Obesity and eating disorders

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					Obesity and Eating Disorders

         Dr Savitha

• 25 -50% prevalence in American adults

• > 20 % of ideal body weight

• BMI > 25 – overweight ; > 30 obese

•Normal BMI – 20-25
• Prevalence varies by ethnic group in women

• In most groups, more common in women

• Overweight in children: at or above the 95th percentile
  of the sex specific BMI for age growth charts
• Cardio-respiratory problems (HT)

• Risk for hypercholesteremia, cancer, diabetes,
  orhtopaedic problems, early death
• Pickwickian syndrome:

•   Body weight more than twice normal
•   Alveolar hypoventilation
•   CVS problems
•   Sleep problems
• Not an eating disorder

• Bio-psycho-social factors
Obesity: known Associations
• Prenatal: mother’s caloric intake; maternal DM

• Breastfeeding: protective

• FH: one or both parents- strong genetic component

• Mutations in Leptin receptor (LEPR) gene & Melanocortin
4 receptor (MC4R) gene
Obesity: known Associations
• Sleep deprivation (Spiegel 2004): causes decrease in
  leptin and increase in ghrelin

• Eating!

• ―Fast food‖: incr weight and insulin resistance (Pereira2005)

• Medications: antipsychotics, AED, antihistaminics,
• Endocrine disorders: hypothyroidism, Cushing’s

• Sedentary lifestyle, reliance on automobiles

• Type and degree of psychopathology similar to
  normal weight individuals
Effects of Overeating: Metabolic Syndrome

• Elevated waist circumference:
  Men — Equal to or greater than 40 inches (102 cm)
  Women — Equal to or greater than 35 inches (88 cm)

• Elevated triglycerides:
  Equal to or greater than 150 mg/dL

• Reduced HDL (―good‖) cholesterol:
  Men — Less than 40 mg/dL
  Women — Less than 50 mg/dL
• Elevated blood pressure:
 Equal to or greater than 130/85 mm Hg

• Elevated fasting glucose:
 Equal to or greater than 100 mg/dL
Treatment of Obesity

• Psychological

• Spiritual

• Medical

• Surgical
• Although many commercial dieting and weight
  loss programs are effective, most weight lost is
  gained within a 5 year period
         Medications for Obesity


• Dextroamphetamine: abuse potential

• Phentermine (Adipex): sympathomimetic amine

•Dexfenfluramine, Fenfluramine: heart valve
• FDA approved weight loss agents:

• Orlistat – pancreatic lipase inhibitor, limits
  breakdown of dietary fats

• Sibutramine – blocks monoamine uptake;
  increases feeling of satiety
• Negative effects:

• GI problems with orlistat

• Elevated BP with sibutramine

• Topiramate (Topomax)

• Zonisamide
• Diet & exercise – best way to maintain weight

• Low carb, high protein & fat (Atkins) diet –
  greater weight loss
              Surgical methods
• Gastric bypass – food rerouted past part of stomach &
  small intestine

• Bariatric surgery – reduce size of stomach

• Serious sequelae: vomiting, diarrhoea, intestinal
  obstruction, electrolyte disturbances
• 12- step peer support programs
 Two Main Types
   Anorexia Nervosa
   Bulimia Nervosa
 Share Strong Drive to be Thin
 Largely a Female Problem
 Largely a Westernized Problem
 Largely an Upper SES Problem
 Many Die as a Result!
• Normal appetite

• Abnormal behaviour associated with food

• Compensatory mechanisms: vomiting,
  diuretics, enemas laxatives
• Purging: Malnutrition, electrolyte imbalance

• Laxative abuse: melanosis coli

• Use of drugs or thyroid hormones

• Liposuction
• Engage excessively in sports – hypergymnasia

• Gymnastics and ballet dancing

• Feel they look fat
• Women> men

• 1-3% women, 0.1-0.2% men

• Late adolescence and young adulthood
• Occult malignancy, regional enteritis, chronic
• Syndromal depression
• Kleine-Levin syndrome: episodic eating binges and
• Borderline PD
• Impulsive eating
• An 18 year old college student presented
  to the gynecologist with 7 months h/o
  amenorrhea. She also gives h/o hair loss,
  feels anxious that she is fat, watches her
  diet very stringently and spends hours
  exercising. Examination reveals a very thin
  person with a BMI of 14.9
             Anorexia Nervosa
• Criteria

  – Person’s weight is less than 85% of normal weight/
    fails to gain weight during a period of expected

  – Person has an intense fear of gaining weight

                                                   Ch 9.1
– Person has a distorted sense of their body shape

– In females, anorexia nervosa leads to a loss of the
  menstrual periods (atleast 3 MCs missed

– Denial of the disorder, depression
              Anorexia Nervosa
• Two types of anorexia nervosa:

   – Restricting type loses weight by severely limiting the amount
     of food consumed/ exercising

   – Binge-eating-purging type engages in binges (large amount
     of food consumed) following by purging (vomiting or use of

                                                             Ch 9.3
 Associated Features and Facts
   Begins Early in Adolescence
   Perfectionistic High-Achievers
   Obsessive and Orderly
   Comorbid DSM Disorders
    – Depression
    – Obsessive-Compulsive Disorder
    – Substance Abuse
 Causes
  Social and Cultural Factors
   – Thinness Equals Success
   – Has Increased Over Time
  Media
   – Sets Impossible Idealized Images
 Causes
  Family Influences
   – Successful and Driven
   – Concerned About Appearances
   – Eager to Maintain Harmony
   – Deny or Ignore Conflicts
   – Lack of Open Communication
           Anorexia Nervosa
• Anorexia nervosa is linked to depression

• Anorexia nervosa can have severe physical
  effects including
  – Altered electrolyte levels (potassium and sodium)
    lead to changes in nerve and muscle function;
  – cardiac arrythmias

                                                   Ch 9.4
•   Raised liver enzymes
•   Raised BUN
•   Reduced thyroid hormone
•   Decreased serum glucose
•   Mild anaemia
•   Mild leukopaenia
•   Lanugo
•   Decreased bone density
•   Cold intolerance
•   Cyanotic hands and feet
•   Syncope
•   Lack of interest in sex
• First stage- restore body weight and save life
• Second stage – prevent relapse

• Reinstate the patient’s nutritional condition
• If weight is 20% or more below normal: IP stay
• These patients resist hospitalisation

• Amitriptylline, Fluoxetine

• Cyproheptadine : increase appetite
• Most effective form of therapy: family

• Early age of onset, early treatment, few or
  no previous hospitalizations predict
  positive outcome
• A 17 year old girl is brought to the psychiatrist by
  her parents with a h/o repeated attempts at fad
  diets. She revealed that she has been very
  conscious about her weight since high school.
  She at times sneaks into the kitchen at midnight
  and gorges on large quantities of pastry and
  cake, later feels disgusted with herself and
  forces herself to vomit.
                Bulimia Nervosa
• Bulimia Nervosa involves episodes of rapid overeating,
  feeling out of control, followed by purging

   – A binge is defined as eating an excessive amount of food
     within two hours

   – Purging refers to vomiting, laxative abuse, fasting or
     excessive exercise

                                                              Ch 9.5
• Bulimia involves a fear of gaining weight

• Prevalence of bulimia nervosa is 1-2% of the
  female population; only .1% of male
Bulimia nervosa: the diet-binge-purge disorder
             Person binge eats.
            Feels out of control while eating.
            Vomits, misuses laxatives, exercises, or
              fasts to get rid of the calories.
            Diets when not bingeing. Becomes
            hungry and binges again.
            Believes self-worth requires being thin.
            Weight may be normal or near normal unless
            anorexia is also present.
            Bulimia Nervosa
• Purging type – Binge eating & purging

• Nonpurging type- Binge eating, excessive
  fasting or exercing . Non purging.

• Twice a week for at least 3 months for the
• Poor self image

• Distress about having disorder

• Relatively normal sexuality

• Report feeling depressed
       Medical consequences
• Parotid gland swelling and infection
• Enamel erosion & caries
• Electrolyte disturbances
• Russell’s sign: metacarpal phalangeal calluses
  for the teeth
• Arrythmias
• Melanosis coli – laxative abuse

Cognitive behavior therapy: change thought processes
 that result in overeating;

Interpersonal therapy also effective.

                                                  Ch 9.11
• Antidepressants, particularly SSRI’s

• Combination of psychotherapy and
  pharmacotherapy useful

• At 10 year f/u, 50% patients are free of
Thank you

Description: Lecture slides on behavioral sciences, psychology.