EATING DISORDERS

CONCEPT OF EATING DISORDERS

Eating disorders are complex conditions that

arise from a combination of long-standing
behavioral, emotional, psychological,
interpersonal, and social factors.
 Defination of eating disorders

Eating disorders are conditions defined by

abnormal eating habits that may involve either
insufficient or excessive food intake to the
detriment of an individual’s physical and mental
health.
Bulimia nervosa and anorexia nervosa are the
most common specific forms in the united
kingdom.
Assessing Eating Disorders
 Assessing Eating Disorders

No specific tests to diagnose

No routine screening for eating disorders

Medical history, physical exam, and specific

screening questions, along with other
assessment tests help to identify eating
disorders
 What should an assessment include?

A full physical exam

Laboratory and other diagnostic tests
A general diagnostic interview
Specific interview that goes into more detail
about symptoms
 Thorough Medical Assessment
Physical Exam
– Check weight
– Blood pressure, pulse, and temperature
– Heart and lungs
– Tooth enamel and gums
Nutritional assessment/evaluation
– Eating patterns
– Biochemistry assessment—how chemistry with eating
disorders contributes to additional appetite decline and
decreased nutritional intake
 Thorough Medical Assessment
Lab & other diagnostic tests
– Blood tests
– X-rays
– Other tests for heart and kidneys
Interviews
– History of body weight
– History of dieting
– Eating behaviors
– All weight-loss related behaviors
– Past and present stressors
– Body image perception and dissatisfaction
 Mental Health Assessment

Screen for depression

Self-esteem
Anxiety
Appearance, mood, behavior, thinking, memory
Substance, physical, or sexual abuse
Any mental disorders?
 Screening Questions

Some sample questions to ask during an interview

include:
– How many diets have you been on in the past year?
– Do you think you should be dieting?
– Are you dissatisfied with your body size?
– Does your weight affect the way you think about yourself?
Any positive responses to these questions should
prompt further evaluation using a more comprehensive
questionnaire
 Assessment Tools

There are numerous tests that can be used to

assess eating disorders

EAT, EDI-2, PBIS, FRS, and SCOFF are some

of the more popular tests
 EAT (Eating Attitudes Test)
26 item self-report questionnaire broken down into 3
subscales
– Dieting
– Bulimia & food preoccupation
– Oral control
Designed to distinguish patients with anorexia from weight-

preoccupied, but healthy, female college students

Has advantages & limitations

– Subjects are not always honest when self-reporting
– Has been useful in detecting cases of anorexia nervosa
 EDI-2 (Eating Disorder Inventory)
A self-report measure of symptoms
Assess thinking patterns & behavioral characteristics
of anorexia and bulimia
8 subscales
– 3 about drive for thinness, bulimia, & body dissatisfaction
– 5 measure more general psychological traits relevant to
eating disorders
Provides information to clinicians that is helpful in
understanding unique experience of each patient
Guides treatment planning
 PBIS
(Perceived Body Image Scale)
Provides an evaluation of body image
dissatisfaction & distortion in eating disordered
patients
A visual rating scale
11 cards containing figure drawings of bodies
ranging from emaciated to obese
Subjects are asked 4 different questions that
represent different aspects of body image
 FRS
(Figure Rating Scale)
Widely used measure of body-size estimation
9 schematic figures varying in size
Subjects choose a shape that represents:
– their "ideal" figure
– how they "feel" they appear
– the figure that represents "society’s ideal" female figure
Used to determine perception of body shape
Used for self and “target” body size estimation
 SCOFF
Questionnaire to determine eating disorders
– Sick
– Control
– One stone
– Fat
– Food
1 point for every “YES” answer
Score greater than 2 means anorexia and/or bulimia
Differential
Diagnosis
 Anorexia Nervosa

Superior Mesenteric Artery Syndrome

Major Depressive Disorder
Schizophrenia
 Bulimia Nervosa

Kleine-Levin Syndrome
Major Depressive Disorder
Borderline Personality Disorder
ETIOLOGY OF EATING DISORDER

Personality Traits
Genetics
Environmental Influences
Biochemistry
 Personality Traits
Low self-esteem
Feelings of inadequacy or lack of control in life
Fear of becoming fat
Depressed, anxious, angry, and lonely feelings
Rarely disobey
Keep feelings to themselves
Perfectionists
Achievement oriented
– Good students
– Excellent athletes
– Competitive careers
 Personality traits contribute to the development of
eating disorders because:

Food and the control of food is used as an attempt to cope

with feelings and emotions that seem overwhelming
Having followed the wishes of others...
– Not learned how to cope with problems typical of adolescence,
growing up, and becoming independent
People binge and purge to reduce stress and relieve
anxiety
Anorexic people thrive on taking control of their bodies and
gaining approval from others
Highly value external reinforcement and acceptance
 Genetic Factors

Increased risk of anorexia nervosa among first-degree biological relatives of

individuals with the disorder
increased risk of mood disorders among first-degree biological relatives of people
with anorexia, particularly the binge-eating/purging type.
Twin studies
– concordant rates for monozygotic twins is significantly higher than those for dizygotic
twins.
Mothers who are overly concerned about their daughter’s weight and physical
attractiveness might cause increase risk for development of eating disorders.
Girls with eating disorders often have brothers and a father who are overly
critical of their weight.
 Genetics Linked to Anorexia, Bingeing
- Indianapolis Star, March 12, 2006
2 new studies show that genetics may outweigh
environmental factors in producing eating disorders.
1) Records from 30,000 Swedish twins found identical
twins more likely to share an eating problem than fraternal
twins or non twin siblings
• found that genes were responsible for 56% of the
cases.
– “People need to understand that they are fighting their
biology and not just a psychological need to be thin” - Dr.
Cynthia Bulik of University of North Carolina
School of Medicine
 Genetics linked to anorexia, bingeing
- Indianapolis Star, March 12, 2006
2) Strong genetic contribution to binge-eating - Dr. James Hudson
at Harvard Medical School
– Interviewed the parents, siblings, and children of 300 people,
half with a history of binge-eating
– Findings:
• family members of binge-eaters were twice as likely to
have a similar eating disorder than those without a history.
• relatives of binge-eaters were more than twice as likely to
be obese
 Environmental Factors
- Interpersonal and Social
Interpersonal Factors
– troubled family and personal relationships
– difficulty expressing emotions and feelings
– history of being teased or ridiculed based on size or
weight
– history of trauma, sexual, physical and/or mental
abuse
• 60-75% of all bulimia nervosa patients have a history of
physical and/or sexual abuse
 Environmental Factors
Social Factors (media and cultural pressures)
– Cultural pressures that glorify "thinness" and place value on
obtaining the "perfect body”
– Narrow definitions of beauty that include only women and men of
specific body weights and shapes
– Cultural norms that value people on the basis of physical
appearance and not inner qualities and strengths
– People pursing professions or activities that emphasize thinness
are more susceptible
• ie. Modeling, dancing, gymnastics, wresting, long distance
running
 Environmental Factors
Media messages help to create the context within
which people learn to place value on the size and
shape of their body.
– Advertising and celebrity spot lights scream “thin is in,”
defining what is beautiful and good.
– Media has high power over the development of self-
esteem.
 Some Basic Facts About the Media’s Influence in Our Lives:

According to a recent survey of adolescent girls, the media is

their main source of information about women’s health issues

Researchers estimate that 60% of Caucasian middle school girls

read at least one fashion magazine regularly

Another study of mass media magazines discovered that

women’s magazines had 10.5 times more advertisements and
articles promoting weight loss than men’s magazines did
The average young adolescent watches 3-4 hours of TV
per day

A study of 4,294 network television commercials

revealed that 1 out of every 3.8 commercials send some
sort of “attractiveness message,” telling viewers what is
or is not attractive (as cited in Myers et al., 1992). These
researchers estimate that the average adolescent sees
over 5,260 “attractiveness messages” per year.
A study of one teen adolescent magazine over
the course of 20 years found that in articles
about fitness or exercise plans, 74% cited “to
become more attractive” as a reason to start
exercising and 51% noted the need to lose
weight or burn calories
 Biochemical Factors
Chemical imbalances in the neuroendocrine system
– these imbalances control hunger, appetite, digestion, sexual function,
sleep, heart and kidney function, memory, emotions, and thinking

Serotonin and norepinephrine are decreased in acutely ill anorexia and

bulimia patients
– representing a link between depression and eating disorders

Excessive levels of cortisol in both anorexia and depression

– caused by a problem that occurs in or near the hypothalamus
 Eating Disorders ICD-10 Classification

ANOREXIA NERVOSA

BULIMIA NERVOSA

OBESITY( overeating associated with other psychological

disturbances )
 EPIDEMIOLOGY
Over one-half of teenage girls and one-third of
teenaged boys use unhealthy weight control behaviors
such as skipping meals, smoking, fasting, vomiting,
or taking laxatives
42% of 1st-3rd grade girls want to be thinner
81% of 10 year olds are afraid of being fat
The average woman is 5’4’’ and weighs 140
pounds. The average supermodel is 5’11’’ and
weighs 117 pounds.

Americans spend over $40 billion on dieting and

diet related products each year
 Anorexia Nervosa
– Characterized by excessive weight loss
– Self-starvation
– Preoccupation with foods, progressing restrictions
against whole categories of food
– Anxiety about gaining weight or being “fat”
– Denial of hunger
– Consistent excuses to avoid mealtimes
– Excessive, rigid exercise regimen to “burn off” calories
– Withdrawal from usual friends
Anorexia nervosa
 Anorexia
Symptoms
– Resistance to maintaining body weight at or above a
minimally normal weight for age and height
– Intense fear of weight gain or being “fat” even though
underweight
– Disturbance in the experience of body
weight or shape on self-evaluation
– Loss of menstrual periods in girls and
women post-puberty
 Anorexia

What do counselors look for?

– Rapid loss of weight
– Change in eating habits
– Withdrawal from friends or social gatherings
– Peach fuzz
– Hair loss or dry skin
– Extreme concern about appearance or dieting
 Anorexia

Age Range
– Most cases are in women ranging in age from early
teens to mid-twenties
– Recently there have been more cases of women and
men in 30’s and 40’s suffering from an eating
disorder
– 40% of newly identified cases are in girls 15-19
– Significant increase in women aged 15-24
 Anorexia

Prevalence in Population
– 0.5%-1% of women from late adolescence to early
adulthood meet the full criteria for anorexia
– Even more are diagnosed under a sub threshold
– Limited data on number of males with anorexia
– 10 million people have been diagnosed with having
an eating disorder of some type
 Anorexia Nervosa
*onset and course
mean age at onset is 17 years
affects about 1% of all females in late adolescence and early
adulthood
bi-modal peaks at ages 14 and 18
rarely occurs in females over age 40
course and outcome are highly variable
• recover after a single episode
• fluctuation pattern of weight gain followed by relapse
• chronic deteriorating course of the illness over many
years
 Anorexia Nervosa
*onset and course cot.
Deluded thinking develops
– some girls believe they can ward of pregnancy by
being thin
– fast track professionals believe the only way they
can compete in a “man’s world” is to be thin
– being thin is the only way to receive attention
 Health Consequences of Anorexia Nervosa

Abnormally slow heart rate and low blood pressure, which mean that the
heart muscle is changing. The risk for heart failure rises as heart rate and
blood pressure levels sink lower and lower.
Reduction of bone density (osteoporosis), which results in dry, brittle
bones.
Muscle loss and weakness.
Severe dehydration, which can result in kidney failure.
Fainting, fatigue, and overall weakness.
Dry hair and skin, hair loss is common.
Growth of a downy layer of hair called lanugo all over the body, including
the face, in an effort to keep the body warm.
 COMPLICATION OF ANOREXIA
NERVOSA
Neurological
– Psuedo-atrophy of brain
– Sleep disturbances
– Neural damage
– Neurotransmitter disturbances (CCK; serotonin – happy hormone in brain
& gut)
Dermatological
– Lanugo
– Alopecia
– Acrocyanosis
– Xerosis
– Brittle fingernails
– Yellow-coloured skin (hypervitaminosis A/ hypercarotaemia )
Endocrine
  thyroxine level with normal TSH level
  production of ACTH leads to  production of stress hormone cortisol
by adrenal cortex, resulting in release of protein from muscle (wasting)
 production of FSH and LH; this leads to production of oestrogen &
progesterone in females;  production of testosterone in males
ANOREXIA contd
Cardiovascular
– Sinus bradycardia (as low as 30 bpm)
– Hypotension
  in myocardium
– NB cause of mortality – sudden death in AN
Heamatological
– Anaemia; leucopaenia (impaired cell-mediated immune func) – however not more prone
to infectious diseases; thrombocytopaenia
GIT
  concentration of serum liver enzymes and sometimes hepatomegaly
  serum cholesterol (inverse to weight)
  gastric emptying &  gut motility
– Constipation
Renal
– Dehydration & possible irreversible renal tubule damage
– Partial diabetes insipidus may occur secondary to abnormal vasopressin release with 
renal concentrating capacity
– Renal calculi
Skeletal
  oestrogen and  cortisol levels are largely implicated
– If menstruation interrupted for a prolonged period of time, bone loss
results.
  risk of fractures and osteoporosis
Refeeding syndrome
– Syndrome characterised by +++ fluid & electrolyte shifts
– Hypokalemia
– Hyponatremia
– Hypophosphatemia
– Hypomagnesemia
– Oedema
– Also: hyperglycaemia, rebound hypoglycaemia, possible nausea and
vomiting, possible diarrhoea, possible cardiopulmonary failure….. death
 COMPLICATION

Hypothalamus

Changes in the production of specific hormone-releasing factors

PITUATARY

 
Reduced production of TSH Increased production of ACTH
Reduced production of FSH and LH
THYROID GLAND
Reduced production of thyroxine,
resulting in slowed heart rate, low blood
pressure, poor thermal response
and cold extremities ADRENAL CORTEX

Increased production of cortisol as a

normal stress response, resulting in release
                                             
of protein from muscle and muscle wasting
GONADS

Reduced production of oestrogen

and progesterone in females,
resulting in loss of ovulation
and menstruation

Reduced production of testosterone

Endocrine effects of starvation (Trotter 1997)
in males resulting in impotence
“I want to go to sleep and not wake up, but I
don't want to die. I want to eat like a normal
person eats, but I need to see my bones or I will
hate myself even more and I might cut my heart
out or take every pill that was ever made.” 
― Laurie Halse Anderson, Wintergirls
“Anorexia is not an illness of the body; it is an
illness of the mind.” 
― Lynn Crilly, Hope with Eating Disorders

“Anorexia cannot be cured by treating the

physical symptoms alone; it is the mind which
must be treated.” 
― Lynn Crilly, Hope with Eating Disorders
 Anorexia Treatment
Three main phases:
– Restoring weight lost
– Treating psychological issues,
– such as:
• Distortion of body image, low
• self-esteem, and
• interpersonal conflicts.
• Psychological support
- Achieving long-term remission
and rehabilitation.
Early diagnosis and treatment increases the treatment
success rate.
Hospitalization (Inpatient)
– Extreme cases are admitted for severe weight loss
– Feeding plans are used for nutritional needs
• Intravenous feeding is used for patients who refuse to eat or the
amount of weight loss has become life threatening
Weight Gain
– Immediate goal in treatment
– Physician strictly sets the rate of weight gain
• Usually 1 to 2 pounds per week
• In the beginning 1,500 calories are given per day
• Calorie intake may eventually go up to 3,500 calories per day
Nutritional Therapy
– Dietitian is often used to develop strategies for
planning meals and to educate the patient and
parents
– Useful for achieving long-term remission
BULIMIA NERVOSA
 Description

Recurrent episodes of binge eating. An episode of

binge eating is characterized by both of the following:
-eating, in a discrete period of time (e.g., within any
2-hour period), an amount of food that is definitely
larger than most people would eat during a similar
period of time and under similar circumstances
-a sense of lack of control over eating during the
episode (e.g., a feeling that one cannot stop eating
or control what or how much one is eating)
 Description
Recurrent inappropriate compensatory behavior in order to
prevent weight gain, such as self-induced vomiting; misuse
of laxatives, diuretics, enemas, or other medications; fasting;
or excessive exercise.
The binge eating and inappropriate compensatory behaviors
both occur, on average, at least twice a week for 3 months.
Self-evaluation is unduly influenced by body shape and
weight.
The disturbance does not occur exclusively during episodes
of Anorexia Nervosa.
 Symptoms
Eating large amounts of food uncontrollably (binging)
Vomiting, using laxatives, or using other methods to eliminate food
(purging)
Excessive concern about body weight
Depression or changes in mood
Irregular menstrual periods
Unusual dental problems, swollen
cheeks or glands, heartburn,
or bloating (swelling of the stomach)
BULIMIA NERVOSA
 Warning Signs That Counselors
Look For
Evidence of binge eating
Evidence of purging behaviors
Excessive, rigid exercise regimen
Unusual swelling of the cheeks and jaw area
Calluses on the back of the hands and knuckles
from self-induced vomiting
Discoloration or staining of teeth
 Warning Signs That Counselors
Look For
Creation of lifestyle schedules and rituals to make time for
binge-and-purge sessions
Withdrawal from friends and activities
In general, behaviors and attitudes indicating that weight
loss, dieting, and control of food are becoming primary
concerns
 Developmental Level

The average onset of Bulimia begins in late

adolescence or early adult life
– Usually between the ages of 16 and 21
However, more and more women in their 30s are
reporting that they suffer from Bulimia
 Prevalence

The prevalence of Bulimia Nervosa among

adolescent and young adult females is
approximately 1%-3%.
The rate of occurrence in males is approximately
one-tenth of that in females.
 Bulimia Nervosa
*onset and course
usually begins in late adolescence or early adult life and
affects 1-2% of young women
90% of individuals are female
frequently begins during or after an episode of dieting
course may be chronic or intermittent
for a high percentage the disorder persists for at least
several years
periods of remission often alternate with recurrences of binge
eating
purging becomes an addiction
 Bulimia Nervosa
*onset and course cont..
occurs with similar frequencies in most
industrialized countries
most individuals presenting with the disorder in
the U.S. are Caucasian.
only 6% of people with bulimia receive mental
health care
the incidence of bulimia in 10-39 year old
women TRIPLED between 1988 and 1993
 Health Consequences of Bulimia Nervosa:
Causes electrolyte imbalances that can lead to irregular
heartbeats and possibly heart failure and death. Electrolyte
imbalance is caused by dehydration and loss of potassium and
sodium from the body as a result of purging behaviors.
Inflammation and possible rupture of the esophagus from
frequent vomiting.
Tooth decay and staining from stomach acids released during
frequent vomiting.
Chronic irregular bowel movements and constipation as a result
of laxative abuse.
Gastric rupture is an uncommon but possible side effect of
binge eating.
 Onset often associated with a
stressful life event:
leaving home for college
termination or disruption of an intimate
relationship
family problems
physical abuse
sexual abuse
 COMPLICATIONS

Neurological
– Disturbances in serotonin levels
– Blunting of postprandial CCK( cholecystokinin) release – decreased
satiety
Dermatological
– Dry skin
– Russell’s sign
Endocrine
– Usually continue to menstruate; dysmenorrhea is common
– Blunting of TSH and GH in response to thyroid-releasing hormone
– Hyper-and hypoglycaemia
Cardiovascular
– Idiopathic oedema may be present; often attributable to laxative/ diuretic
 COMPLICATIONS OF BULIMIA
NERVOSA
Metabolic: electrolyte abnormalities, particularly
hypokalemic, hypochloremic
alkalosis ,hypomagnesemia.
Digestive – gastrointestinal: salivary gland and
pancreatic inflammation and enlargement with
increase in serum amylase , esophageal and
gastric erosion, dysfunction bowel with haustral
dilation.
Dental : erosion of dental enamel , particularly of
froth teeth , with corresponding decay.
Neuropsychiatric: seizures , mild neuropathies ,
fatigue and weakness , mild congnitive disorder.
 Bulimia Treatment
Primary Goal
– Cut down or eliminate binging and purging
– Patients establish patterns of regular eating
Treatment Involves:
– Psychological support
• Focuses on improvement of attitudes related to E.D.
• Encourages healthy but not excessive exercise
• Deals with mood or anxiety disorders
– Nutritional Counseling
• Teaches the nutritional value of food
• Dietician is used to help in meal planning strategies
– Medication management
• Antidepressants (SSRI’s) are effective to treat patients
who also have depression, anxiety, or who do not respond
to therapy alone
• May help prevent relapse
 The problem with writing a book about bulimia is that
whenever you go to the washroom, people think you're
throwing up.
Emma Forrest

 Exercise is the yuppie version of bulimia.

Barbara Ehrenreich
 OBESITY
Obesity is a complex resulting from a combination of
genetic susceptibility, increased availability of high-
energy foods, and decreased requirement for
physical activity in modern society.
OBESITY
 Prevalence

The prevalence of obesity has reached epidemic

proportions in industrialized countries and is now
considered the leading cause of preventable
death in united states.because it is associated
with significant increases in morbidity and
mortality.
 Epidemiology of obesity

Obesity rates continue to grow at epidemic

proportions in the united states and other
industrialized nations, representing a serious
public health threat to millions of people.
In the united states , 34 % of the population is
overweight
 Etiology of obesity

Physical activity factors

Brain-damage factors
Health factors
Other –cushing’s disease, myxedema
Physical activity factors- the marked decrease
in physical activity inaffluent societies seems to
be the major factor in the rise of obesity as a
public health problem.
Brain-damage factors- destruction of the
ventromedial hypothalamus can produce obesity
in animals, but this is probably a very rare cause
of obesity in humans.
Health factors – in only a small number of cases
is obesity the consequence of identifiable illness.
Such cases include a variety of rare genetic
disorders, such as prader-willi syndrome, as well
as neuroendocrine abnormalities.
 Diagnosis and clinical features

The diagnosis of obesity , if done in a

sophisticated way , in volves the assessment of
body fat. As this is rarely practical ,the use of
height and weight to calculate BMI is
recommended .
The habitual eating patterns of many obese
person often seem similar to patterns found in
experimental obesity.
Impaired satiety is a particularly important
problem.
Obese person are usually susceptible to all
kinds of external stimuli to eating .but they
remain relatively unresponsive to the usually
internal signals of hunger.
Treatment of obesity
 Objectives

Describe the efficacy of the following for the treatment of

obesity:
– Behavioral methods
– Pharmacological therapy
– Surgical approaches
Identify the pros and cons of self-help diets for the
treatment of obesity.
Review new guidelines for successful outcomes
in obesity treatment.
 Treatment of Obesity
Behavioral
Pharmacological
Surgical
Self help programs and books
Behavioral Treatment Philosophy

Consists of a set of principles and techniques

to modify eating and activity habits.

Emphasizes small and sustainable changes.

 Behavioral Treatment Methods
Identifying Patterns
Buy chips
Leaves chips on table
Come home from work, tired and hungry
See kids eating chips
Eat several handfuls of chips standing up
Feel guilty
Finish bag of chips
 Behavioral Treatment Methods
Self-monitoring
– Recording food intake/evaluating nutrients
– Recording physical activity
Stimulus control techniques
– Time
– Place
– Activity
– Sight/smell
– Emotions
Behavioral Treatment Methods
Rationale for Increasing Physical Activity

Associated with significant health benefits.

Single best predictor of weight maintenance.

Not associated with short-term weight loss.

Behavioral Treatment Methods
Increasing Physical Activity
Identify barriers
– Lack of time
– Lack of motivation
– Increased safety concerns
Prescribe small changes
– Take the stairs
– Gardening
– Walking during work
Behavioral Treatment Results

10% reduction over 20 to 24 weeks

33% regain at one year

More weight regained over time

 Improving Weight-loss Maintenance

Continued care

Sustaining dietary changes

Exercise

Pharmacotherapy
 Treatment of Obesity
Pharmacological Therapy
Pharmacological interventions to facilitate weight
loss and behavior change include:
– Enhancing satiety
– Decreasing fat absorption
– Increasing energy expenditure
– Decrease appetite
 Sibutramine (Meridia)
Mechanism of Action
Serotonin and norepinephrine re-uptake
inhibitor (SNRI).
Animal research data shows drug reduces
body weight by:
– Decreasing food intake in rats
– Stimulates thermogenesis in rats
 Sibutramine (Meridia)
Summary of Research Findings
6% to 8% weight loss with 10 to 15 mg/day.

2% weight loss with placebo.

Published data available up to one year.

 Sibutramine (Meridia)
Summary of Reported Adverse Event
Percent (%) of Patients
Adverse Event Placebo (n = 884) Sibutramine (n=2068)
Dry mouth 4 17
Anorexia 4 13
Constipation 6 12
Insomnia 5 11
Appetite increase 3 9
Dizziness 4 7
Nausea 3 6
Package insert data, Sibutramine, 1998.
 Sibutramine (Meridia)
Prescribing Information
For patients with BMI > 30 or > 27 in the presence of
risk factors.
5 to 15 mg per day.
Not for patients on SSRIs (e.g. Paxil, Zoloft, Prozac)
Not for patients with poorly controlled hypertension,
history of coronary artery disease, CHF, arrhythmia
or stroke.
Regular BP and heart rate monitoring required.
 Sibutramine (Meridia)
Summary of Reported Adverse Event
Percent (%) of Patients
Adverse Event Placebo (n = 884) Sibutramine (n=2068)
Dry mouth 4 17
Anorexia 4 13
Constipation 6 12
Insomnia 5 11
Appetite increase 3 9
Dizziness 4 7
Nausea 3 6
Package insert data, Sibutramine, 1998.
 Orlistat (Xenical):
Mechanism of Action
Activity occurs in the stomach and small intestine.
Inhibits gastric and pancreatic lipases.
30% of ingested fat is unabsorbed and excreted.
Minimal systemic absorption.
Low-fat diet ( 30%) required to minimize side effects.
 Orlistat (Xenical)
Summary of Research Findings
0 0
Placebo
-2 Orlistat

-4
% Wt Loss

-4.6
-6
-6.1
-8 -7.8

-10
-10.2
-12
0 1 2
Time (years)
Sjostrom L et al. Lancet 1998;352:167-172.
 Orlistat (Xenical)
Summary of Reported Adverse Events
Overall Incidence
Adverse Events
(% of Patients)
Oily spotting 26.6
Flatus with discharge 23.9
Fecal urgency 22.1
Oily stool 20.0
Oily evacuation 11.9
Increased defecation 10.8
Fecal incontinence 7.7
Package insert data, Orlistat, 1998.
 Orlistat (Xenical)
Prescribing Information
120 mg TID with meals containing fat.
Patients should be on a nutritionally balanced, low-
fat diet (< 30%) to minimize side effects.
Prescribe multivitamin to be taken at least two
hours before or after the medication.
Orlistat is contraindicated for pregnant or lactating
women, and those with chronic malabsorption
syndromes or cholestasis.
Chronic Pharmacological Treatment
and Challenges
Similar to pharmacotherapy of other chronic
conditions.
Consistent weight gain seen when medications are
discontinued.
Requires intensive risk/benefit analysis and careful
patient selection.
Safe and effective medications.
 Surgical Treatment of Obesity
Patient selection criteria
– BMI > 40 or > 35 for those with weight related co-morbidities.
– History of failed conservative weight loss approaches.
– No substance abuse and/or psychiatric disorders.
Surgical options
– Vertical banded gastroplasty (VBG)
– Gastric bypass (GBP)
Outcomes
– Weight loss is 25% to 35% of initial weight.
– Weight loss is generally well maintained.
– Significant improvement in co-morbidities.
 Surgical Treatment of Obesity
Vertical Banded Gastroplasty (VBG)
– Formation of small proximal
Staple Line
gastric pouch.

– Restricts amount of food

without bypassing the gut.
Pouch
– Delays gastric emptying.

– Creates feeling of early Band

satiety.

Fundus
 Surgical Treatment of Obesity
– Formation of 20-30 ml
Gastric Bypass
proximal gastric pouch. Staple Line

– Delays gastric emptying.

Pouch Fundus
– Interferes with absorption
of nutrients.

– May induce dumping Jejunum

syndrome after high
carbohydrate meal.
 Treatment of Obesity
Popular
Low-calorie diets
Weight Loss Diets
– Calorie deficit allows for 1 to 2 pound weight loss/week
– Nutritionally balanced food plan
(15% protein, 30% fat, 55% carbohydrate)
– Weight Watchers, Jenny Craig
High protein, low carbohydrate diets
– Emphasis can vary between unrestricted sources of protein
and consumption of only lean sources (chicken, fish).
– Dr. Atkins’ New Diet Revolution, The Zone.
 Treatment of Obesity
Popular Weight Loss Diets
Low-calorie diets
– Weight Watchers
– Jenny Craig

Low-carbohydrate diets
– Dr. Atkins’ New Diet Revolution
– The Zone
– Sugar Busters
 Low-Calorie Diets

Usually provide a total calorie deficit to allow for

1 to 1 1/2 pounds of weight loss per week.

Rely on use of fat-free and low-fat foods.

Balanced nutritional food plan.

(15% protein, 30% fat, 55% carbohydrate)

Mulitvitamin/mineral supplement recommended.

 Commercial Programs
Weight Watchers
Traditional program includes a balanced low calorie diet containing
1200 calories per day for women; 1800 calories for men.
Offers a flexible 1-2-3 program which enables you to eat whatever
you want using a point system which are determined based on
your weight loss goals.
Priced reasonably; approximately $12.00 per visit.
Weekly “weigh-ins” and purchasing your own food.
Group meetings lead by successful program graduates which
provide support and advice on behavior modification, exercise, and
nutrition.
 Commercial Programs
Jenny Craig
Offers several programs to meet individual needs
Provides weekly planned menus which are nutritionally balanced
Menus feature Jenny Craig packaged foods which can cost
approximately $65 - $75 per week
Offers convenience for the person who does not cook
Calorie levels range from 1000 - 2300 calories/day
Provides basic strategies for managing stress and physical
activity
Staff not medically trained
 Dr Atkins’ Diet Book

• High protein diet.

• To identify methods to assess the nutritional status of healthy

patients as well as those with acute or chronic illness.

• To identify risk factors and usual physical findings

associated with malnutrition and determine who would benefit
from additional nutrition counseling.
 Atkins Diet: The Rules of the
•
Induction Diet (14 days)
Diet consists of pure proteins and fat with < 20 grams carbohydrates per day.

• Sample menu:
– Breakfast: Ham, cheese, mushroom omelet with bacon
or smoked fish with cream cheese.
– Lunch: Chef salad with ham, chicken, cheese, eggs,
creamy Italian dressing or bacon cheeseburger- no
bun.
– Dinner: rack of lamb, salmon or chicken and salad.
– Dessert: assorted cheeses or diet Jello with heavy
cream.
 Biochemical Aspects of
the Atkin’s Diet
• No more than 20 grams of carbohydrates/day so that insulin levels are
decreased.
• Low insulin/glucagon (IG) ratio results in fatty acid oxidation
and gluconeogenesis for energy
• Goal is to achieve ketosis/lipolysis.
• . High protein diet needed to preserve lean body mass (muscle protein)
however there is always a state of low protein synthesis due to low IG ratio.
 Metabolic Effects of Low
Carbohydrate Diets
Significant reduction in caloric intake.
Significant reduction in B vitamins and fiber intake.
Increased ketone formation if severe CHO
restriction.
High saturated fat diet clearly shown to increase
serum LDL levels and risk of CVD.
No long-term studies on weight change (-/+) or
effects on serum glucose or LDL levels.
 Sugar Busters
Drs. Rachael and Richard Heller
• Follows the basic diet plan of Dr. Atkins’ high protein,
low carbohydrate diet, emphasizing lean meats.
• Focus is on avoiding refined carbohydrates such as
sugar and white rice.
• Diet allows one reward meal each day in which
carbohydrates are permitted.
• Avoids food eaten in combination (i.e. fruits should not
be eaten with meat dishes).
Improving Weight-loss Maintenance

Continued care
Exercise
Pharmacotherapy
Other
 Weight Change:
Former Criteria for Success

Reduction to ideal body weight.

Reduction of 50% of excess weight.

Reduction to upper limit of “normal” body fat

Reasons for Abandoning Ideal Weight with
Significantly Overweight People

Most cannot achieve ideal weight, even with most

aggressive approaches.
Most cannot maintain losses >15% of initial body
weight without surgery.
Losses of 5% to 10% of body weight are associated
with significant health improvements.
 Weight Change
New Criteria for Success
According to the Institute of Medicine’s report, Weighing the
Options:
– Successful long-term weight control by our definition means losing at
least 5% of body weight and keeping it below our definition of
significant weight loss for at least one year.

– Weight loss of only 5% to 10% of body weight may improve many of

the problems associated with overweight, such as high blood
pressure and diabetes.

Thomas P (ed). Weighing the Options. Washington, DC: IOM, National

Academy Press,1995.
 What Is A Reasonable Weight Loss ?
Patients’ Expectations and Evaluations of Obesity
Treatment and Outcome
Study design
– 60 obese women, age 40 + 8.7 yrs.
– BMI 36.3 + 4.3 kg/m2
Subjects questioned about their goal weight
– Dream weight
– Happy weight
– Acceptable weight
– Disappointed weight
Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.
 Results
Defined Weights % Reduction
Dream 38%

Happy 31%

Acceptable 25%

Disappointed 17%
Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.
 Percent Achieving Defined
Weight at Week 48 (n=45)
Dream = 0%
Happy
9%
Acceptable
24%

Weight loss:
16.3 ± 7.2 kg Did not Reach
Disappointed Disappointed
20% Weight 47%

Foster GD, et al. J Consult Clin Psychol 1997;65:79-85.

 Helping Patients Accepts More
Modest Weight Loss
Be clear about what treatment can and cannot do.
Discuss biological limits.
Focus on non-weight outcomes.
Be empathic about dissatisfaction with weight and
shape.
Treatment Strategies

For Eating Disorders

 Treatment Strategies:
Ideally, treatment addresses physical and psychological
aspects of an eating disorder.
People with eating disorders often do not recognize or
admit that they are ill
– May strongly resist treatment
– Treatment may be long term
E.D. are very complex and because of this several health
practitioners may be involved:
– General practitioners, Physicians, Dieticians, Psychologists,
Psychiatrists, Counselors, etc.
Depending on the severity, an eating disorder is usually
treated in an:
– Outpatient setting: individual, family, and group therapy
– Inpatient/Hospital setting: for more extreme cases
 Eating Disorder Treatment
Medical Treatment
– Medications can be used for:
• Treatment of depression/anxiety that co-exists with the eating
disorder
• Restoration of hormonal balance and bone density
• Encourages weight gain by inducing hunger
• Normalization of the thinking process
– Drugs may be used with other forms of therapy
• Antidepressants (SSRI’s such as Zoloft)
– May suppress the binge-purge cycle
– May stabilize weight recovery
 Eating Disorder Treatment
Individual Therapy
– Allows a trusting relationship to be formed
– Difficult issues are addressed, such as:
• Anxiety, depression, low self-esteem, low self-confidence,
difficulties with interpersonal relationships, and body image
problems
– Several different approaches can be used, such as:
• Cognitive Behavioral Therapy (CBT)
– Focuses on personal thought processes
• Interpersonal Therapy
-Addresses relationship difficulties with others
 Eating Disorder Treatment
• Rational Emotive Therapy
– Focuses on unhealthy or untrue beliefs
• Psychoanalysis Therapy
– Focuses on past experiences
Nutritional Counseling
-Dieticians or nutritionists are involved
-Teaches what a well-balanced diet looks like
This is essential for recovery
Useful if they lost track of what “normal eating” is.

-Helps to identify their fears about food and the

physical consequences of not eating well.
 Eating Disorder Treatment

Family Therapy
– Involves parents, siblings, partner.
– Family learns ways to cope with E.D. issues
– Family learns healthy ways to deal with E.D.
– Educates family members about eating disorders
– Can be useful for recovery to address conflict,
tension, communication problems, or difficulty
expressing feelings within the family
 Eating Disorder Treatment

Group Therapy
– Provides a supportive network
• Members have similar issues
– Can address many issues, including:
• Alternative coping strategies
• Exploration of underlying issues
• Ways to change behaviors
• Long-term goals
 Prognosis for Improvement
Anorexia
– 50% have good outcomes
– 30% have intermediate outcomes
– 20% have poor outcomes
Bulimia
– 45% have good outcomes
– 18% have intermediate outcomes
– 21% have poor outcomes
 Prognosis for Improvement

Factors that predict good outcomes:

– Early age at diagnosis
– Beginning treatment as soon as possible
– Good parent-child relationships
– Having other healthy relationships with friends or
therapists
 Prognosis for Improvement
Anorexia
– Poorer prognosis with:
• Initial lower weight
• Presence of vomiting
• Failure to respond to previous treatment
• Bad family relationships before illness
• Being Married
Bulimia
– Poorer prognosis with:
• High number hospitalizations because of severity
• Extreme disordered eating symptoms at start of treatment
• Low motivation to change habits
 Relapse Triggers
Factors that may cause relapse:
– Allowing to become excessively hungry
• May lead to overeating and temptation to purge
– Frequent weigh-ins on the scale
• Weight gain may cause anxiety and high chance of relapse
– Depriving self of good tasting food
• Deprivation can lead to cravings and food binges
• Deprivation may build to include most food resulting in relapse
– Not paying attention to emotions
• Certain emotions may be triggers
• Not learning alternative ways to deal with strong emotions
may cause relapse
Anorexia and bulimia seem to be getting much m
ore common in boys, men, and women of all age
s and socioeconomic backgrounds; they are also
becoming more common in racial groups previo
usly thought to be impervious to the problem.

Marya Hornbacher
“[Eating disorders] are a wonderful tool for
helping you reject others before they can reject
you. Example: You're at a party. The popular
girls are there. You know you can never be as
cool as they are, but when one of the pops a
potato chip into her mouth or chooses real Coke
over Diet,for that moment you are better” 
― Stacy Pershall
Thank you