have a high incidence of history of substance abuse Two studies on BED and gender Barry, et al (2002) and Tanofsky, et al (1997) Both found no significant difference between genders on:  Age at first overweight episode, age of first diet, age of first binge, or number of weight cycles Men were found to have a higher BMI Gender specific ED risk factors for males  Exercise status (running, wrestling, weight lifting)  Sexual orientation (gay males have increased risk)  Femininity (increased femininity equals increased risk) ANAD (2000) Anorexia Nervosa affects over 1 million males yearly  5-10% of reported cases are males  Vastly overlooked-virtually no research on males in early adolescence Crosscope-Happel, et al (2000) Amenorrhea hallmark feature of AN in women  No analogous criterion for men  For males, endocrine disturbance is general decline in testosterone  Reduction in gonadotropin secretion in anorectic males may be a corresponding feature to amenorrhea Common features of males with AN/BN: Loss of sex drive, dysphoric mood, dichotomous thinking, body image dissatisfaction, excessive exercise, social withdrawal, personality disorders (BPD, OCPD, dependent, avoidant), sexual orientation or sex role struggles, history of being overweight Treatment for males similar to females:  Multidisciplinary team approach with education  Medical Intervention  Weight restoration/stabilization  Psychotherapy with added sensitivity to unique aspects of gender Hepp and Milos (2002)  ED and Gender Identity Disorder-very limited data  Female to male transgendered person with AN  Hypothesized that starvation stopped adult female development and menstruation Williamson and Spence (2001)  Gay men are at higher risk that heterosexual men for development of an ED  Lesbian women are at the same risk as heterosexual women  Negative feelings about sexual orientation associated with body dissatisfaction and eating disturbance Herzog, et al (1990) Sexuality central theme in males with ED  Negative attitudes (disgust/anxiety) towards sexual relationships  Difficulties in premorbid sexual fantasy and activity  Gender dysphoria  Concerns about sexual identity  Ego dystonic homosexuality Herzog, et al (1990) Why gay men are at increased risk for ED  Unresolved, internalized homo-negativity  Role of sub cultural/sociocultural processes in gay community Halvarsson, et al (2002)  7- year longitudinal study with 7-14 year old girls  Over past 5 years, increasing trend towards thinness and dieting in this age group  As young girls grow older, dieting practices and wishes for thinness intensify Many studies confirm:  Dieting and restrictive behaviors occur pre-puberty  Children acquire cultural values of beauty much prior to adolescence  Longing to be thin is desirable before beauty (Childress, et al; Feldman, et al; Halvarsson, et al; Kostanski and Gullone) Patton, et al in Halvarsson, et al (2002) Female teenagers (14-15 yrs old) who diet severely are 18x more likely to develop ED and those who diet moderately are 5x more likely to develop ED than non-dieting peers Childress, et al (1993); Kostanski, et al (1999) Children with ED are at risk of developing:  Convulsions; renal failure; cardiac arrhythmia; dental erosion; gastric rupture; growth retardation; cognitive impairment Maloney, et al 318 7-13yr olds  45% wanted to be thinner  37% had tried to lose weight  6.9% scored within anorexia range on CHEAT Rolland, et al (1997) 8-12yr olds  50% of girls and 33% of boys wanted to be thinner  Over 40% of girls and 24% of boys had attempted to lose weight Von Ranson, et al (2002)  Community based study with 672 adolescent girls and 718 women  Disordered eating associated with nicotine, alcohol, and illicit drug use  In adolescents, bulimia associated with alcohol misuse and anorexia associated with illicit drug use (cannabis, stimulants)  Weak and inconsistent results-effects weak even when significant  Substance use and ED not strongly related in non-clinical samples Becker (1995) One month after satellites brought TV to this region, 63 Fijian secondary school girls interviewed (average age 17) 38 months later, another 65 girls interviewed (matched for age, wt., etc.) Becker (cont’d)  15% of latter sample (vs. 3% in ’95) had induced vomiting to control weight  29% of latter sample (vs. 3%) scored at risk for ED on EAT  Before 1995, little talk of dieting on the island  69% of girls in the later study were dieting  74% of the earlier sample said they felt too fat at follow-up The Changing Faces of Eating Disorders Medications Dr. Nina Schlachter CLOZARIL (clozapine) GEODON (ziprasidone) ABILIFY (aripiprazole) RISPERDAL (risperidone) ZYPEXIA (olanzapine) SEROQUEL (quetiapine fumerate) The Changing Faces of Treatment Gastric Bypass Surgery Dr. Nina Schlachter Causes of overweight  Genetics  Weight at time one finishes physical growth  Arguably, simply overeating or food addiction Insulin – stores glucose Leptin - satiety Ghrenlin - hunger CCK – fullness PYY 3-36 – fullness Thermogenesis Diet and exercise – 5-10% success rate Maximum of 18% Regain Gastric bypass – 70% success BMI greater than 25 – overweight BMI greater than 30 – obese BMI greater than 40 – morbidly obese men 100 pounds overweight women 80 pounds overweight Medical illnesses may be caused or exacerbated by obesity 1. 2. 3. 4. 5. 6. 7. Hypertension Diabetes mellitus type II (insulin resistant) Hypercholesterolemia Sleep Gastric reflux Stress incontinence Multiply joint pain and degeneration BMI over 40 – gastric bypass is now considered medical treatment of choice BMI 30-35 – gastric bypass is treatment option if patient 1. Has been at this weight 3-5 years 2. Has been unable to lose weight other ways 3. Has 1 or more life threatening illnesses (Medical insurance criteria) Intestinal bypass Restrictive surgeries Maladaptive surgeries Normal stomach contents: Up to 2 quarts Vertical Band – most common  Limits quantity to about 1 ounce  Staple limits stretching of pouch  Band is tightened through external port  Side effects - sugar Malabsorption surgery – most common  Abdominal or laproscopy  Loop just below grehlin and just above CCK  Limits quantity to about 1 ounce  Side effects  Death rate  Reversible Lifetime of malabosptive type of bypass  First 18 months rapid weight loss  Vomiting  Dumping Psychological assessment and follow through Pre-surgical assessment – 1. No major psychiatric illness 2. Realistic expectations 3. Willingness to take partial responsibility for changing eating and exercising behaviors Psychological follow through Post-surgery – 1. Nutritional counseling 2. Exercise program 3. Body acceptance 4. Mourn food as comfort 1. Eating Disturbances Before and After Vertical Banded Gastroplasty: A Pilot Study. HSU, L.K. George, Betancourt, Sergio, Sullivan, Sean P., International Journal of Eating Disorders. Volume 19, Number 1, 23-34. January, 1996. 2. Gastric Surgery and Restraint from Food as Triggering Factors of Eating Disorders in Morbid Obesity. Guisado, Juan A., Vaz, Francisco J., Lopez-Ibor, Juan J., Lopez-Ibor, M. Ines, del Rio, Julia, Rubio, Miguel A. International Journal of Eating Disorders. Volume 31, 99-100. January, 2000. 3. Obesity: The Continuing Saga. Journal Watch Psychiatry. December 2, 2002. 4. Cincinnati’s Children’s Hospital Medical Center, Comprehensive Weight Management Center. 2001. 5. Obesity, diabetes are “epidemic.” McKenna, M.A.J. The Atlanta Journal and Constitution. 2002. 6. Ralph Carson, Ph.D., R.D. 7. Emmett R. Bishop, M.D. 8. James Champion, M.D. 9. Harvard edu/ www.com 10. The Secret of Feeling Full. Gorman, Christine. Time Magazine, August 19, 2002. 11. The National Enquirer 12. Olanzaine Use as an Adjunctive Treatment for Hospitalized Children with Anorexia Nevose: Case Reports. Boachie, Ahmed, Goldfield, Gary S., Spettigue, Wendy. International Journal of Eating Disorders, Volume 33, November 1, 98-103. January, 2003. Changing Faces of Treatment     Increased severity in the medical/clinical picture Pregnancy and active eating disorder behaviors Obesity, gastric bypass and the psychological aspects of weight maintenance Type I Diabetes and active eating disorder behaviors Mitchel-Gieleghem et al. Women born after 1960 are at greater risk for the development of bulimia nervosa, and these women are in their childbearing years. Birth 29:3 Sept 2002 Detection of Eating Disorders in Clinical Practice Initial BMI < 19  Regular weigh-ins  History of prolonged amenorrhea  Past nutritional issue  History of unexplained spontaneous pregnancy loss  Detection of Eating Disorders in Clinical Practice     Low body weight History of infertility Range of weight gains and losses over the course of her life span Patient’s identification of ideal body weight Birth 29:3 Sep 2002 Pregnancy Complications Associated with Eating Disorder Behaviors      Preterm delivery Low birth weight Intrauterine growth restriction Cesarean birth Low apgar scores Eating Disorders, Fertility, and Pregnancy: Relationships and . Complications, James 2001 Mitchell-Gieleghem, 2002 13% of infants born to the women during the active phase of the disease and  6% of infants born after recovery from anorexia were delivered by Cesarean section  Birth 2002 Sep; 29 (3), pp. 182-191 Impact of Eating Disorders on Fertility and Pregnancy Outcome  “Complications in each phase of childbearing, from conception through postpartum, that jeopardize maternal and fetal well-being are more likely to occur when an underlying eating disorder is overlooked.” Birth 29:3 Sept 2002 p 185 Bodily Sensations Associated with Pregnancy         Nausea Vomiting Changes in hunger and fullness Cravings Fatigue Bloating Physical changes: larger breast and abdomen Disruption in body image Bodily Sensations Associated with Eating Disorders     Nausea: strong feelings associated with real or perceived fullness Vomiting: inability to tolerate full feeling in stomach and fear of weight gain Changes in hunger and fullness: inability to listen to increasing physiological hunger cues or stop when cues stop Cravings associated with obsessive food thoughts or need to self soothe Bodily Sensations Associated with Eating Disorders     Fatigue: inability to listen to body cues regarding eating, resting, and/or moderating exercise Bloating: inability to tolerate physiological changes associated with fullness, hormonal changes, real weight gain or fluid intake Physical changes: inability to differentiate between real or imagined physiological changes Disruption in body image: body image negativity driven by low self esteem and poor self-acceptance National Institute of Health  Five million Americans are so seriously overweight it affects their health and life expectancy. Obesity surgery for 2002 reported 63,000 surgeries which constitutes a 71% increase NIH Consensus Development Conference Statement 1991 Psychological Aspects of Weight Maintenance and Relapse in Obesity A number of psychological factors, such as having unrealistic goals, poor coping or problem solving skills and low self-efficacy may have an important effect on the behaviors involved in weight maintenance and relapse in obesity. Byrne, Journal of Psychosomatic Research, 53 (2002) 1029-1036 Successful Weight Maintenance and Weight Gain In this study, their were two classifications of groups: Weight maintainer: maintained for at least one year, a weight loss of 5-10% of patient’s maximum body weight or achieved and maintained a healthy weight (BMI=20-25) for more than 2 years Weight regainer: Subject who has returned to their pretreatment weight Psychological Aspects of Weight Maintenance and Relapse in Obesity Journal of Psychosomatic Research 53 (2002) 1029-1036 Byrne 2002  The main features distinguishing maintainers from regainers related to problem solving skills. Over 70% of the regainers attributed their weight gain to eating in response to stressful life events or to negative emotional states. Escape-avoidance was the way regainers coped engaging in eating, sleeping more or wishing the problem would go away. Byrne 2002   Regainers are more likely to report over-eating in response to negative emotional states than are maintainers Regainers may use food or eating to moderate negative mood states than apply more appropriate coping strategies Byrne 2002  Maintainers tend to cope more successfully with adverse life events than do regainers  Maintainers may be able to use problem-solving skills to cope with stressful situations in a way that does not interfere with their adherence to a weight maintenance regime Gastric Bypass Screening “ The need for psychiatric evaluation of all patients with morbid obesity seeking treatment in obesity units seem clear in order to detect vulnerability factors that might lead to future psychiatric complications” International Journal of Eating Disorders, Jan (53) 2002 p 99 Patients Selected for Gastric Bypass “Obese patients selected for gastric surgery seem to have a higher prevalence of major depression, agoraphobia, simple phobia, PTSD, bulimia nervosa and personality disorder.” International Journal of Eating Disorders, Jan (53) 2002 pp97-100 Gastric Bypass Psychological Risk Factor “People suffering form morbid obesity risk developing anorexic and bulimic symptoms as a consequence of the restrictions in eating behavior or during the period of weight loss that follows gastric surgery.” International Journal of Eating Disorder, Jan(53)2002 Eating Disorder and Nutrition Concerns Post Gastric Bypass      Increased concern with the attention subjects paid to their weight, shape and appearance Difficulty separating needing to restrict certain foods post-gastric bypass due to digestion/absorption reasons vs. the emerging fears of weight gain or being out-of-control with food Difficulty accepting changes in body weight and size due to quick weight loss vs. the reality of weight and size Nausea due to over filling of pouch vs. vomiting due to inability to tolerating the feelings of fullness Inability to separate food from feelings from gastric bypass Diabetes and Eating Disorders Diabetes Management requires adherence to a complex treatment plan, including multiple injections of insulin daily, frequent selfmonitoring of blood glucose levels, regular exercise and attention to a dietary plan that emphasizes consistency in the timing, quantity and types of food eaten. Daneman and Frank 1996 Diabetes and Eating Disorders “Hunger associated with hypoglycemia encourages binge eating. These deviations from natural eating behaviors, combined with weight loss at diagnosis and then weight gain associated with good glycemic control, disrupt the natural relationship between weight, hunger and satiety and thus promoting abnormal eating patterns in Type I Diabetes.” The Diabetes Control and Complications Trial Research Group 1993 Daneman, Olmsted, Rydall et al. 1998 Diabetes Eating Behaviors Characteristics       Metabolic control Age of diabetes onset Illness duration Body image and dissatisfaction Drive for thinness Inappropriate eating/weight loss behaviors laxatives/diuretic vomiting insulin under dosing food avoidance binge eating POTENTIATION OF EATING DISORDERS BY TYPE I DIABETES RODIN ET AL. 2002 DM DIET DIETARY RESTRICTION BINGE – EATING WT GAIN PURGING & INSULIN OMISSION INSULIN THERAPY Jones 2000 Research indicates that eating disorder associated with bingeing and purging, such as bulimia nervosa and binge eating disorder, are the most common types of eating disorders among girls with diabetes. Rodin et al. 1993 “Diabetes may increase dependence on parents at the very time teens are struggling to gain greater independence— challenging the teen’s development of a separate self ” S. Maharaj 2001 “Standard interventions designed to improve diabetes control, including intensive diabetes management, are unlikely to be effective as long as eating problems and family interaction difficulties persist.” Eating Problems and the Observed Quality of Mother-Daughter interactions among girls with Type I Diabetes Journal of Consulting and Clinical Psychology Dec.(69)2001. pp950-958
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