The Alliance for Eating Disorders Awareness
Joann Hendelman, Ph.D., R.N., FAED, CEDS-SClinical Director
Johanna S. KandelFounder/CEO
Eating Disorders 101: How to Screen, Assess, and Diagnose Students with Eating Disorders
Eating Disorders Stats…
More than 30 Million Americans are currently battling
eating disorders
25% of college-aged students have eating disorders (NIMH 2012).
College administrators report a 24.3% rise in eating disorder behavior among college students (2010 National Survey of Counseling Center Directors).
91% of women on college campuses have attempted to control their weight through excessive dieting (ANAD)
At least three quarters (75%) of college students are dissatisfied with their weight (Soet, J. and T. Sevig, 2006)
Less than 20% who screened positive for EDs report receiving treatment on college campuses (Stanford 2013)
College Students and Eating Disorders
ACHA’s 2010 National College Health Assessment
44% of college women are dieting to lose weight
27% of college men are dieting to lose weight 61% of college women are exercising to lose
weight 45% of college men are exercising to lose
weight
College Students and Eating Disorders
“The mortality rate for those with anorexia nervosa is estimated at 5% per decade… making it one of the leading contributors to excess mortality of any of the psychiatric disorders. Research tells us that anorexia is a brain disease
with severe metabolic effects on the entire body. While the symptoms are behavioral, this illness has a biological
core, with genetic components, changes in brain activity and neural pathways
currently under study.”
Thomas Insel, M.D., Director, National Institute of Mental Health, Bethesda, MD, April 2007
Heritability in Anorexia and Bulimia
50 to 80% of cause is genetic AN & BN share common genes AN & BN run in families
“We think genes load the gun by creating behavioral susceptibility such as
perfectionism or the drive for thinness. Environment then pulls the trigger.”
– Walter H. Kaye, M.D.
Genetics
Contributing Factors Genetics Traumatic experiences Family difficulties Onset of mental illness History of substance abuse History of dieting Sports/activities where weight regulation is demanded Physical illness that causes weight loss Perfectionism Vegetarianism
Eating disorders display substantial co-morbidity with other mental health disorders.
While eating disorders often coexist with other mental health disorders, eating disorders often go undiagnosed and untreated.
A low number of sufferers obtain treatment for their eating disorder hence inaccurate measures of incidence (Only 1 in 10).
Eating disorders frequently impair the sufferer's home, work, personal, and social life.
Binge Eating Disorder is more common than anorexia or bulimia and is commonly associated with severe obesity.
Researchers found a surprisingly high rate of anorexia and bulimia among men, representing approximately one fourth of all the cases of each disorder.
Eating disorders DO NOT discriminate
between age, gender, race and class –
NO ONE IS IMMUNE
New Trends…
Men Women in Midlife Young Children
“Which of these trends has the highest percent increase?”
Women in Midlife Triggers
Desire to remain young in a society that does not let you grow old gracefully.
Divorce Rate in the U.S. (50%)MenopauseEmpty Nest SyndromeLoss (i.e. spouse, parent, child)Eating Disorders that were not
treated years prior
Males and Eating Disorders
• Recent research indicates that 1 in 4 people with eating disorders is male
• Rate of men with BED is similar to women
• Greater tendency to use compulsive exercise rather than purging for weight control.
• Preferred body image is muscular. • Increasing evidence as concerned
about body image as women.
Eating Disorders in Children
10% of eating disorders clients are < 10 years of age.
119% increase in hospitalizations in children < 12 yrs.
Nearly HALF of 3- to 6-year-old girls reported they worry about being fat (Tantleff-Dunn, 2009)
Children maturing earlier and earlier
Being teased by peers
Society’s obsession with thinness
OBESITY EDUCATION
.
Anorexia Nervosa:(Self-Starvation)
A self-imposed starvation resulting from a distorted body image and an
intense fear of gaining weight.
Demographics of Anorexia
1% of suburban female teens Bimodal peak of onset:
12-13 years old17 years old
50% restrictors (limit food and exercise)
50% bulimic subtype:also purge
Anorexia Nervosa:(Self-Starvation)
Restricting type - dieting, fastingand/or excessive exercise
Binge-eating/purging type - vomiting,
misuse of laxatives, enemas and/ordiuretics; carries greater medical
risk.
Review of Symptoms:Anorexia
Sizeable weight change Disturbed body image Cold
intolerance/hypothermia
Constipation Loss of muscle mass Depressive symptoms Anxiety Cognitive impairment
Dizziness/fainting Loss/delay menses
(Amenorrhea) Orthostatic
hypotension Self mutilation Sleep disturbance Brittle nails Thinning/dull hair
Physical Findings:Anorexia
Emaciation Bradycardia Hypothermia Lanugo hair Dry skin Carotenemia
Hyperkeratosis Edema Anemia Cyanotic
extremities Hypotension Gastroparesis
Anorexia: The Dangerous Reality
MortalityAnorexia Nervosa has the
highest mortality rate among all psychiatric disorders.
10 – 20 % will die○Death from cardiac arrest, suicide,
starvation, other medical complications
Bulimia Nervosa(Binge-Purge)
“A disorder in which an individual engages in episodes
of bingeing and purging.”
Demographics:Bulimia
21% of college-aged women Peak onset: college age Duration before presentation: 5
years Normal weight range
30% hx of obesity20% hx anorexia
Bulimia Nervosa(Binge-Purge)
75% - 85% of individuals with Bulimia are normal
weight to overweight
Review of Symptoms:Bulimia
Average weight w/ weight fluctuation
Disturbed body image
Depressive symptoms
Anxiety
Dizziness and fainting
Fatigue
Chipmunk facies
Abdominal pain
Self mutilation
Feelings of shame and guilt
Sleep disturbance
Bloating/heartburn
Bowel paralysis
Physical Findings:Bulimia
Normal or Overweight
Hypertensive Parotid
enlargement Dental erosions Russell's sign -
scars on knuckles Boerhaave
Syndrome
Edema Extremity
weakness Esophagitis Electrolyte
imbalance Sore throat Dehydration
Binge Eating Disorder(Bingeing)
“Recurrent episodes ofbinge eating without the
purging behavior ofBulimia Nervosa.”
Binge Eating Disorder
Recurrent episodes of binge eating with: Eating in discrete period of time an amount of food larger than most
people would eat A sense of lack of control over eating during the episode (a feeling
that one cannot stop eating or control what or how much one is eating)
The binge eating occurs at least once a week for three (3) months.
The binge eating episodes are associated with: eating much more rapidly than normal eating until feeling uncomfortably full eating large amounts of food when not feeling physically hungry eating alone because of feeling embarrassed by how much one is
eating feeling disgusted with oneself, depressed, or very guilty afterwards
Binge Eating Disorder : Physical Findings
Overweight or obesity
Gallbladder disease
Increased BP
Increased cholesterol
Heart disease
Type II diabetes
Lipid abnormalities
Osteoarthritis
Sleep apnea
Obesity
30-50% of hospital based obese population have BED
20-30% of patients seeking medical weight loss treatment have BED
Treatment issues of obesity with consideration of eating disorders (obesity prevention)Following involvement in an obesity prevention program,
30% of children aged 6-14 displayed one or more behaviors that could be associated with the development of an eating disorder (Science Daily, 2012)
Eating Disorders Not Otherwise Specified
Significant eating disorder that does not exactly meet
criteria for AN or BN
Avoidance/RestrictiveFood Intake Disorder
Persistent disturbance in eating leading toWeight loss/inadequate growthSignificant nutritional deficiencyDependence on tube feeding/nutritional
supplementsImpaired psycho-social functioning/inability to eat
with others
ExclusionsLack of food, cultural practiceOther medical/psychological issuesIrrational fear of weight & shape = eating disorder
Other Types of Eating Disorders
Orthorexia Muscle Dysmorphia Drunkorexia PICA Diabulimia
Orthorexia
Coined in 1997 by Steven Bratman, MD Defined as an obsession with "healthy or
righteous eating.” It often begins with someone's simple and
genuine desire to live a healthy lifestyle. The severe restrictive nature of orthorexia
could easily morph into anorexia. Can result after major illness
Muscle Dysmorphia
Obsess/worry about being small, underdeveloped, and/or underweight.
Many are obsessed with having the perfect physique and are addicted to lifting weights.
Muscle-bound, but believe their muscles are inadequate.
Steroid abuse, unnecessary plastic surgery, and even suicide.
Drunkorexia A non medical term, for the
practice of swapping food calories for those in alcohol.
Statistics suggest that 30% of 18-24 year olds skip food in order to drink more.
Also known as a mixture of alcoholism, bulimia and anorexia
Prominent among young college women who skip meals so they can get drunk at night and not worry about the calories
PICA (as an Eating Disorder)
Pica is disorder in which a person has a strong desire to eat, lick, or chew non-food items in lieu of eating caloric foods.
Persistent eating of nonnutritive substances for a period of at least 1 month. The eating of nonnutritive substances is inappropriate to the developmental level.
Diabulimia:Type 1 Diabetes
"Diabulimia" is used to describe people with diabetes that manipulate their intake of insulin in order to temporarily alter their weight.
"Diabulimia" is extremely seriousDoubled rate of physical toll taken on the body
than diabetes or an eating disorder alone. Manipulation of ketone levels may result in
dehydration, kidney dysfunction, and blindness.
40% mortality rate.
Warning!!!
Do NOT ask your patient if
they are manipulating their insulin in order to lose weight. You do not
want to teach them a ‘trick!’
Screening Questions Do you feel big/small in your body? When/what did you last eat? What did you eat
yesterday? Do you have forbidden foods? What is your ideal body weight? How often do you
weigh yourself? Have you lost/gained weight within the last 3 months? What has your weight range been?
Do you make yourself sick (i.e. purge) when you feel uncomfortably full?
Do you binge? What constitutes a binge for you? Do you eat when you’re hungry and stop when you are
full? Do you worry you have lost control over how much you eat?
Would you say that food/ food thoughts dominate your life?
What is your exercise regimen? Be mindful when screening not to ignore males!!
Evaluation of patients with eating disorders
History:
Weight/diet history
Menstrual history & pattern
Body image disturbance
Eating habits Binge eating &
purging behaviors
Current & past medications
Substance abuse
Exercise regimen Compensatory behaviors:
laxative, diuretic, diet pills/stimulants, ipecac use
Suicidal ideationsPsychiatric history○ including - family history
of disordered eating, addictive disorders, depression, anxiety, etc.
Sexual history
Evaluation Continued
Systems:Vitals○ Body temperature○ Heart rate○ Blood pressure○ Height & weight
Heart:Cardiac arrhythmiasHeart palpitationsChest pain
Heent:PerimyolysisDental cariesChipped teethMouth soresSialadenosis
Physical exam:
Evaluation Continued
EndocrineAmenorrhea/irregular
mensesLoss of libidoDecreased bone density OsteoporosisInfertility Poor glucose control &
diabetic ketoacidosis (in diabetics)
Physical exam:
SkinDry skinBrittle nailsCarotenemia PigmentationHair loss/thinningLanugo hairRussell’s signPoor wound
healing
Evaluation Continued
Labs/Studies
EKG CBC w/ diff Full thyroid panel (T², T³, T, TSH) Urinalysis; specific gravity, sodium Bone density scan Complete metabolic profile Full chemistry amylase Serum magnesium/glucose/electrolytes Amenorrhea evaluation
Evaluation Continued
Special Circumstances (e.g. clients <15% IBW)Chest x-rayComplement 324 hour creatinine clearanceUric acidBrain scanEchocardiogramSkin testing for immune functioningDXA scan (amenorrhea 6+ months)Estradiol level (or testosterone in males)ANA, amylase, lipase, LH, FSH, prolactinUGI+/-SBFT
Laboratory Clues
Low Glucose = Poor nutrition High Glucose = Insulin omission Low Potassium = Vomiting, laxatives, etc Low Chloride = Vomiting High Chloride = Laxatives High Blood Bicarbonate = Vomiting Low Blood Bicarbonate = Laxatives High Blood Urea Nitrogen = Dehydration
Laboratory Clues
High Creatinine = Dehydration Low Calcium = Poor nutrition at expense of
bone Low Phosphate = Poor nutrition or refeeding Low Magnesium = Poor nutrition or laxatives High Amaylase = Vomiting, pancreatitis High Lipase = Pancreatitis High Total Bilirubin = Liver dysfunction High Total Protein/Albumin = Malnutrition
Occasional Lab Findings
HormonesLow Estradiol (Females)Low Testosterone (Males)
Lipids: anything goesHigh Cholesterol = Short term starvationLow Cholesterol = Long term starvation
“Sick euthyroid” Low T4, normal TSH
Electrocardiogram
Usually normal Bradycardia or other arrhythmias Signs of hypokalemia Low voltage changes Prolonged QTc – Greater than 440 Occasional ST-segment depression
Criteria for Hospitalization
Weight more than 25% below IBW Bradycardia < 50 BPM Temperature < 96 degrees F (< 35.6
C) Hypotension < 80/50 mm Hg Orthostasis > 20 BMP Hypokalemia < 3 Renal failure ECG abnormalities Failure in outpatient intervention Suicidality
Role of the Practitioner
Selling patients treatment they don’t want for a
problem they don’t think they have
Do’s
Offer empathy Roll with the
resistance Avoid
accusations/arguing/ pressuring
Ask open ended questions
Listen reflectively Affirm/validate Summarize
Motivational Interviewing:
Don’ts
Do not believe all patient reports are accurate
Do not tell an underweight person with ED’s to “just eat” or they are “lucky” to be thin
Do not tell an overweight person to just stop eating
Do not expect this will go away with time
DON’T DELAY with early onset ED symptoms
Clinic Culture
WeighingOffice staff must be trained to use standardized
protocols to record consistent, reliable measurements
Scale should be located in a private area
Client should be weighed backwards to avoid revealing their true weight to them (Blind weights)
Be aware that clients may drink extra fluids (water-loading), put weight in pockets/rocks in underwear, and/or wear layers of extra clothing before being weighed
Weighing
Never leave chart unattended – and do not vocalize number or share whether it’s up/down
Comments about weight should be minimized and made discretely
Clinic Culture
Clinic Culture When words have unintentional meanings
“Healthy” Fat Gained weight Out of Control
“Look Better” Fat Gained weight Out of Control
“You look very nice today” Fat Gained weight Out of Control
Clinic Culture They Said What???
“If you have an eating disorder, then why aren’t you skinnier?”
“So what? An eating disorder? I’ve had one of those…This is all your choice. Some people have real problems.”
“You’re a guy, and guys don’t get eating disorders.”“No you don’t have an eating disorder…you’re not
that skinny and your teeth are not yellow.”“I had an eating disorder when I was younger, but I
weighed much less than you do now.”“You can starve yourself, and binge and purge as
much as you want as long as you take vitamins, and don’t hit your head when you pass out. You’ll grow out of this stage eventually.”
Hostile Recovery Environment
We are In A Hostile Recovery Environment
Pervasive on college campuses
Glamorization/encouragement of the illness
Thinness = control, popularity, success, relational connection
Fat = out of control, shunned, failure, relational rejection
Readily available and legal drug of choice
War on Obesity
Questions?For more information, please call:
The Alliance for Eating Disorders Awareness
(866) 662-1235www.allianceforeatingdisorders.com
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