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Eating Disorders Related to Obesity

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Eating Disorders Related to Obesity REVIEW Eating disorders related to obesity Varsha Vaidya 1† & Obesity is a chronic disease with multifactorial cause, associated with significant mortality Abdul Malik2 and morbidity. It impacts every aspect of the patient’s life. This review discusses the eating †Author for correspondence disorders that are related to obesity. Binge eating disorder is more frequently seen in 1Johns Hopkins University School of Medicine, obese patients, but bulimia nervosa/disordered-eating behaviors have been included in the Assistant Professor of review as they can sometimes be associated with obesity. However, it is important to note Psychiatry & Internal that most patients with bulimia tend to be of normal weight or overweight. The two Medicine, Baltimore, MD, USA disorders are reviewed with diagnostic criteria, risk factors, medical complications, Tel.: +1 410 6050 180 evaluation and treatment recommendations. There is also a comparison between the two Fax: +1 410 6050 181 disorders. The essential key point is that eating disorders are impulse-control disorders and Email: vvaidya@ obesitypsychiatry.com are similar to addictive behaviors in some aspects. It is essential to treat a patient with 2Psych Associates of obesity and eating disorders multimodally to ensure success. Maryland, Towson, MD, USA The global explosion of obesity has resulted in reported that 80% of black women aged increased awareness and research leading to 40 years or over is overweight; 50% are obese. innovative new diets, medications and surger- Asians have lower obesity prevalence when com- ies. However, the problem continues to grow at pared with other ethnic groups. However, an alarming rate, especially in adolescents. The Asians born in the USA are four times more Center for Disease Control and prevention likely to be obese than their foreign-born coun- (CDC) has reported that data from two terparts. White children and adolescents had the National Health and Nutrition Examination lowest prevalence and risk of being overweight Survey surveys show that among adults aged compared with their black and Mexican 20–74 years, the prevalence of obesity increased counterparts. Educated people seemed to have a from 15.0% (in the 1976–1980 survey) to lower prevalence of obesity, with the exception 32.9% (in the 2003–2004 survey). The two of black women [1]. surveys also show, for children aged 2–5 years, Obesity is a chronic disease that leads to the prevalence of overweight children increased much medical morbidity and mortality. In from 5.0 to 13.9%; for those aged 6–11 years, 2004, a study reported that in the USA, obesity- prevalence increased from 6.5 to 18.8%; and attributable medical expenditures were esti- for those aged 12–19 years, prevalence mated at US$75 billion, with US$17 billion increased from 5.0 to 17.4%. Approximately financed by Medicare and US$21 billion two-thirds of the US population is overweight financed by Medicaid [2]. or obese; that is, 133.6 million or 66%. A third Eating disorders that are normally related to of the population is obese; 66.3 million or obesity are binge eating disorder (BED) (clas- 31.4% [101]. sified under Eating Disorder NOS in the According to a recent epidemiological review Diagnostic and Statistical Manual of Mental by Wang and Beydoun, 75% of adults will be Disorders [DSM] IV) and bulimia nervosa overweight and 41% will be obese by 2015. (BN). While most patients with BN have Minority and low socioeconomic status groups normal weight or may be overweight, some such as “non-Hispanic black women and chil- can present with obesity. Patients with BN dren, Mexican-American women and children, tend to be more preoccupied with their weight low socioeconomic status black men and white and a pursuit for thinness and tend to have Keywords: binge eating disorder, bulimia nervosa, women and children, Native Americans and severe restrictive dieting, interspersed with cognitive behavior therapy, Pacific Islanders” are disproportionately affected. binge/purge episodes. Therefore, few patients eating disorders, obesity, The meta-analysis found that 66% of US adults with BN present with obesity; most tend to treatment of eating disorders were overweight or obese in 2003–2004; with have normal weight or overweight. In the cur- part of women 20–34 years having the fastest increase rent review we will focus on eating disorders, in rates of obesity and overweight. It also diagnosis, risk factors evaluation and treatment. 10.2217/14750708.5.1.109 © 2008 Future Medicine Ltd ISSN 1475-0708 Therapy (2008) 5(1), 109–117 109 REVIEW – Vaidya & Malik Box 1. Diagnostic criteria for 307.51 bulimia nervosa. 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). 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. Specify type Purging type • During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Nonpurging type • During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. We will make note of differences/similarities Demographics between the two. BED is not an approved The peak prevalence of BN is 2–4% in white DSM IV diagnosis, perhaps because of its overlap females aged 17–25 years in the Western nations. with BN nonpurge type. The age of onset is typically 18–19 years; BN is In our experience, some patients present with rare in patients of a younger age [3]. symptoms related to BED, wherein episodes of eating are related to emotions and triggered by Diagnosis specific emotions such as sadness, depression, The diagnostic criteria as per DSM IV text happiness, stress, anxiety and lastly, and perhaps revision are listed in Box 1. most commonly, boredom. Currently, this would have to be diagnosed within the Eating Risk factors Disorder not Otherwise Specified (EDNOS) Family history of eating disorders increases the group as it is an undefined ‘emotional eating dis- risk of developing eating disorders 7–12 times. order’. The patients typically recognize the trig- It has been shown that up to 83% of the vari- ger but are unable to reduce the behavior. ance in BN can be accounted for by genetic Treatment of the emotions by alternative meth- factors. Twin studies have noted an increase in ods, such as antidepressants and cognitive behav- prevalence in monozygotic twins compared ioral therapy (CBT), helps reduce the abnormal with dizygotic twins. Research in molecular eating in response to the emotion. genetics has focused on the 5HT 2A receptor gene, the estrogen receptor β gene and the Bulimia nervosa UCP2/UCP3 gene and have introduced new Bulimia nervosa, as first described by Russell in paths to understanding BN and anorexia 1979, is characterized by episodic binge eating nervosa (AN) [4]. followed by compensatory purging, both occur- Childhood sexual abuse, parental alcoholism ring at least twice a week for 3 months. The or affective disorders, high levels of family con- DSM IV further subdivides BN into purging flict, low parental contact, lack of parental (those who use behaviors such as laxative abuse warmth and care, inappropriate parental con- and induce vomiting) and the nonpurging (that trol and high expectations in parents are all use excessive exercise and starvation). considered risk factors [5]. 110 Therapy (2008) 5(1) futurefuture sciencescience groupgroup Eating disorders related to obesity – REVIEW Premorbid negative self evaluation, impul- Binge eating sivity as well as stressful life events all predis- Binge eating can result in gastric dilatation. pose to the development of BN [6]. Body dissatisfaction has also been identified as a risk Menstrual irregularities factor for developing BN [7]. Patients often Menstrual irregularities have been reported in report very strict dieting followed by episodes approximately 45% of women. In a study of of binge/purge, associated with guilt, depres- patients with BN, it was shown that 45% of sion or anxiety that seem to engulf the patient. patients who had BN but were of normal weight BN occurs across all ethnic and racial groups had menstrual irregularities. These patients had a and is five times more common in urban than higher frequency of vomiting, more cigarette rural areas [8]. smoking, and lower thyroxine T4 than those with BN and normal menses. Half of the patients who Medical complications initially reported irregular menses resumed normal The medical complications with BN vary with cycles after 12 months of treatment; a third of the the compensatory mechanisms used [9]. patients still reported irregular menses. Higher rates of depressive symptoms, longer duration of Induced vomiting eating disorder, current smoking, lower minimum • Electrolyte abnormalities (hypokalemic, body weight and greater difference between maxi- hypochloremic metabolic alkalosis) dehydration; mum and minimum weight were noted in • Erosion of dental enamel; patients with persistent menstrual irregularity after 12 months of treatment. Patients with BN who • Calluses on the dorsum of the hand (Russell’s have menstrual irregularities are at an increased sign); risk of developing osteopenia.
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