Eating, Disordered Eating and Eating Disorders. Primary Care Interventions. Disclosures. Acknowledgements 10/3/13. Joseph P. Arpaia, M.D.

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1 Eating, Disordered Eating and Eating Disorders Primary Care Interventions Joseph P. Arpaia, M.D. Disclosures Dr. Arpaia has a private practice in Eugene, OR of which he is the sole owner. (He is not currently taking new patients.) Dr. Arpaia is also the medical director of RainRock, the Eating Disorder Center of Eugene, and the Eating Disorder Center of Portland. Their number is He has no ownership in any of these facilities. Acknowledgements I want to thank Deanna Lineville, Ph.D. for sharing her thoughts and also for providing materials for several of the slides. Dr. Lineville is a professor in the Department of Marriage and Family Therapy at the University of Oregon. 1

2 Objectives Recognize and screen a patient for disordered eating Identify patients at risk for eating disorders Assess patients at risk for eating disorders Interventions with deteriorating patients who refuse help Case 1 42 year old professional Caucasian female Major depressive disorder and generalized anxiety disorder responsive to SSRI and CBT History of alcohol, stimulant, and opioid dependence and PTSD from sexual abuse Now seen occasionally for medication adjustment and review of CBT techniques. After 4 years revealed that she was bingeing and purging several days at a time every couple of months Case 2 22 year old Caucasian female lab tech presenting with major depressive disorder and severe social anxiety disorder Medications (SSRI s) and CBT only partially effective even after several medication changes. After 18 months revealed that had not been honest and was bingeing and purging several times per week Moved out of area for new job shortly afterward 2

3 Case 3 50 year old medical professional Presented for treatment of binge/purge episodes 5-7 days per week over 30 years. No prior treatment. Had lost all her teeth from purging. Medically stable On workup had severe social anxiety. SSRI and CBT targeting both social anxiety AND bulimic symptoms led to remission of both. Disordered Eating A significant disconnection between the experience of hunger, the need for nutrition, satiety, and eating. Comfort eating or episodic dieting are most common forms. Usual outcome is obesity. Restricting, binge eating, and purging are more severe forms and are associated with eating disorders. The DE ED Spectrum 3

4 Disordered Eating: Risk Factors Being alive (short answer) Low socioeconomic status Chronic distress physical, emotional, occupational, social, or relational Chronic stress financial, time Fear of being overweight Body image distress Disordered Eating: Treatment Key principles are motivation, moderation, and sustainability. These reinforce each other. A healthy family, social, or support group enhances these. These are counter to the prevailing advertised solutions and you will need to work very hard to help the patient avoid quick fixes or extreme solutions. Need to avoid treating disordered eating in ways that can lead to eating disorders. Adherence to the above principles will reduce this possibility. Important Fact The body does not necessarily store every calorie consumed that is not absolutely needed for survival and movement. There is a range of up to several hundred calories within which the body will either spend or store the extra. The more stressed, the more likely the body is to store the extra. Financial metaphor. 4

5 Disordered Eating: Medications No medication that has been approved for obesity has been helpful over the course of years. Medications can be helpful if used to treat co-morbid conditions (depression, anxiety, pain). Make sure patient is not on medications that can cause weight gain Antipsychotics (mood stabilizers), anticonvulsants Tricyclic antidepressants (often used for pain or IBS) Wellbutrin can increase activity in depressed patients (avoid if patient has AN or BN). Naltrexone ( mg) and topiramate ( mg) may reduce impulsive behaviors. Watch metabolic acidosis with topiramate. Disordered Exercise Occurs when the purpose of exercise is to attain goals which are not related to improved functioning or the improvement is not sustainable Weight loss Body sculpting / Body building Extreme performance / Overtraining Problems in Athletes Females Disordered eating Oligomenorrhea: increased length of time between menses Reduced bone mineral density Males Focus often on muscle gain leading to unbalanced diets and abuse of anabolic steroids Both Excessive exercise extra workouts Caffeine use Beware of amateur experts : coaches, trainers, parents Your relationship with the patient as a source of information is critical May need to get sports medicine specialist involved 5

6 Case 4 - History 14 year-old Caucasian female GAD and occasional panic attacks responsive to CBT Now with anxiety and fatigue Perfectionistic Mother very anxious and this impacts daughter Starting high school high level of stress Dances and is trying out for cheer team Workout schedule is clearly overtraining girls Case 4 - Data Diet egg or breakfast bar and berries and nuts for breakfast sandwich and macaroni and cheese for lunch full dinner with dessert Irregular menses but frequency decreasing in last few months Weight 123 lbs, 5 6, BMI 20 Orthostatics Supine: pulse 60 bpm BP 92/48 Standing: pulse 91 bpm BP 86/62 Case 4 - Intervention Discussed concept of energy availability and her signs that she needed more energy to sustain her pace. Menstrual changes Her fatigue Orthostatic changes Advocated Rest days from workouts Suggested ways to increase calories by adding a couple of snacks 6

7 Thoughts - Reflections Eating Disorders Estimates vary but it is quite possible that ~15% of the adult and adolescent population struggles with an eating disorder: anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) Historically female:male ratio has been 10:1, but the number of men with eating disorders has been increasing. Binge Eating Disorder (BED) New in DSM 5 Co-Morbid Conditions Substance Abuse AN and BN often abuse stimulants including prescribed ones Anxiety especially Social Anxiety Depression PTSD IBS Diabetes Family Dysfunction 7

8 Myths about Eating Disorders ED patients are underweight Most are normal or overweight (BN and BED) ED patients are only trying to get attention Neither attention nor the lack of it seems to help ED is a phase and they will outgrow it Lifetime mortality in untreated AN is ~20% often from suicide ED patients are not treatable After 5-6 years of treatment 75% of AN were recovered Risk Factors of Eating Disorders Social class, education and professional status are NOT associated with increased risk of reporting an ED ED affect people from all classes. The number of hypocaloric diets is linked with increased risk of all EDs. Hx of being overweight was linked with increased risk of BN and BED. Difficult acculturation & adjustment processes (think puberty in girls and middle school milieu) are linked with increased risk for body image disturbances and EDs. Cultures that emphasize thinness and disseminate these values through the media. Participation in activities in which thinness (or lower body mass) is seen as an important factor for success: modeling, acting, gymnastics, dance, running, wrestling. A history of eating disorders or disordered eating in the family of origin. Protective Factors Interpersonal skills training and reducing body image distress increases the chance of long-term recovery in patients treated for eating disorders This suggests that helping the patient develop interpersonal skills will reduce their chance of developing an eating disorder Similarly helping the patient reduce their body image distress should reduce their chance of developing an eating disorder 8

9 Assessment Areas to Explore Eating / Dieting Patterns Exercise Patterns / Purpose Body Image / Weight Goals Perfectionism / Drive to Achieve / B-W Thinking Family Relationship to Food / Weight Peer Group Values / Internet Influences Emotion Regulation Motivation for Change Assessing Eating Patterns When and what do they eat and how variable is that? When do they feel hungry and what do they do then? Do they have food rules or good/bad foods? If so what are they? Do they ever feel like they have eaten too much or too little? Has anyone ever expressed concern about their eating? Assessing Exercise Patterns What does the patient see as the purpose for physical activity? What is the patient s pattern of physical activity: how long, how often, what activities? What makes a workout a good or bad workout? What happens when the patient misses a workout? 9

10 Weight Goals and Focus What do they consider a healthy weight? What do they consider an unhealthy weight? How much energy/focus do they put into checking their weight? What happens to them if their weight goes up? For adolescents - GROWTH CURVE Body Image - Assessment Who (or what) do they compare their body to? How satisfied are they with their body What it looks like to them? What it looks like to others? What it can do? What part of their happiness is governed by these? Healthy Body Image Self-acceptance is not based only on looks. Able to accept advice from you or experts you refer them to regarding weight, eating, and exercise. Interest in improving physical appearance, health, and overall wellness. Enthusiasm about physical training that also incorporates good nutrition and balances training with need for rest, sleep, and social/ occupational activities. 10

11 Body Image Issues Punitive approach to body image which includes selfdenigrating comments about the self or about parts of the body or about fat. Self-worth based entirely on body image. Working out to lose weight without regard for health and nutritional needs. Compulsive, rigid or inflexible approach to a diet/ exercise routine without regard to health. Close-minded with circular logic and selective use of information from medical sources to justify their attitudes and behaviors. CAG (no E) Variation of CAGE questionnaire for alcohol abuse (Cut down, Annoyed, Guilty, Eye-Opener) How much do you want to Change your weight? Have you ever been Annoyed if someone questions your eating or exercise routine? Do you feel Guilty if you are not able to adhere to your eating or exercise routine? Perfectionism What are their goals for themselves in work, relationships, school, appearance? What are the family s expectations for them in these areas? How do they tolerate making mistakes or not being the best at something? What is wrong with being just good enough? 11

12 Perfect - Definition 1. Fully formed 2. Functional 3. Made with attention to detail 4. Flawless New Oxford English Dictionary Family / Social Relationships Who can they talk to without being judged? Who listens to them? What is their family s relationship with food, appearance and exercise? What about their friends? What are they learning from the internet and social media? How does their relationship with food and exercise affect their relationships with others? Emotional Regulation What emotions can they actually feel? What do they do when they feel those emotions? What can they learn from their emotions? Fear: what is dangerous and how to have courage Sadness: how to value people or things and grieve their loss Anger: how to generate energy to change a situation Guilt: awareness that a relationship might be in danger 12

13 Motivation for Change Are they willing to consider that different points of view are valid? Are they willing to explore the short and longterm consequences of their behaviors? If they show some ambivalence can you increase that? Assessment Labs Lab tests are usually normal except in extremely severe disease. When I went to the doctor, I was bingeing and vomiting up to ten times daily. When my test results came back normal, I felt excited thinking, I can get away with this. In some ways I wish the tests had been worse. I wish they would have scared me; maybe it would have helped me to stop. Now I feel like the lab tests say I have not done any damage so why stop. My voice was raspy, my skin was grayish, my cheeks were puffy but my lab tests were fine! Hypokalemia, often with increased bicarb, is a consequence of vomiting or laxative abuse. Treatment The Team Multidisciplinary treatment is best Primary care physician Monitor weight gown only Do NOT show patient their weight (problem with some EMRs) Therapist Dietitian Possibly psychiatrist especially if comorbid anxiety, depression, OCD, PTSD May also need substance abuse treatment 13

14 Treatment - Principles Influence patient without trying to control. Team members must communicate to avoid being led astray by patient deceit. Have requirements based on objective data for allowing patient to remain in outpatient treatment. If patient not doing well in outpatient care refer to specialized treatment setting. Treatment - Principles Address co-morbid conditions Anxiety is almost always present even if patient does not meet criteria for an anxiety disorder Disordered eating can reduce anxiety. Mary Dallman, Ph.D. UCSF Energy Availability Ann Loucks, Ph.D. Ohio University The Non-Complaint Patient Non-compliance is part of the disease. If non-compliance is occurring and the patient is medically unstable then Treat patient just as you would treat a patient with a medical illness who was unstable and refused to adhere to medical advice. Document that patient not following an acceptable treatment plan. May refuse to see patient any longer unless also seeing specialists (check with your risk management department on how to do this appropriately). 14

15 Thoughts - Reflections Anorexia Nervosa Failure to maintain at least 85% of IBW (whatever that is). Intense fear of weight gain or of being fat. Distorted perception of body (sees self as fat). Amenorrhea in post-menarchal females (not in DSM 5) Two types Restricting type: no use of purging behaviors (vomiting, laxatives, exercise) Purging type: use of purging behaviors Other Signs of AN Dressing in baggy clothes or avoiding mirrors Cold intolerance or cold extremities Impaired attention; difficulty making decisions Orthostatic dizziness; fainting Denying an eating problem and giving false reassurance when confronted Demonstrating mood changes such as depression or irritability Work or school failure (this is usually the last to show up, just like with many addicts) 15

16 Anorexia Nervosa: Medications No FDA approved medications to treat AN Off-label uses for weight gain phase of treatment Olanzapine: mg to 20 mg at bedtime Watch for orthostasis Patients often refuse to take because of fears of weight gain Cyproheptadine: 2 mg tid and can increase to 8 mg qid Antihistamine Watch for sedation Can stimulate appetite; also useful for functional dyspepsia Anorexia Nervosa: Medications Zn 20 mg bid elemental zinc Well tolerated and I do not do Zn levels first May increase ability to taste food Fluoxetine only one study showed increased length of time before return of symptoms in patients who had weight restored. The best medication for seriously underweight patients (BMI < 18) is FOOD. 16

17 Bulimia Nervosa DSM IV Criteria Recurrent episodes of binge eating -Eating in a discreet amount of time an amount of food that is larger than what most people would eat in a similar amount of time. -A lack of control over eating during the episode. Recurrent inappropriate compensatory behavior in order to prevent weight gain. These behaviors occur at least twice a week for three months. Self-evaluation is unduly influenced by shape and weight. Two Types: -Purging Type: The person regularly engages in self-induced vomiting, the misuse of laxatives, diuretics, enemas. -Non-Purging Type: The person uses other inappropriate compensatory behaviors such as fasting and excessive exercise. Signs of Bulimia Nervosa Frequent weight fluctuation. Hoarding or stealing food for consumption. Going to the bathroom frequently after meals. Frequent plumbing problems. Exhibiting broken blood vessels under eyes, marks on the hands from self induced vomiting, yellowgray teeth from stomach acid. Occasionally parotid enlargement. Substance abuse is often present. Bulimia Nervosa: Medications Fluoxetine doses less than 60 mg per day not effective in clinical trials. Doses above 60 mg per day not systematically studied. This is FDA approved. Tricyclic antidepressants have been used with efficacy but risk-benefit ratio is poor because of TCA side effects. Off-label use. Topiramate has also been used. Off-label use. 17

18 Binge-Eating Disorder DSM 5 Binge Eating Eating in a discrete amount of time definitely more food than most people would eat in that time A sense of loss of control over the eating Binge eating is associated with 3 or more of Eating more rapidly than normal Eating till uncomfortably full Eating large amounts of food when not hungry Eating alone because of embarrassment about how much one is eating Feeling disgusted, depressed or very guilty after the episode Marked distress regarding the binge eating Binge eating occurs on average 1/week for 3 months Binge eating not associated with compensatory behaviors BED - Medications No approved treatments. Sertraline and topiramate have been used with some repeated success. This is off-label use of these. 18

19 Thoughts - Reflections Conclusion Goal is to work with patients who have disordered eating in ways that facilitate consistent positive changes and reduce the chance that they will deteriorate and develop an eating disorder. Key Point #1 Your relationship with the patient is very important, especially when the patient is a child/ adolescent. Use appointment time to get to know the patient as a person, and let them know they are important even if they are not following all (or any) of your advice. Assess and intervene over multiple appointments. Behavior change can take a lot of time, be patient. 19

20 Key Point #2 Explore the details about weight, eating, and exercise even if you might upset the patient. While the relationship with the patient may get strained if you ask probing questions, that can make the relationship stronger in the long run. If you avoid asking questions you may give the patient (and you) a sense of relief, but the relationship will suffer and so will the patient. Key Point #3 Use motivational interviewing techniques to increase the patient s drive and hope for success. Your goal is to listen in a way that enables the patient to hear themselves say what they need to hear (I m sorry if this sounds too Zen). Use other experts as sources of support, either to consult with or to refer to. Key Point #4 What messages does your office send, especially to the women you treat, about what it means to be healthy? Office magazines: are there airbrushed models on the covers? 20

21 Print Materials Motivational Interviewing by William R. Miller and Stephen Rollnick Very helpful approach for learning to work with patients who have behavioral disorders The Eating Disorder Sourcebook by Carolyn Costin Overview of issues involved in treatment of eating disorders The Body Image Workbook by Thomas Cash Self-help book to increase acceptance of one s body Real Meditation in Minutes a Day by Joseph Arpaia and Lobsang Rapgay Teaches mental skills to help people deal effectively with stress Articles (free full text) Too fat to fit through the door: first evidence for disturbed bodyscaled action in anorexia nervosa during locomotion. Keizer, A et.al.; PLoS One 2013 May 29;8(5) Update on the female athlete triad. Barrack MT et.al.; Curr Rev Musculoskelet Med June; 6(2): Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions. Becker CB, et. al. Body Image Jan; 9(1):31-42 Physician communication techniques and weight loss in adults: Project CHAT. Pollak KI, et. al.. Am J Prev Med, 2010 Oct; 39(4): New moves-preventing weight-related problems in adolescent girls a group-randomized study. Neumark-Sztainer DR, et. al. Am J Prev Med 2010 Nov;39(5): Thank you You can contact me via at jparpaia@icloud.com I also have audio materials for relaxation and stress reduction available at These are free and I receive no revenue from the site. 21