Nina K. Schlachter, D.O

Ephrat L. Lipton, LCSW, BCD

Christine Engstrom, MS, RD, LD

““Anorexia nervosa and bulimia nervosa have been Anorexia nervosa and bulimia nervosa have been considered to be influenced by cultural forces; as considered to be influenced by cultural forces; as these forces change, the disorders themselves are these forces change, the disorders themselves are altered.altered.

Awareness of the impact of sociocultural forces is Awareness of the impact of sociocultural forces is critical to enhancing the understanding of the critical to enhancing the understanding of the etiology and pathogenesis and to informing etiology and pathogenesis and to informing models of care.”models of care.”

Dorian and Garfinkel (1999) p. 187Dorian and Garfinkel (1999) p. 187

Eating DisordersEating Disorders

As They Pertain To:As They Pertain To: Race/Culture/EthnicityRace/Culture/Ethnicity

Socioeconomic StatusSocioeconomic Status

Gender/Gender IdentityGender/Gender Identity

Sexual OrientationSexual Orientation

AgeAge

Comorbidity with Substance Comorbidity with Substance AbuseAbuse

Eating Disorders are Eating Disorders are Becoming GlobalBecoming Global

Eating disorders are on the Eating disorders are on the rise in:rise in:

Arabic, Asian, Latin, African Arabic, Asian, Latin, African culturescultures

Diverse populations in the US Diverse populations in the US

including African Americans, including African Americans, Mexican Mexican Americans, Native Americans Americans, Native Americans

Afifi-Soweid, et al (2002)Afifi-Soweid, et al (2002)

954 Lebanese collage 954 Lebanese collage studentsstudents

53% Male53% Male

47% Female47% Female

Afifi-Soweid, et al (2002)Afifi-Soweid, et al (2002)

70% were trying to lose body weight70% were trying to lose body weight

49% of those were normal to low body 49% of those were normal to low body weightweight

52% were currently engaging in 52% were currently engaging in disordered eating behaviorsdisordered eating behaviors

Lee and Lee (2000)Lee and Lee (2000)

ED reports increasing in Japan, Hong Kong, ED reports increasing in Japan, Hong Kong, Singapore,Singapore,

Taiwan and KoreaTaiwan and Korea

Increased reports in urbanized regions of Increased reports in urbanized regions of low-incomelow-income

Asian countries such as:Asian countries such as:

ChinaChina IndiaIndia PhilippinesPhilippines MalaysiaMalaysia ThailandThailand

Girls in Asian countries exhibit similar Girls in Asian countries exhibit similar fat concerns as western femalefat concerns as western female

Fat concern has increased among Fat concern has increased among Chinese females since late 1990’sChinese females since late 1990’s

(Efron, 1997; Feldman, et al, (Efron, 1997; Feldman, et al, 1988; 1988; Gunewardene,et al, 2001; Lee, et Gunewardene,et al, 2001; Lee, et al, 2002; Lee al, 2002; Lee and Lee, 2000) and Lee, 2000)

American Psychiatric American Psychiatric Association (2000)Association (2000)

Japan:Japan: The only non-western country with The only non-western country with

figures of ED comparable to those in figures of ED comparable to those in the USthe US

(May even be under diagnosed)(May even be under diagnosed)

Until recently, nearly all ED research Until recently, nearly all ED research was focused on young, white, femaleswas focused on young, white, females

Recent studies report a clear rise in ED Recent studies report a clear rise in ED among non-white womenamong non-white women

Prevalence of binge eating in people of Prevalence of binge eating in people of color comparable to Caucasianscolor comparable to Caucasians

American Psychiatric Association (2000)American Psychiatric Association (2000)

In the US:In the US:

ED appear to be as common in young Hispanic ED appear to be as common in young Hispanic women and Native Americans as Caucasianswomen and Native Americans as Caucasians

Mexican American females are reported to be the Mexican American females are reported to be the fastest rising group of individuals struggling with fastest rising group of individuals struggling with EDED

In the Southeast, ED are more common among In the Southeast, ED are more common among African American women than anywhere else in African American women than anywhere else in the countrythe country

Gard and Freeman (1996)Gard and Freeman (1996)

Extensive review of the literature from 1970 to mid Extensive review of the literature from 1970 to mid 90’s90’s

Looked at stereotype that high SES correlates with Looked at stereotype that high SES correlates with increasedincreased

incidence of EDincidence of ED

Extensive research fails to support the stereotypeExtensive research fails to support the stereotype

8 major studies failed to show a positive relationship between 8 major studies failed to show a positive relationship between SES and EDSES and ED

Evidence supporting this stereotype based on small, Evidence supporting this stereotype based on small, uncontrolled case studiesuncontrolled case studies

Who gets services? Hoek (1993)Who gets services? Hoek (1993)

70% of people with ED visit general 70% of people with ED visit general practitioner within a yearpractitioner within a year

Of these, about 50% are anorectic, and Of these, about 50% are anorectic, and most are referred outmost are referred out

Only 50% of bulimia cases are referred Only 50% of bulimia cases are referred outout

Freeman and Gard (1996)Freeman and Gard (1996)

83 homeless people83 homeless people

19.1% suffered from ED19.1% suffered from ED

4x more suffered from BN than AN4x more suffered from BN than AN

The World Bank reports that ED are The World Bank reports that ED are on the riseon the rise

in low income communitiesin low income communities

Lee and Lee (2000)Lee and Lee (2000)

Young females in low income rural Young females in low income rural China were concerned with dieting and China were concerned with dieting and being fat, despite the fact that they being fat, despite the fact that they were normal to under weightwere normal to under weight

Rogers, et al (1997)Rogers, et al (1997)

““Among young women who meet the diagnostic Among young women who meet the diagnostic criteria for an ED, SES does not appear to be a criteria for an ED, SES does not appear to be a significant factor.”significant factor.”

State-wide survey of public schools in MinnesotaState-wide survey of public schools in Minnesota

17,571 adolescent girls between grades 7-1217,571 adolescent girls between grades 7-12

Broad based community sample to avoid selection Broad based community sample to avoid selection biasbias

High SES was related to body shape and size, High SES was related to body shape and size, unhealthy dieting, poor body imageunhealthy dieting, poor body image

NoNo relationship was found between diagnostic ED relationship was found between diagnostic ED and SESand SES

Streigel-Moore, et al (2000) Streigel-Moore, et al (2000)

Children of less educated parents had Children of less educated parents had more severe EDmore severe ED

Parental unemployment and mother only Parental unemployment and mother only employment were risk factors for high employment were risk factors for high EAT scoresEAT scores

Moorhead, et al (2003)Moorhead, et al (2003)

““Our study found no association Our study found no association between socioeconomic between socioeconomic characteristics and ED”characteristics and ED”

22 year longitudinal study 1977-199922 year longitudinal study 1977-1999

Beginning in kindergartenBeginning in kindergarten

74 full participants74 full participants

Barry, et al (2002)Barry, et al (2002)

Men comprise a substantial proportion of the BED Men comprise a substantial proportion of the BED populationpopulation

Women are only 1 ½ x more likely to have BED Women are only 1 ½ x more likely to have BED than menthan men

Men report less dissatisfaction with body image Men report less dissatisfaction with body image and less drive for thinnessand less drive for thinness

In men, binge eating associated with negative In men, binge eating associated with negative emotions (anger and depression)emotions (anger and depression)

In women, binge eating is linked to failed diet In women, binge eating is linked to failed diet attempts and poor body imageattempts and poor body image

Females who binge are prone to extreme dieting Females who binge are prone to extreme dieting and wt. compensatory behaviorsand wt. compensatory behaviors

Men with BED have a high incidence of history of Men with BED have a high incidence of history of substance abusesubstance abuse

Two studies on BED and genderTwo studies on BED and gender

Barry, et al (2002) and Tanofsky, et Barry, et al (2002) and Tanofsky, et al (1997)al (1997)

Both found no significant difference betweenBoth found no significant difference between

genders on:genders on:

Age at first overweight episode, age of first diet, Age at first overweight episode, age of first diet, age of first binge, or number of weight cyclesage of first binge, or number of weight cycles

Men were found to have a higher BMIMen were found to have a higher BMI

Gender specific ED risk factors for malesGender specific ED risk factors for males

Exercise status (running, wrestling, weight lifting)Exercise status (running, wrestling, weight lifting)

Sexual orientation (gay males have increased risk)Sexual orientation (gay males have increased risk)

Femininity (increased femininity equals increased Femininity (increased femininity equals increased risk) risk)

ANAD (2000)ANAD (2000)

Anorexia Nervosa affects over 1 million Anorexia Nervosa affects over 1 million malesmales

yearlyyearly

5-10% of reported cases are males5-10% of reported cases are males

Vastly overlooked-virtually no research Vastly overlooked-virtually no research on males in early adolescenceon males in early adolescence

Crosscope-Happel, et al (2000)Crosscope-Happel, et al (2000)

Amenorrhea hallmark feature of AN in Amenorrhea hallmark feature of AN in womenwomen

No analogous criterion for menNo analogous criterion for men

For males, endocrine disturbance is general For males, endocrine disturbance is general decline in testosteronedecline in testosterone

Reduction in gonadotropin secretion in Reduction in gonadotropin secretion in anorectic males may be a corresponding feature anorectic males may be a corresponding feature to amenorrheato amenorrhea

Common features of males with AN/BN:Common features of males with AN/BN:

Loss of sex drive, dysphoric mood, dichotomous Loss of sex drive, dysphoric mood, dichotomous thinking, body image dissatisfaction, excessive thinking, body image dissatisfaction, excessive exercise, social withdrawal, personality disorders exercise, social withdrawal, personality disorders (BPD, OCPD, dependent, avoidant), sexual (BPD, OCPD, dependent, avoidant), sexual orientation or sex role struggles, history of being orientation or sex role struggles, history of being overweightoverweight

Treatment for males similar to Treatment for males similar to females:females:

Multidisciplinary team approach with Multidisciplinary team approach with educationeducation

Medical InterventionMedical Intervention

Weight restoration/stabilizationWeight restoration/stabilization

Psychotherapy with added sensitivity to Psychotherapy with added sensitivity to unique aspects of genderunique aspects of gender

Hepp and Milos (2002)Hepp and Milos (2002)

ED and Gender Identity Disorder-very limited ED and Gender Identity Disorder-very limited datadata

Female to male transgendered person with ANFemale to male transgendered person with AN

Hypothesized that starvation stopped adult Hypothesized that starvation stopped adult female development and menstruationfemale development and menstruation

Williamson and Spence (2001)Williamson and Spence (2001)

Gay men are at higher risk that Gay men are at higher risk that heterosexual men for development of an EDheterosexual men for development of an ED

Lesbian women are at the same risk as Lesbian women are at the same risk as heterosexual womenheterosexual women

Negative feelings about sexual orientation Negative feelings about sexual orientation associated with body dissatisfaction and associated with body dissatisfaction and eating disturbanceeating disturbance

Herzog, et al (1990)Herzog, et al (1990)

Sexuality central theme in males with EDSexuality central theme in males with ED

Negative attitudes (disgust/anxiety) Negative attitudes (disgust/anxiety) towards sexual relationshipstowards sexual relationships

Difficulties in premorbid sexual fantasy Difficulties in premorbid sexual fantasy and activityand activity

Gender dysphoriaGender dysphoria

Concerns about sexual identityConcerns about sexual identity

Ego dystonic homosexualityEgo dystonic homosexuality

Herzog, et al (1990)Herzog, et al (1990)

Why gay men are at increased risk for Why gay men are at increased risk for EDED

Unresolved, internalized homo-negativityUnresolved, internalized homo-negativity

Role of sub cultural/sociocultural Role of sub cultural/sociocultural processes in gay communityprocesses in gay community

Halvarsson, et al (2002)Halvarsson, et al (2002)

7- year longitudinal study with 7-14 year old 7- year longitudinal study with 7-14 year old girlsgirls

Over past 5 years, increasing trend towards Over past 5 years, increasing trend towards thinness and dieting in this age groupthinness and dieting in this age group

As young girls grow older, dieting practices As young girls grow older, dieting practices and wishes for thinness intensifyand wishes for thinness intensify

Many studies confirm:Many studies confirm:

Dieting and restrictive behaviors occur pre-Dieting and restrictive behaviors occur pre-pubertypuberty

Children acquire cultural values of beauty Children acquire cultural values of beauty much prior to adolescencemuch prior to adolescence

Longing to be thin is desirable before beautyLonging to be thin is desirable before beauty

(Childress, et al; Feldman, et al; Halvarsson, (Childress, et al; Feldman, et al; Halvarsson, et al;et al;

Kostanski and Gullone)Kostanski and Gullone)

Patton, et al in Halvarsson, et al Patton, et al in Halvarsson, et al (2002)(2002)

Female teenagers (14-15 yrs old) who diet Female teenagers (14-15 yrs old) who diet severely are 18x more likely to develop ED severely are 18x more likely to develop ED and those who diet moderately are 5x more and those who diet moderately are 5x more likely to develop ED than non-dieting peerslikely to develop ED than non-dieting peers

Childress, et al (1993); Kostanski, et al Childress, et al (1993); Kostanski, et al (1999)(1999)

Children with ED are at risk of developing:Children with ED are at risk of developing:

Convulsions; renal failure; cardiac Convulsions; renal failure; cardiac arrhythmia; dental erosion; gastric rupture; arrhythmia; dental erosion; gastric rupture; growth retardation; cognitive impairmentgrowth retardation; cognitive impairment

Maloney, et alMaloney, et al

318 7-13yr olds318 7-13yr olds

45% wanted to be thinner45% wanted to be thinner

37% had tried to lose weight37% had tried to lose weight

6.9% scored within anorexia range on 6.9% scored within anorexia range on CHEATCHEAT

Rolland, et al (1997)Rolland, et al (1997)

8-12yr olds8-12yr olds

50% of girls and 33% of boys 50% of girls and 33% of boys wanted to be thinnerwanted to be thinner

Over 40% of girls and 24% of boys Over 40% of girls and 24% of boys had attempted to lose weighthad attempted to lose weight

Von Ranson, et al (2002)Von Ranson, et al (2002)

Community based study with 672 adolescent girls and Community based study with 672 adolescent girls and 718 women718 women

Disordered eating associated with nicotine, alcohol, Disordered eating associated with nicotine, alcohol, and illicit drug useand illicit drug use

In adolescents, bulimia associated with alcohol In adolescents, bulimia associated with alcohol misuse and anorexia associated with illicit drug use misuse and anorexia associated with illicit drug use (cannabis, stimulants)(cannabis, stimulants)

Weak and inconsistent results-effects weak even Weak and inconsistent results-effects weak even when significantwhen significant

Substance use and ED not strongly related in non-Substance use and ED not strongly related in non-clinical samplesclinical samples

Becker (1995)Becker (1995)

One month after satellites brought TV to One month after satellites brought TV to this region, 63 Fijian secondary school this region, 63 Fijian secondary school girls interviewed (average age 17)girls interviewed (average age 17)

38 months later, another 65 girls 38 months later, another 65 girls interviewed (matched for age, wt., interviewed (matched for age, wt., etc.)etc.)

Becker (cont’d)Becker (cont’d)

15% of latter sample (vs. 3% in ’95) had 15% of latter sample (vs. 3% in ’95) had induced vomiting to control weightinduced vomiting to control weight

29% of latter sample (vs. 3%) scored at 29% of latter sample (vs. 3%) scored at risk for ED on EATrisk for ED on EAT

Before 1995, little talk of dieting on the Before 1995, little talk of dieting on the islandisland

69% of girls in the later study were dieting69% of girls in the later study were dieting

74% of the earlier sample said they felt too 74% of the earlier sample said they felt too fat at follow-upfat at follow-up

The Changing Faces The Changing Faces of Eating Disordersof Eating Disorders

MedicationsMedications

Dr. Nina SchlachterDr. Nina Schlachter

CLOZARIL (clozapine)CLOZARIL (clozapine)

GEODON (ziprasidone)GEODON (ziprasidone)

ABILIFY (aripiprazole)ABILIFY (aripiprazole)

RISPERDAL (risperidone)RISPERDAL (risperidone)

ZYPEXIA (olanzapine)ZYPEXIA (olanzapine)

SEROQUEL (quetiapine SEROQUEL (quetiapine fumerate)fumerate)

The Changing Faces The Changing Faces of Treatment of Treatment Gastric Bypass Gastric Bypass

SurgerySurgery

Dr. Nina SchlachterDr. Nina Schlachter

Causes of overweightCauses of overweight

GeneticsGenetics

Weight at time one finishes physical Weight at time one finishes physical growthgrowth

Arguably, simply overeating or food Arguably, simply overeating or food addictionaddiction

InsulinInsulin – stores – stores glucoseglucose

LeptinLeptin - satiety - satiety

GhrenlinGhrenlin - hunger - hunger

CCKCCK – fullness – fullness

PYY 3-36PYY 3-36 – fullness – fullness

ThermogenesisThermogenesis

Diet and exercise – 5-10% success Diet and exercise – 5-10% success raterate

Maximum of 18%Maximum of 18%

RegainRegain

Gastric bypass – 70% successGastric bypass – 70% success

BMI greater than 25 – overweightBMI greater than 25 – overweight

BMI greater than 30 – obeseBMI greater than 30 – obese

BMI greater than 40 – morbidly obeseBMI greater than 40 – morbidly obese

men 100 pounds overweightmen 100 pounds overweight

women 80 pounds overweightwomen 80 pounds overweight

Medical illnesses may be caused or Medical illnesses may be caused or exacerbated by obesityexacerbated by obesity

1.1. HypertensionHypertension

2.2. Diabetes mellitus type II (insulin resistant)Diabetes mellitus type II (insulin resistant)

3.3. HypercholesterolemiaHypercholesterolemia

4.4. SleepSleep

5.5. Gastric refluxGastric reflux

6.6. Stress incontinenceStress incontinence

7.7. Multiply joint pain and degenerationMultiply joint pain and degeneration

BMI over 40 – gastric bypass is now BMI over 40 – gastric bypass is now considered medicalconsidered medical

treatment of choicetreatment of choice

BMI 30-35 – gastric bypass is treatment BMI 30-35 – gastric bypass is treatment option if patientoption if patient

1.1. Has been at this weight 3-5 yearsHas been at this weight 3-5 years

2.2. Has been unable to lose weight other waysHas been unable to lose weight other ways

3.3. Has 1 or more life threatening illnessesHas 1 or more life threatening illnesses

(Medical insurance criteria)(Medical insurance criteria)

Intestinal bypassIntestinal bypass

Restrictive surgeriesRestrictive surgeries

Maladaptive Maladaptive surgeriessurgeries

Normal stomach contents:

Up to 2 quarts

Vertical BandVertical Band – most common – most common

Limits quantity to about 1 ounceLimits quantity to about 1 ounce

Staple limits stretching of pouchStaple limits stretching of pouch

Band is tightened through Band is tightened through external portexternal port

Side effects - sugarSide effects - sugar

Malabsorption surgeryMalabsorption surgery – most – most commoncommon

Abdominal or laproscopyAbdominal or laproscopy

Loop just below grehlin and just Loop just below grehlin and just above CCKabove CCK

Limits quantity to about 1 ounceLimits quantity to about 1 ounce

Side effectsSide effects

Death rateDeath rate

ReversibleReversible

Lifetime of malabosptive type of Lifetime of malabosptive type of bypassbypass

First 18 months rapid weight lossFirst 18 months rapid weight loss

VomitingVomiting

DumpingDumping

Psychological assessment and follow Psychological assessment and follow throughthrough

Pre-surgical assessmentPre-surgical assessment – – 1.1. No major No major psychiatric illnesspsychiatric illness

2.2. Realistic expectations Realistic expectations

3.3. Willingness to take Willingness to take partialpartial

responsibility for responsibility for changingchanging

eating and exercising eating and exercising behaviorsbehaviors

Psychological follow throughPsychological follow through

Post-surgeryPost-surgery – – 1.1. Nutritional counseling Nutritional counseling

2.2. Exercise program Exercise program

3.3. Body acceptance Body acceptance

4.4. Mourn food as comfort Mourn food as comfort

1.1. Eating Disturbances Before and After Vertical Banded Eating Disturbances Before and After Vertical Banded Gastroplasty: A Pilot Study. HSU, L.K. George, Gastroplasty: A Pilot Study. HSU, L.K. George, Betancourt, Sergio, Sullivan, Sean P., International Betancourt, Sergio, Sullivan, Sean P., International Journal of Eating Disorders. Volume 19, Number 1, 23-Journal of Eating Disorders. Volume 19, Number 1, 23-34. January, 1996.34. January, 1996.

2.2. Gastric Surgery and Restraint from Food as Gastric Surgery and Restraint from Food as Triggering Factors of Eating Disorders in Morbid Triggering Factors of Eating Disorders in Morbid Obesity. Guisado, Juan A., Vaz, Francisco J., Lopez-Obesity. Guisado, Juan A., Vaz, Francisco J., Lopez-Ibor, Juan J., Lopez-Ibor, M. Ines, del Rio, Julia, Rubio, Ibor, Juan J., Lopez-Ibor, M. Ines, del Rio, Julia, Rubio, Miguel A. International Journal of Eating Disorders. Miguel A. International Journal of Eating Disorders. Volume 31, 99-100. January, 2000.Volume 31, 99-100. January, 2000.

3.3. Obesity: The Continuing Saga. Journal Watch Obesity: The Continuing Saga. Journal Watch Psychiatry. December 2, 2002.Psychiatry. December 2, 2002.

4.4. Cincinnati’s Children’s Hospital Medical Center, Cincinnati’s Children’s Hospital Medical Center, Comprehensive Weight Management Center. 2001.Comprehensive Weight Management Center. 2001.

5.5. Obesity, diabetes are “epidemic.” McKenna, M.A.J. Obesity, diabetes are “epidemic.” McKenna, M.A.J. The Atlanta Journal and Constitution. 2002.The Atlanta Journal and Constitution. 2002.

6.6. Ralph Carson, Ph.D., R.D.Ralph Carson, Ph.D., R.D.

7.7. Emmett R. Bishop, M.D.Emmett R. Bishop, M.D.

8.8. James Champion, M.D.James Champion, M.D.

9.9. Harvard edu/ Harvard edu/ www.comwww.com

10.10. The Secret of Feeling Full. Gorman, Christine. Time The Secret of Feeling Full. Gorman, Christine. Time Magazine, August 19, 2002.Magazine, August 19, 2002.

11.11. The National EnquirerThe National Enquirer

12.12. Olanzaine Use as an Adjunctive Treatment for Olanzaine Use as an Adjunctive Treatment for Hospitalized Children with Anorexia Nevose: Case Hospitalized Children with Anorexia Nevose: Case Reports. Boachie, Ahmed, Goldfield, Gary S., Reports. Boachie, Ahmed, Goldfield, Gary S., Spettigue, Wendy. International Journal of Eating Spettigue, Wendy. International Journal of Eating Disorders, Volume 33, November 1, 98-103. January, Disorders, Volume 33, November 1, 98-103. January, 2003.2003.

Changing Faces of Changing Faces of TreatmentTreatment

Increased severity in the Increased severity in the medical/clinical picturemedical/clinical picture

Pregnancy and active eating disorder Pregnancy and active eating disorder behaviorsbehaviors

Obesity, gastric bypass and the Obesity, gastric bypass and the psychological aspects of weight psychological aspects of weight maintenance maintenance

Type I Diabetes and active eating Type I Diabetes and active eating disorder behaviorsdisorder behaviors

Mitchel-Gieleghem et al.Mitchel-Gieleghem et al.

Women born after 1960 are at Women born after 1960 are at greater risk for the greater risk for the development of bulimia development of bulimia nervosa, and these women are nervosa, and these women are in their childbearing yearsin their childbearing years..

Birth 29:3 Sept 2002Birth 29:3 Sept 2002

Detection of Eating Detection of Eating Disorders in Clinical Disorders in Clinical

PracticePractice

Initial BMI < 19Initial BMI < 19 Regular weigh-insRegular weigh-ins History of prolonged amenorrheaHistory of prolonged amenorrhea Past nutritional issuePast nutritional issue History of unexplained History of unexplained

spontaneousspontaneous

pregnancy losspregnancy loss

Detection of Eating Detection of Eating Disorders in Clinical Disorders in Clinical

PracticePractice Low body weightLow body weight History of infertilityHistory of infertility Range of weight gains and Range of weight gains and

losses over the course of her losses over the course of her life spanlife span

Patient’s identification of Patient’s identification of ideal body weightideal body weight

Birth 29:3 Sep 2002Birth 29:3 Sep 2002

Pregnancy Complications Pregnancy Complications Associated with Eating Associated with Eating

Disorder BehaviorsDisorder Behaviors Preterm deliveryPreterm delivery Low birth weightLow birth weight Intrauterine growth restrictionIntrauterine growth restriction Cesarean birthCesarean birth Low apgar scoresLow apgar scores

Eating Disorders, Fertility, and Pregnancy: Eating Disorders, Fertility, and Pregnancy:

RelationshipsRelationships and Complications, James 2001 and Complications, James 2001..

Mitchell-Gieleghem, 2002Mitchell-Gieleghem, 2002

13% of infants born to the women13% of infants born to the women

during the active phase of the disease during the active phase of the disease andand

6% of infants born after recovery from6% of infants born after recovery from

anorexia were delivered by Cesarean anorexia were delivered by Cesarean sectionsection

Birth 2002 Sep; 29 (3), pp. 182-191 Birth 2002 Sep; 29 (3), pp. 182-191

Impact of Eating Disorders Impact of Eating Disorders on Fertility and Pregnancy on Fertility and Pregnancy

OutcomeOutcome

““Complications in each phase of Complications in each phase of childbearing, from conception childbearing, from conception through postpartum, that jeopardize through postpartum, that jeopardize maternal and fetal well-being are maternal and fetal well-being are more likely to occur when an more likely to occur when an underlying eating disorder is underlying eating disorder is overlooked.”overlooked.”

Birth 29:3 Sept 2002 p 185Birth 29:3 Sept 2002 p 185

Bodily Sensations Bodily Sensations Associated with PregnancyAssociated with Pregnancy

Nausea Nausea VomitingVomiting Changes in hunger and fullnessChanges in hunger and fullness CravingsCravings FatigueFatigue BloatingBloating Physical changes: larger breast and Physical changes: larger breast and

abdomenabdomen Disruption in body imageDisruption in body image

Bodily Sensations Bodily Sensations Associated with Eating Associated with Eating

DisordersDisorders Nausea: strong feelings associated with Nausea: strong feelings associated with

real or perceived fullnessreal or perceived fullness Vomiting: inability to tolerate full feeling Vomiting: inability to tolerate full feeling

in stomach and fear of weight gainin stomach and fear of weight gain Changes in hunger and fullness: Changes in hunger and fullness:

inability to listen to increasing inability to listen to increasing physiological hunger cues or stop when physiological hunger cues or stop when cues stopcues stop

Cravings associated with obsessive food Cravings associated with obsessive food thoughts or need to self soothethoughts or need to self soothe

Bodily Sensations Bodily Sensations Associated with Eating Associated with Eating

DisordersDisorders Fatigue: inability to listen to body cues Fatigue: inability to listen to body cues

regarding eating, resting, and/or moderating regarding eating, resting, and/or moderating exerciseexercise

Bloating: inability to tolerate physiological Bloating: inability to tolerate physiological changes associated with fullness, hormonal changes associated with fullness, hormonal changes, real weight gain or fluid intakechanges, real weight gain or fluid intake

Physical changes: inability to differentiate Physical changes: inability to differentiate between real or imagined physiological changesbetween real or imagined physiological changes

Disruption in body image: body image Disruption in body image: body image negativity driven by low self esteem and poor negativity driven by low self esteem and poor self-acceptanceself-acceptance

National Institute of Health National Institute of Health

Five million Americans are so Five million Americans are so seriously overweight it affects their seriously overweight it affects their health and life expectancy.health and life expectancy.

Obesity surgery for 2002 Obesity surgery for 2002 reported reported

63,000 surgeries which 63,000 surgeries which constitutes a constitutes a

71% increase71% increase NIH Consensus Development Conference Statement 1991NIH Consensus Development Conference Statement 1991

Psychological Aspects of Weight Psychological Aspects of Weight Maintenance and Relapse in Maintenance and Relapse in

ObesityObesity

A number of psychological factors, A number of psychological factors, such as having unrealistic goals, such as having unrealistic goals, poor coping or problem solving poor coping or problem solving skills and low self-efficacy may skills and low self-efficacy may have an important effect on the have an important effect on the behaviors involved in weight behaviors involved in weight maintenance and relapse in obesity.maintenance and relapse in obesity.

Byrne, Journal of Psychosomatic Research, 53 (2002) 1029-Byrne, Journal of Psychosomatic Research, 53 (2002) 1029-10361036

Successful Weight Maintenance Successful Weight Maintenance and Weight Gainand Weight Gain

In this study, their were two classifications of groups:In this study, their were two classifications of groups:

Weight maintainerWeight maintainer: maintained for at least : maintained for at least one year, a weight loss of 5-10% of patient’s one year, a weight loss of 5-10% of patient’s maximum body weight or achieved and maintained maximum body weight or achieved and maintained a healthy weight (BMI=20-25) for more than 2 a healthy weight (BMI=20-25) for more than 2 yearsyears

Weight regainerWeight regainer: Subject who has returned to : Subject who has returned to their pretreatment weight their pretreatment weight

Psychological Aspects of Weight Maintenance and Relapse in Obesity Psychological Aspects of Weight Maintenance and Relapse in Obesity Journal of Psychosomatic Research 53 (2002) 1029-1036Journal of Psychosomatic Research 53 (2002) 1029-1036

Byrne 2002Byrne 2002

The main features distinguishing maintainers The main features distinguishing maintainers from regainers related to problem solving from regainers related to problem solving skills.skills.

Over 70% of the regainers attributed Over 70% of the regainers attributed their weight gain to eating in their weight gain to eating in response to stressful life events or to response to stressful life events or to negative emotional states.negative emotional states.

Escape-avoidance was the way regainersEscape-avoidance was the way regainers

coped engaging in eating, sleeping more or coped engaging in eating, sleeping more or wishing the problem would go away.wishing the problem would go away.

Byrne 2002Byrne 2002

Regainers are more likely to report Regainers are more likely to report over-eating in response to negative over-eating in response to negative emotional states than are emotional states than are maintainersmaintainers

Regainers may use food or eating to Regainers may use food or eating to moderate negative mood states than moderate negative mood states than apply more appropriate coping apply more appropriate coping strategiesstrategies

Byrne 2002Byrne 2002

Maintainers tend to cope more Maintainers tend to cope more successfully with adverse life events successfully with adverse life events than do regainersthan do regainers

Maintainers may be able to use Maintainers may be able to use problem-solving skills to cope with problem-solving skills to cope with stressful situations in a way that does stressful situations in a way that does not interfere with their adherence to not interfere with their adherence to a weight maintenance regimea weight maintenance regime

Gastric Bypass ScreeningGastric Bypass Screening

“ “ The need for psychiatric evaluation of The need for psychiatric evaluation of all patients with morbid obesity seeking all patients with morbid obesity seeking treatment in obesity units seem clear in treatment in obesity units seem clear in order to detect vulnerability factors that order to detect vulnerability factors that might lead to future psychiatric might lead to future psychiatric complications” complications”

International Journal of Eating Disorders, Jan (53) International Journal of Eating Disorders, Jan (53) 2002 p 992002 p 99

Patients Selected for Gastric Patients Selected for Gastric BypassBypass

““Obese patients selected for gastric Obese patients selected for gastric surgery seem to have a higher surgery seem to have a higher prevalence of major depression, prevalence of major depression, agoraphobia, simple phobia, PTSD, agoraphobia, simple phobia, PTSD, bulimia nervosa and personality bulimia nervosa and personality disorder.”disorder.”

International Journal of Eating Disorders, Jan (53) 2002 pp97-100International Journal of Eating Disorders, Jan (53) 2002 pp97-100

Gastric Bypass Gastric Bypass Psychological Risk FactorPsychological Risk Factor

“ “People suffering form morbid obesity People suffering form morbid obesity risk developing anorexic and bulimic risk developing anorexic and bulimic symptoms as a consequence of the symptoms as a consequence of the restrictions in eating behavior or restrictions in eating behavior or during the period of weight loss that during the period of weight loss that follows gastric surgery.”follows gastric surgery.”

International Journal of Eating Disorder, Jan(53)2002International Journal of Eating Disorder, Jan(53)2002

Eating Disorder and Eating Disorder and Nutrition Concerns Post Nutrition Concerns Post

Gastric BypassGastric Bypass Increased concern with the attention subjects paid to Increased concern with the attention subjects paid to

their weight, shape and appearancetheir weight, shape and appearance Difficulty separating needing to restrict certain foods Difficulty separating needing to restrict certain foods

post-gastric bypass due to digestion/absorption reasons post-gastric bypass due to digestion/absorption reasons vs. the emerging fears of weight gain or being out-of-vs. the emerging fears of weight gain or being out-of-control with foodcontrol with food

Difficulty accepting changes in body weight and size due Difficulty accepting changes in body weight and size due to quick weight loss vs. the reality of weight and sizeto quick weight loss vs. the reality of weight and size

Nausea due to over filling of pouch vs. vomiting due to Nausea due to over filling of pouch vs. vomiting due to inability to tolerating the feelings of fullnessinability to tolerating the feelings of fullness

Inability to separate food from feelings from gastric Inability to separate food from feelings from gastric bypassbypass

Diabetes and Eating Diabetes and Eating DisordersDisorders

Diabetes Management requires Diabetes Management requires adherence to a complex treatment plan, adherence to a complex treatment plan, including multiple injections of insulin including multiple injections of insulin daily, frequent self-monitoring of blood daily, frequent self-monitoring of blood glucose levels, regular exercise and glucose levels, regular exercise and attention to a dietary plan that attention to a dietary plan that emphasizes consistency in the timing, emphasizes consistency in the timing, quantity and types of food eaten.quantity and types of food eaten.

Daneman and Frank 1996Daneman and Frank 1996

Diabetes and Eating Diabetes and Eating DisordersDisorders

“ “Hunger associated with hypoglycemia Hunger associated with hypoglycemia encourages binge eating. These deviations encourages binge eating. These deviations from natural eating behaviors, combined with from natural eating behaviors, combined with weight loss at diagnosis and then weight gain weight loss at diagnosis and then weight gain associated with good glycemic control, disrupt associated with good glycemic control, disrupt the natural relationship between weight, the natural relationship between weight, hunger and satiety and thus promoting hunger and satiety and thus promoting abnormal eating patterns in Type I Diabetes.”abnormal eating patterns in Type I Diabetes.”

The Diabetes Control and Complications Trial Research Group The Diabetes Control and Complications Trial Research Group 19931993

Daneman, Olmsted, Rydall et al. 1998Daneman, Olmsted, Rydall et al. 1998

Diabetes Eating Behaviors Diabetes Eating Behaviors CharacteristicsCharacteristics

Metabolic controlMetabolic control Age of diabetes onsetAge of diabetes onset Illness durationIllness duration Body image and dissatisfactionBody image and dissatisfaction Drive for thinnessDrive for thinness Inappropriate eating/weight loss behaviorsInappropriate eating/weight loss behaviors laxatives/diuretic vomitinglaxatives/diuretic vomiting insulin under dosing food avoidanceinsulin under dosing food avoidance binge eatingbinge eating

POTENTIATION OF EATING POTENTIATION OF EATING DISORDERS BY TYPE I DIABETESDISORDERS BY TYPE I DIABETES

RODIN ET AL. 2002RODIN ET AL. 2002

DM DIET

DIETARY RESTRICTION

BINGE – EATING

WT GAIN

PURGING & INSULIN OMISSION

INSULIN THERAPY

Jones 2000Jones 2000

Research indicates that eating Research indicates that eating disorder associated with disorder associated with bingeing and purging, such as bingeing and purging, such as bulimia nervosa and binge bulimia nervosa and binge eating disorder, are the most eating disorder, are the most common types of eating common types of eating disorders among girls with disorders among girls with diabetes.diabetes.

Rodin et al. 1993Rodin et al. 1993

““Diabetes may increase dependence on Diabetes may increase dependence on parents at the very time teens are parents at the very time teens are struggling to gain greater struggling to gain greater independence—challenging the teen’s independence—challenging the teen’s development of a separate self”development of a separate self”

S. Maharaj 2001S. Maharaj 2001

““Standard interventions designed to Standard interventions designed to improve diabetes control, including improve diabetes control, including intensive diabetesintensive diabetes

management, are unlikely to be management, are unlikely to be effective as long as eating problems and effective as long as eating problems and family interaction difficulties persist.”family interaction difficulties persist.”

Eating Problems and the Observed Quality of Mother-Daughter Eating Problems and the Observed Quality of Mother-Daughter interactions among girls with Type I Diabetesinteractions among girls with Type I Diabetes

Journal of Consulting and Clinical Psychology Dec.(69)2001. Journal of Consulting and Clinical Psychology Dec.(69)2001. pp950-958pp950-958