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Integrative Medicine Approaches to Eating Disorders

Integrative Medicine Approaches to Eating Disorders. Carolyn Ross, MD, MPH Eating Disorder and Integrative Medicine Consultant 1855 S. Pearl St. Denver, CO 80210 520-440-0079 Crossmd@mac.com www.carolynrossmd.com. Objectives.

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Integrative Medicine Approaches to Eating Disorders

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  1. Integrative Medicine Approaches to Eating Disorders • Carolyn Ross, MD, MPH • Eating Disorder and Integrative Medicine Consultant • 1855 S. Pearl St. • Denver, CO 80210 • 520-440-0079 • Crossmd@mac.com • www.carolynrossmd.com

  2. Objectives • Participants will be able to list two common characteristics between all eating disorder diagnoses • Participants will be able to name one medication studied in the treatment of eating disorders • Participants will be able to understand American Psychiatric Association recommendations for Anorexia or Bulimia 2

  3. Eating Disorders • 7 million females • .5-3.7% of females have AN • 1.1-4.2 % have BN • 2-5% - B.E.D. • 1 million males with AN • 10-25% of those with AN will die as a direct result of the disease • 19% of college-aged females are bulimic • 35% of US population is obese

  4. Eating Disorders • Have one of the highest mortality rates of all psychiatric diagnoses • SMR = 11.6 for anorexia; 1.3 for bulimia • SMR for suicide in anorexia = 56.9 • Severity of alcohol use was associated with increased risk for mortality • Hospitalization for an affective disorder was protective from mortality • Keel PK, et al. Arch of Gen Psych. 2/2003;60(2)

  5. DSM-IV Criteria for Anorexia Nervosa • Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight reduction less than 85% of expected or failure to gain weight during growth to less than 85% of expected) • Unrealistic fear of gaining weight or becoming fat • Unrealistic appraisal of body weight or shape or denial of seriousness of current low body weight. • In postmenarcheal females, amenorrhea (i.e. absence of at least 3 consecutive menstrual cycles.) • May be binge-purge type of restricting type

  6. DSM-IV Criteria for Bulimia Nervosa • Note: may be purging type (self-induced vomiting or using laxatives) or nonpurging type (exercise or fasting) • Inappropriate behavior to compensate for overeating (e.g. self-induced vomiting, laxatives, diuretics, fasting • Eating and compensation at least twice a week for 3 months • Self-evaluation is unduly influenced by body shape and weight • Recurrent episodes of binge eating • Eating, in a discrete period of time (e.g. up to two hours) 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 during the episode

  7. DSM-IV Criteria for B.E.D. or C.E. • Recurrent episodes of binge eating. An episode is characterized by: • Eating a larger amount of food than normal during a short period of time (within any two hour period) • Lack of control over eating during the binge episode (i.e. the feeling that one cannot stop eating). • Binge eating episodes are associated with three or more of the following:. • Eating until feeling uncomfortably full Eating large amounts of food when not physically hungry • Eating much more rapidly than normal • Eating alone because you are embarrassed by how much you're eating • Feeling disgusted, depressed, or guilty after overeating • Marked distress regarding binge eating is present • Binge eating occurs, on average, at least 2 days a week for six months • The binge eating is not associated with the regular use of inappropriate compensatory behavior (i.e. purging, excessive exercise, etc.) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa

  8. Definitions of Eating Disorders • Weight preoccupation and excessive self-evaluation of weight and shape • 50-64% of anorexics develop bulimic behaviors / bulimics often begin to restrict

  9. Common Co-Morbidities • Major Depressive Disorder • Lifetime risk in Anorexics = 80% • Anxiety Disorders, ADHD, OCD, Panic • OCD prevalence= 30% in patients with eating disorders • Personality Disorders - 21-97% • Cluster B most common with bulimia (dramatic/erratic) • Cluster C most common with anorexia (avoidant/anxious) • Social Phobias • Substance Use Disorders • Prevalence in anorexia = 12-18% • Prevalence in bulimia = 30-70% • PTSD

  10. 4th CORE BELIEFS: Beliefs formed in the midst of intense emotion, often forgotten but unconsciously these beliefs continue to shape and drive behaviors 1st SUPERFICIAL LEVEL OF BEHAVIORS: Eating Disorders, Substance Use, Depression, Anxiety, Sexual Compulsivity, others 2nd EMOTIONAL SOUP: Shame, Fear, Anger, Joy, Guilt – Emotions in control of the person. Emotions are the fuel for behaviors. 3rd SENSATE LEVEL: The body sensations associated with emotions 5th Deeper Urges of the Soul: The authentic or true self which caismouflaged by all of the above, Passion or Bliss. Your soul’s desires Integrative Approach to ED

  11. Screening for Eating Disorders • SCOFF Questions* • Do you make yourself Sick (induce vomiting) because you feel uncomfortably full? • Do you worry that you have lost Control over how much you eat? • Have you recently lost more than One stone (14 lb [6.4 kg]) in a three-month period? • Do you think you are too Fat, even though others say you are too thin? • Would you say that Food dominates your life? • One point for every yes answer; a score >= 2 indicates a likely case of anorexia nervosa or bulimia nervosa (sensitivity: 100 percent; specificity: 87.5 percent). • Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999; 319:1467. • *12.5% False positive rate 11

  12. Screening for Eating Disorders • TABLE 4 Suggested Screening Questions for Anorexia Nervosa and Bulimia Nervosa • How many diets have you been on in the past year? • Do you think you should be dieting? • Are you dissatisfied with your body size? • Does your weight affect the way you think about yourself? • A positive response to any of these questions warrants further evaluation. • Information from Anstine D, Grinenko D. Rapid screening for disordered eating in college-aged females in the primary care setting. J Adolesc Health 2000;26:338-42. 12

  13. Newer Pieces to the Puzzle • SPECT scans in anorexics show decreased cerebral blood flow in multiple areas of the brain associated with • Emotional stability, social function, Learning and memory (temporal) • Impulsivity and Attentiveness (prefrontal cortex) • Worry and Obsessiveness (cingulate system) • Scans showed improvement with weight restoration

  14. This is your brain on STRESS: HPA Axis, ED, SUD and Trauma • Hypothalamus ----------------- Pituitary ------------ Target organ Hormone production • Thyroid: TRH  TSH  T3 and T4 • CRH/CRFACTH & Beta endorphinsCortisol • Sex Hormones: GnRH  FSH and LH  Estrogen/Testoster • Serotonin decreased  self-mutilation, impulsiveness, cravings • No consistent serotonin findings in ED/CD/SUD

  15. Obesity and Stress • Acute stress associated with severe, yet reversible, form of insulin resistance • Brandi LS, et al. Clin Sci 1993;85:525-35 • Psychosocial stress associated with insulin resistance • Raikkonen K, et al. Metabolism 1996; 45:1533-38 • Nilsson PM, et al. J Intern Med 1995; 237:479-86

  16. ED and Stress • Bulimics may have a complex and poorly understood dysregulation of the HPA axis associated with the disease.[1] • A study in patients with night eating syndrome also demonstrated dysregulation of the HPA axis with blunting of the CRH-induced ACTH and cortisol response.[2] • 1] Birketvedt GS, Drivenes E, Agledahl I, et al. Bulimia nervosa – a primary defect in the hypothalamic-pituitary-adrenal axis? Appetite. 2006 Mar;46(2):164-7. Epub 2006 Feb 24. • [2] Krupa D. www.the-aps.org/press/journal/release2-7-02-4.htm. [

  17. Genetics • Twin studies show: • a substantial contribution to AN and BN and traits associated with both • Unique environmental influences (trauma, sports that emphasize thinness) > shared environmental influences (SES, religion, parenting style) • Those with a mother or sister with AN are: • 12 X more likely to develop AN • 4 X more likely to develop BN 17

  18. Genetics • Binge Eating Disorder • Binge-eating disorder is a familial disorder caused in part by factors distinct from other familial factors for obesity • Hereditability estimated at 57% (Javaras KN, et al. 2007) • Obesity / Compulsive Overeating • Hereditability estimated at between 40-70%

  19. Causes of Eating Disorders

  20. Causes of eating disorders • Family history of eating disorder or chemical dependency • Early onset puberty • Increased BMI prior to onset • Mood disorder history • Highly competitive academic/social environments • Enmeshed or disengaged family system 20

  21. Precipitating factors • Internal or external sense of loss of control • Puberty and attendant weight gain • Major life transitions: separation/individuation/identity • Traumatic events: abuse / rejection / failure • Family issues: divorce • Innocent weight loss • Onset of co-morbid illness 21

  22. Eating Disorders • Influence of the culture

  23. Ana Carolina Reston Brazilian Model Died at age 21 after prolonged hospitalization for Anorexia Bulimia Kidney Failure Septicemia BMI 13.5 Weight 88 lbs. “There were times I felt fat. I had a distorted image of myself” Ana Carolina Reston (1985-2006)

  24. Eating Disorders Haven’t you had enough calories? Parents divorced at age 9, no longer “Daddy’s little girl” or gifted student

  25. Julie and Morticia

  26. One-quarter of what you eat keeps you alive. The other three-quarters keeps your doctor alive. (Hieroglyph found in an ancient Egyptian tomb) The doctor of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition. Thomas Edison

  27. Nutrition and Eating Disorders: “It’s not just about food” • Keys 1950’s study • Signs of under/malnutrition • mood disorders • obsession with food • bizarre food rituals 27

  28. “Let they food be thy medicine, and let thy medicine be food.” • Protein • Nutrient Density • Sugar

  29. Dietary Supplements

  30. Depression Longer remission with Omega-3 FA supplementation Cott J, 2004 Populations with high depression have low EFAs Eating Disorders Levels of EFAs decreased in AN EFAs effect zinc absorption Zinc necessary for EFA metabolism Dietary Supplements

  31. Suicide Risk Low DHA% and Low Omega-3:6 ratio predicted risk in depressed patients over 2 year period Am J Psychiatry, Sublette M, et al. 2006 Borderline personality disorder Omega 3 FA decrease anger and aggression BMJ 3/05 Omega 3 FA

  32. Dietary Supplements • Calcium, Magnesium, Vitamin D • Food sources of zinc: Oysters Fortified breakfast cereal Lean meats Yogurt Beans Nuts and seeds

  33. Supplements • Digestion & Absorption: • Enzymes: Thorne or Tyler • Probiotics: Lactobacillus GG • Deficient in patients with chronic constipation • Hongisto, 2005 • With fiber  decreased constipation and bloating • Khalif, 2005 • IBS • Kajander, 2005

  34. Supplements for Depression • 5-HTP: Serotonin precursor • Treatment for refractory depression • Insomnia • Cowan 1996 • Cangiano C, 1992 • Cochrane Database

  35. L-Theanine Valerian Root Benzodiazepine withdrawal Sleep Morin CM, 2005 Shinomiya K, 2005 Anxiety Kohnen R, 1988 Andreatini R, 2003 Kava-Kava Yager, et al. (1999) – patient on Prozac (20 mg/day) for alcohol-induced mood disorder. Hx ETOH hepatitis. Pt. took 2 gelcaps of Valerian root and felt like “I’m on acid.” Mc Gregor, et al. (1989) reported 4 cases of hepatotoxicity with combined preparations containing valerian root. Chan (1995) Cases of ingestion of 15-20 grams of valerian root caused headache, excitability, uneasiness, cardiac disturbances but no signs of hepatitis Supplements for Anxiety

  36. Dosage: 300 mg three times a day SAD, ADHD, OCD, Anxiety, Depression Study done on (Perika-Nature’s Way): Extract WS5572: 3% hyperforin 300 mg three times daily SIDE EFFECTS Reduces effect of digitalis May increase effects and side effects of products that increase serotonin (5-HTP, SAMe, SSRI’s) May increase the effect of Xanax, Coumadin, Immunosuppresive agents Robitussin DM increase serotonin May decrease effectiveness of OCP’s May increase metabolism of Dilantin May reduce levels of Zocor(not Pravacol or Lescol) / ?Lipitor/Mevacor Other: may induce mania in bipolar patients Other: high doses may cause sunburn-like reaction St. John’s Wort

  37. St. John’s Wort Case Report • Yager, et al. – Patient with long-standing GAD with panic attacks. Patient began taking St. John’s wort and reported reduction in panic attacks from 3-4/day to 3-4/week. Patient also taking passionflower and wild oat and in CBT.

  38. Patient comments about supplements • “The nutritional supplements made it easier for me to begin eating again. I didn’t have the bloating and stomach pain I had when I went through this process in my last treatment.” • “I never thought I could sleep without my sleep medications. I feel much more well rested and not as groggy as when I took the sleep medicines.” 38

  39. Anorexia Nervosa /Bulimia Nervosa / Binge Eating Disorder

  40. Medications used in the Treatment of Eating Disorders • Topamax - decreased binge eating behavior, BMI and weight in Binge eating disorder (BED) Mc Elroy, et al. Biol Psych 2007 May 1;61(9) • In one study, the use of Clozapine/olanzapine may worsen symptoms of binge eating Gebhart, et al. J Neural Transm 2007 Aug; 114(8) • Sertraline - decrease in Night Eating Syndrome behaviors: nighttime hyperphagia, awakenings, nocturnal ingestions and Beck Depression scores Stunkard AJ, et al. J Clin Psych 2006 Oct; 67(10) 40

  41. Medications for ED • Medications tried for AN have been disappointing and / or studies hampered by small size • None have a significant impact on weight gain • Tricyclics show improvement in mood only • High drop-out rates limit ability to draw conclusions 41

  42. Medications for ED • Bulimia • Trials with Prozac (60 mg/day) for up to 18 weeks • Reduce binging and purging • Reduce psychological symptoms • Trials with Luvox and Trazadone - small studies show some efficacy • Preliminary study on Zofran (Ondansetron) - an antiemetic and 5HT3 Antagonist decreased binging and purging when patients self-administered prn cravings • Medication only trials show abstinence in only a minority of patients.

  43. Medications for Binge Eating Disorder • Trial of Prozac vs. placebo • Decrease in binging, depression • Abstinence rates, high drop-out rates and long-term follow-up not reported - conclusions ? • Overall, in short term studies, SSRI’s lead to reduction in binging, decrease in weight and severity of illness and decrease in psychological symptoms • Long-term follow up is lacking • No data on abstinence from binging • Topamax and Sibutramine - decrease in binging. No long term data • High placebo response in all trials is noteworthy

  44. Mind-Body Therapies

  45. Mind-Body Treatments of Mental Illness • Restoring the mind-body connection • Stress reduction • Research shows efficacy for: • ADD and ADHD • Insomnia • Memory improvements after head trauma • Panic disorder • Chronic Pain • Eating Disorders

  46. Mind-Body Therapies • Guided Imagery • Self-hypnosis • Relaxation Therapies • Breath work, Meditation, PMR • Mindful Practices for • Eating • Exercising • Self-soothing

  47. Research on Yoga • Berger (1992): Yoga & Swimming – decreased anger, confusion, tension and depression more than aerobic training • Shannahoff-Khalsa (1996): Yogic techniques used to treat OCD • Y-BOCS group mean improvement was +54%; improvement on Perceived Stress Scale; 3/5 stopped fluoxetine, 2/5 decreased dose • Woolery, et al (2004): Iyengar yoga effective in decreasing symptoms in subjects with mild depression. • Yoga in ED patients produced increased body contentment, self-confidence and general emotional maturation • Yoga has been effective in treatment of drug addiction in India and US • Hatha yoga found equal to group therapy for reducing drug use and criminal activities in patients on methadone maintenance • SKY yoga breathing in patients with HAM-D >17 (n=45): remission rates were equal for yoga and imipramine but lower than remission rates for ECT.

  48. CASES • Julia’s depression • Thom - from Obesity to Anorexia 48

  49. Thom – “no reason to live” • 40 y.o. WM – Hx of morbid obesity  now severely anorexic • S/P Gastric bypass surgery • Neuromuscular scoliosis • Diet consisted of ¼ grilled cheese sandwich/day + 10-15 Reese’s PB cups • Wheelchair • Day in the Life

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