Jack Sprat and His Wife:
Disordered Eating and the
Continuum From Anorexia
Through Obesity
Stephen Sondike, MD
Medical Director, Disordered Eating Center
Of Charleston (DECC)
Section Head, Adolescent Medicine
Charleston Area Medical Center
Associate Professor of Pediatrics
West Virginia University School of Medicine
Jack Sprat could eat
no fat.
His wife could eat no
lean.
And so between them
both, you see,
They licked the
platter clean
Anorexia Nervosa
Anorexia Nervosa
Female athlete Triad
Anorexia Nervosa
Female athlete Triad
EDNOS
Anorexia Nervosa
Female athlete Triad
EDNOS
Bulimia Nervosa
Anorexia Nervosa
Female athlete Triad
“non-purging” BN
EDNOS
Bulimia Nervosa
Anorexia Nervosa
Binge eating disorder
“non-purging” BN
Female athlete Triad
EDNOS
Bulimia Nervosa
Anorexia Nervosa
overweight
Binge eating disorder
“non-purging” BN
Female athlete Triad
EDNOS
Bulimia Nervosa
Anorexia Nervosa
overweight
Binge eating disorder
“non-purging” BN
Female athlete Triad
EDNOS
Bulimia Nervosa
A case in point:
Pt RS
Anorexia Nervosa
overweight
Female athlete Triad
Binge eating disorder
EDNOS
“non-purging” BN
Bulimia Nervosa
Age 11: 160 lbs (pt
report)
Anorexia Nervosa
overweight
Female athlete Triad
Binge eating disorder
EDNOS
“non-purging” BN
Bulimia Nervosa
Age 13: (3/3/09)
Wt: 39.8 kg
Anorexia Nervosa
overweight
Female athlete Triad
Binge eating disorder
EDNOS
“non-purging” BN
Bulimia Nervosa
Anorexia Nervosa
overweight
Female athlete Triad
Binge eating disorder
“non-purging” BN
Bulimia Nervosa
EDNOS
6/17/09 : wt 51 kg
Mom reports pt
caught exercising and
vomiting in bathroom
Anorexia Nervosa
overweight
Female athlete Triad
Binge eating disorder
“non-purging” BN
EDNOS
Bulimia Nervosa
8/18/09 : wt 56.6 kg
“binging and purging
constantly”
Anorexia Nervosa
overweight
10/15/09 :
Female athlete Triad
wt 70.7 kg Binge eating
No purging.
Eating powdered disorder
EDNOS
scandishakes
from the sink
Bulimia Nervosa
10/21/10 : wt 99.7kg Anorexia Nervosa
overweight
Female athlete Triad
Binge eating disorder
EDNOS
“non-purging” BN
Bulimia Nervosa
7/7/11:hospital admission for abdominal
pain. Wt 72.5 kg
Anorexia Nervosa
overweight
Female athlete Triad
Binge eating disorder
EDNOS
“non-purging” BN
Bulimia Nervosa
Crossing Over
• 28 % of patients with AN (n = 108) had premorbid body weight of 115 % IBW or greater1 .
• Up to 30% of obese patients may have BED2
• Overweight patients commonly use diet
pills/laxatives/purging to try to lose weight (18%
F, 8% M )3
• People with BN are 3 times more likely to be
obese as a child4
1Crisp
et. al. (1980)
2Streigal-Moore et al. (2004)
3Neumark-Sztainer et al. (2006)
4 Fairburn et al. (1997)
Dieting behavior in children
adolescents is common
•
•
•
•
60% of female students trying to lose wt.
29% of male students trying to lose wt.
21% of females use diet pills
7 % of females have tried vomiting
Source YRBSS 2003
“Dieting” and Weight Status
• Parental dieting and “fat talk” is associated
with disordered eating, decreased body
satisfaction and increased weight status in
children
• Personal history of dieting is associated
with higher BMI and increased weight gain
since the onset of “dieting”
“Diabulimia”
• Up to 50% of women with Type 1 Diabetes
binge eat.
• Up to 30% of women with T1DM intentionally
withhold or reduce prescribed insulin to
control weight
• Most DM patients had lost significant weight
prior to diagnosis and gain weight past
baseline with treatment.
• The standard treatment of T1DM are behaviors
that are intrinsic to eating disorders.
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Adolescent Obesity is Increasing
• NHANES III
– 22-23% of American Children are above the 85th
percentile for BMI.
– 10.5% are above the 95th percentile for BMI.
– Adolescent obesity is associated with significant
morbidity and mortality in both the short and long
term.
NIDDM is Epidemic
• Between 1982 and 1994: 10-fold increase in new
diagnosis in pediatric populations1
• Type 2 Diabetes represents up to 50% of new
pediatric Diabetes diagnoses
• Impaired glucose tolerance in 25% of obese children
and 21% of obese adolescents2
1 Pinhaus-Hamiel
2 Sinha
et al, J Pediatr. 1996 May;128(5 Pt 1):608-15.
et.al. NEJM 2002 Mar; 346(11):802-10
Pediatric Hypertension is Increasing
• Concordant increase in SBP and BMI in
middle school students between 1986 and
19961
• In children aged 8-17 over the past 15 years
–  1.4 mm/hg in SBP
–  3.3 mm/hg2 in DSP
Sources: 1Leupker, 1999
2Muntner, JAMA, 2004
Bogalusa Heart Study
• Atherosclerosis begins at an
early age
– Coronary artery and aortic plaques found as
early as age 5
• Atherosclerotic plaques in childhood
associated with traditional risk factors
Metabolic Syndrome
(as defined by Reaven)
• Hyperinsulinemia
• Obesity
• Hypertension
• Dyslipidemia
Metabolic Syndrome in Youth
• At least 3 of the following:
–
–
–
–
–
Abdominal obesity
Low HDL
Hypertriglyceridemia
Hypertension
Impaired Glucose Tolerance
• 30% of overweight Hispanic children with FHx of
NIDDM meet criteria for Metabolic syndrome.1
• 37.8% of moderately obese and 49.7% of severely
obese subjects meet criteria for metabolic syndrome2
1Cruz
2
et. al. J Clin Endocrinol Metab. 2004 Jan;89(1):108-13
Weiss et al. NEJM. 2004 June ; 350 (23) 2362-2374
.
Prevalence of eating disorders
• Anorexia Nervosa
– Females 0.5-1%
– Males 5-10 % of all cases
(female:male 9-1)
• Binge Eating Disorder:
(among college students)
– Females 2.8%
– Males 1.9%
– (Spitzer 1993)
• Bulimia Nervosa
– Females 1-3%
– Males 0.1-0.3 %
EDNOS
up to 20 % of
adolescents
Prevalence of Eating Disorders
• Eating disorders have been steadily
increasing since the 1950s
• Changing demographics
–
–
–
–
More males
More minorities
More worldwide
Younger and younger
• Hospitalizations for ED for children younger that 12
have increased 119% from 1999-2006
America is an Obesogenic Society. . .
•
•
•
•
Supersizing
Marketing high sugar foods to children
Unhealthy foods marketed as good for you
Nintendo and X-Box, Social media
– Thumb exercises
• Healthy foods are more expensive
• Elevators and Moving sidewalks
• The 4 N’s
– ‘Net
– Nintendo
– Nickelodeon
– Nabisco
1140 Kcal
75g fat
America is an Obesogenic Society. . .
•
•
•
•
Supersizing
Marketing high sugar foods to children
Unhealthy foods marketed as good for you
Nintendo and X-Box, Social media
– Thumb exercises
• Healthy foods are more expensive
• Elevators and Moving sidewalks
• The 4 N’s
– ‘Net
– Nintendo
– Nickelodeon
– Nabisco
America is an Obesogenic Society. . .
•
•
•
•
Supersizing
Marketing high sugar foods to children
Unhealthy foods marketed as good for you
Nintendo and X-Box, Social media
– Thumb exercises
• Healthy foods are more expensive
• Elevators and Moving sidewalks
• The 4 N’s
– ‘Net
– Nintendo
– Nickelodeon
– Nabisco
America is an Obesogenic Society. . .
•
•
•
•
Supersizing
Marketing high sugar foods to children
Unhealthy foods marketed as good for you
Nintendo and X-Box, Social media
– Thumb exercises
• Healthy foods are more expensive
• Elevators and Moving sidewalks
• The 4 N’s
– ‘Net
– Nintendo
– Nickelodeon
– Nabisco
America is an Obesogenic Society. . .
•
•
•
•
Supersizing
Marketing high sugar foods to children
Unhealthy foods marketed as good for you
Nintendo and X-Box, Social media
– Thumb exercises
• Healthy foods are more expensive
• Elevators and Moving sidewalks
• The 4 N’s
– ‘Net
– Nintendo
– Nickelodeon
– Nabisco
America is an Obesogenic Society. . .
•
•
•
•
Supersizing
Marketing high sugar foods to children
Unhealthy foods marketed as good for you
Nintendo and X-Box, Social media
– Thumb exercises
• Healthy foods are more expensive
• Elevators and Moving sidewalks
• The 4 N’s
– ‘Net
– Nintendo
– Nickelodeon
– Nabisco
America is an Obesogenic Society. . .
•
•
•
•
Supersizing
Marketing high sugar foods to children
Unhealthy foods marketed as good for you
Nintendo and X-Box, Social media
– Thumb exercises
• Healthy foods are more expensive
• Elevators and Moving sidewalks
• The 4 N’s
– ‘Net
– Nintendo
– Nickelodeon
– Nabisco
. . . In a Culture which Stigmatizes Obesity
• Thin is ideal, the thinner the better
• Abundance of quick weight loss schemes
• Overweight = negative personality traits
. . . In a Culture which Stigmatizes Obesity
• Thin is ideal, the thinner the better
• Abundance of quick weight loss schemes
• Overweight = negative personality traits
. . . in a Culture which Stigmatizes Obesity
• Thin is ideal, the thinner the better
• Abundance of quick weight loss schemes
• Overweight = negative personality traits
HIPAA
Evaluating Adiposity
• BMI = wt (Kg)/ht (m)2
– Limited by inability to differentiate LBM from adiposity
• Skinfold measurements
– limited by operator dependence
• Water Submersion
– you can’t afford it
• Air Dispacement (BodPod), TOBEC, DEXA,
MRI/CT
– Ditto
• Bioimpedence- Dependant on hydration status
• Visual test
HIPAA
HIPAA
SAME BMI
Anorexia Nervosa-Diagnostic
Criteria (DSM IV)
• Weight of less than 85% expected
• Intense fear of becoming fat
• Disturbance in the perception of ones
weight
• Amenorrhea in post menarchal females
– Absence of 3 consecutive cycles
– RESTRICTING TYPE
– BINGE/PURGE TYPE
Female Athlete Triad
• Disordered Eating
• Amenorrhea
• Osteopenia
– Results when caloric intake is insufficient for
the increased need associated with vigorous
exercise
– May be of normal weight but manage like an
anorexic
Bulimia Nervosa-Diagnostic
Criteria (DSM IV)
• Recurrent episodes of Binge Eating,
characterized by both of the following:
– Eating, in a discreet period of time, more than
most people would eat during a similar time
period under similar circumstances
– A sense of lack of control during such episodes
• Recurrent inappropriate compensatory
behaviors to prevent weight gain
– ie. Laxatives, vomiting, exercise, fasting
Bulimia Nervosa-Diagnostic
Criteria (DSM IV)
• At least twice/week for 3 months
• Self-image unduly influenced by weight
• The disturbance does not occur solely
during episodes of AN
BED - Diagnostic Criteria (DSM
IV-Appendix B)
• Recurrent episodes of Binge Eating, characterized
by both of the following:
– Eating, in a discreet period of time, more than most
people would eat during a similar time period under
similar circumstances
– A sense of lack of control during such episodes
• The binge eating is associated with three or more
of the following:
–
–
–
–
–
Eating much more rapidly than normal
Eating until uncomfortably full
Eating large amounts when not hungry
Eating alone due to embarrassment
Feeling disgust or guilt about eating
BED - Diagnostic Criteria (DSM
IV- Appendix B)
– Marked Distress towards Binge eating
– Twice weekly for 6 months
– Not associated with compensatory behavior or
does not occur exclusively during AN or BN
Eating Disorder not Otherwise
Specified (EDNOS)
• Disorders of eating that do not fit full the
criteria for AN or BN
• Common examples:
– All criteria for AN except regular menses
– All criteria for AN except wt. >85% expected
– All criteria for BN except does not occur
twice/week, or for 3 months
– Purging without binging
The DSM 5 will swallow a lot of this up in the
other diagnoses (www.dsm5.org)
Perpetuating factors (cont.)
24 hr energy expenditure
Elevated Body Weight
Physical activity energy
expenditure
Thermic effect of eating
T-3
Sympathetic tone
Parasympathetic tone
Usual Body Weight
(Lean or Obese)
24 hr energy expenditure
Energy expenditure physical
activity
Thermic effect of eating
T-3
Sympathetic tone
Parasympathetic tone
Reduced Body Weight
Hormonal And Neural Control of
AppetiteSerotonin
• Increases satiety
• Decreased in low weight AN but increased from
normal in long term recovered AN
• Possibly lower in BN; Binge on tryptophan?
• Decreased in obese and correlated with
carbohydrate cravings
Hormonal And Neural Control of
AppetiteNorEpi and Dopamine
• Norepi is Orexigenic: Altered in low-weight AN but
normal in recovery
• BN- NorEpi low baseline but increased in in response to
meals
• Dopamine is associated with eating pleasure-Certain obese
patients have an allele which is associates with reduced D2
receptors
Hormonal And Neural Control of
Appetite -Cholecystikinin (CCK)• induces satiety
• AN low in low weight and normal in
recovered (expected response)
• BN inadequate rise after meals
• Obese No specific effect
Hormonal And Neural Control of
Appetite -Cortisol
• Secreted in response to stress- may increase
appetite
– Elevated in those with disordered eating
• Higher cortisol is associated with higher ED
attitudes and behaviors regardless of BMI status
• Likely an adaptive response to starvation which
perpetuates the behaviors.
– Lawson et. Al; Eur J Endocrinol. 2011 Feb;164(2):253-61.
Hormonal And Neural Control of
Appetite –Peptide YY
• Secreted in the intestine in response to food
intake
– Strong anorexic effect
– Appear to be high in disordered eating and
malnutrition and associated with drive for
thinness
– Low in obese subjects.
Hormonal And Neural Control of
Appetite
Ghrelin – abnormally increased in BNpossibly decreased sensitivity in AN.
NPY and PPY- Very potent appetite
stimulators
No specific differences
adiponectin; agouti related protein; leptin;
resistin; others-further study needed
The Dichotomy
• Obese = you should be unhappy about you
weight
• you are only successful in the program if
you lose weight (you are “non-compliant” if
you can’t/won’t)
– Losing weight will improve your life
– You may want to eliminate certain
macronutrients (ie fat, carbs etc.)
“Follow this diet,
Mr. Figby, and I
want to see twothirds of you
back here for a
check-up”
The Dichotomy
• Anorexia Nervosa = You are healthy at any size
– Body weight does (or should) not reflect happiness
– You should be comfortable with all types of food and
dismiss “food phobias”
– “It’s donut day in the AN ward”
“Health at Every Size”
• Accepting and respecting the natural
diversity of body sizes and shapes.
• Eating in a flexible manner that values
pleasure and honors internal cues of hunger,
satiety, and appetite.
• Exercising for pleasure and the joy of
physical movement rather than to lose
weight.
I don’t stop
eating when
I’m full.
The meal is
not over when
I’m full.
The meal is
over when I
hate myself!
Dietary treatment goals
• Attain skills for a lifetime of weight
management
– self monitoring of eating, physical
activity and weight
– social and emotional support
• Realistic weight goal (may differ from that
initially expressed by the teen or parents)
Psychological Treatment
• Cognitive Behavoral Therapy (CBT)
– the mainstay of treatment for disordered eating
– Demonstrated effectiveness in BN and BED.
Emphasizes the interrelationships between
thoughts, feelings, and behaviors as they
relate to a situation.
– Structured, collaborative, time limited
approach to increasing capacity to identify,
challenge, and modify problem thoughts
and behaviors
Family Based Therapy (Mauldsley Method)
Demonstrated effective, and superior to
CBT in younger patients with AN
Pharmacotherapy in ED
• High dose SSRI (60 mg. Fluoxetine) has been
shown in studies to decrease binge-purge cycles in
bulimia
• No medication has been shown to be more
effective than placebo for AN, but studies have
only been done on those patients with very low
weight.
• SSRIs may be effective for treating comorbidities
(OCD, major depression, PTSD)
• To nourish the brain, you must nourish the
body
Pharmacotherapy in Obesity
Approved:
• Sibutramine (Meridia)
• Orlistat (Xenical)
Off label:
• Fluoxitine (Prozac)
• Topirimate (Topamax)
Dangerous:
• Ephedrine
– Ephedrine/Caffeine (off the market)
Pulling it together:
• Your goal weight is whatever your weight
happens to be when living a healthy lifestyle
• Even if you can’t lose/gain weight you are not a
bad person or a failure, you just have a problem
you need to work on which is NOT YOUR
FAULT
• Model good, healthy behaviors
• Have realistic goals
Do:
• Be sensitive and contemplative about
addressing weight issues with kids and
families
• Associate excess adiposity with health risks
and comfort issues rather than self worth
and cosmetic issues
• Practice anticipatory guidance about
unhealthy weight loss behaviors
• Encourage and congratulate even small
behavior changes, even if they don’t bring
immediate “results”
Don’t
• Tell an adolescent that they “need to lose 50
pounds”
• Use sensitive terms like “obese” “fat”
“chunky”
• Criticize a patient who is not meeting a
weight goal
• Suggest a restriction without suggesting a
substitution
Disordered Eating center of
Charleston
• Multidisciplinary, multicampus team
• Stephen B. Sondike MD, Medical Director
Jessica Luzier, PhD, Clinical Director
Jamie Oliver, RD, Dietician
Morgantown Contacts:
Pamela Murray, MD
J. Scott Mizes, PhD
THANKS!