1. health and fitness
2. disorders

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