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Part I – Eating Disorders: General Trends/Issues Early Eating Disorders Anorexia Nervosa Bulimia Nervosa

Part I – Eating Disorders: General Trends/Issues Early Eating Disorders Anorexia Nervosa Bulimia Nervosa. Prevalence/Patterns. Prevalence Increases in prevalence over past 4 years; changing norms regarding size and shape of women* Historically confined to middle to upper SES

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Part I – Eating Disorders: General Trends/Issues Early Eating Disorders Anorexia Nervosa Bulimia Nervosa

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  1. Part I – Eating Disorders:General Trends/IssuesEarly Eating DisordersAnorexia NervosaBulimia Nervosa

  2. Prevalence/Patterns • Prevalence • Increases in prevalence over past 4 years; changing norms regarding size and shape of women* • Historically confined to middle to upper SES • In college-age American women, 10 % or more have some symptoms of an eating disorder • Estimated to occur in 0.5% to 3% of all teenagers • Among athletes and performers, range from 15% to 60%. • Gender & Age Differences • 90-95% of affected individuals are female • Little is known about nature of disorder in males • Less frequently occurs before adolescence or after age 25

  3. *Prorated Trend of Women’s Actual Body Weights Compared with the Trend for Playboy Centerfolds & Miss America Contestants

  4. General Risk Factors • Self-Ideal Body Image Discordance • General sociocultural norms idealizing extremes of thinness in women in Western cultures • This pressure may lead to development of intrusive and pervasive perceptual biases regarding how fat they are • Lead women to believe that men prefer more slender shapes than they in fact do • Related to decreases in self-esteem usually apparent during mid-adolescence in girls • While women’s actual weight has been increasing over past four decades, the weight of cultural beauty icons has decreased at the same rate

  5. Barbie Doll • Interesting Facts • In 1945 Ruth and Elliot Handler form Mattel. In 1957 Ruth conceives of a three dimensional adult-like doll. The body is based on German doll called "Lilli" which is sold as a sex toy for men. • If Barbie was human sized, she would stand 5 foot 6 inches tall, weigh 110 pounds, and have a 39 inch bust, 18 inch waist and 33 inch hips.

  6. General Risk Factors • Developmental Risk Factors • Continuum of “eating pathology” from pickiness and dieting to clinical syndromes • Early eating habits: stability of problem eating in young children (e.g., pickiness, binging, pica (eating non-food items)) • Drive for thinness: key motivational factor underlying dieting and body image (e.g., “losing weight will make them like me more”) • Dieting: between grades 5-8, 1/3 students diet and 45% want to lose weight • Biological Resistance to weight change • Bodies will resist, and try to compensate, for marked variation from one’s “set point” (individual norm) • Physiological compensations include enhanced hunger drive and slowing of metabolism at decreased caloric intake

  7. Early Eating Disorders • Feeding Disorder of Infancy or Early Childhood • Sudden or marked deceleration of weight gain in an infant or young child and a consequent slowing of emotional and social development. • Relatively common (up to 1/3 of infants affected); more often found in high-risk families, where abuse or neglect may be present • Outcome depends on timing and level of intervention • Failure to Thrive • Weight below 5th percentile for age, and/or deceleration in rate of weight gain from birth to present of at least 2 standard deviations • Been associated with poor attachment, poverty, family disorganization, limited social support • Outcome highly related to child’s home environment

  8. Early Eating Disorders • Pica • Ingestion of inedible substances for period at least 1 month • Affects mostly very young kids and those with MR • Causes: poor stimulation and supervision in the home; in some cases of MR also genetic/biological factors • Severity often related to degree of environmental deprivation and intellectual impairment • Most clinical interventions emphasize operant conditioning • Shaping and reinforcement of appropriate eating behavior

  9. Anorexia Nervosa • Core Characteristics • Refusal to maintain body weight at or above a minimally normal weight for age and height (less than 85%) • Intense fear of gaining weight of becoming fat, even though under-weight • Disturbance in experience of body weight or shape by self-evaluation, or denial of seriousness of current low weight • Amenorrhea (absence of 3 consecutive menstrual cycles) • Two Types: • Restricting Type • Binge-Eating/Purging Type

  10. Anorexia Nervosa • Associated Features • Comorbid Conditions • Depression • OCD & extreme self-control (in restricting types) • Substance abuse disorders (in binge-eating/purging type) • Personality disorders (esp. anxious-fearful) • Behavioral Patterns • Isolation from peers; social awkwardness • Severe dietary restriction, excessive exercise (RT) • Misuse of laxatives, diuretics, enemas, self-induced vomiting (B-E/PT)

  11. Anorexia Nervosa • Specific Risk Factors • Personality Characteristics • Emotionally reserved and cognitively inhibited • Preference for routine, order, and predictable environments; poor adaptation • Show heightened conformity and deference to others • Avoid risk and react to stressful events with strong feelings of distress • Focus excessively on perfectionism • Maturity fears • Family Patterns • Mothers described as: excessively dominant, intrusive, overbearing, and less affectionate, discouragement of autonomy • Fathers described as: emotionally absent • Families described as: limited tolerance of disharmonious affect or tension, poor conflict resolution skills, preoccupation with desirability of thinness, dieting, and good physical appearance

  12. Anorexia Nervosa • Treatment Goals • Stabilize Patient • Restoring hormonal function and bone density • Maximize chances for full and lasting recovery • Treatment Components • Hospitalization • Renourish and reestablish weight to ensure survival • Psychological Treatment (Out/Inpatient) • Family therapy • Cognitive-behavioral therapy • Nutritional counseling

  13. Anorexia Nervosa • Prognosis: Long-term Physical Effects • Heart disease • Most common medical cause of death in people with severe anorexia. • Heart develops dangerous rhythms, blood flow is reduced and blood pressure may drop, heart muscles starve, losing size • Cholesterol levels tend to rise • Electrolyte Imbalances • Anemia • Reproductive and Hormonal Abnormalities • Low levels of reproductive hormones& changes in thyroid hormones • Neurological Problems • Nerve damage and seizures, disordered thinking, loss of feeling, or other nerve problems in the hands or feet. • Structural changes and abnormal activity during anorexic states; some damage may be permanent.

  14. Anorexia Nervosa • Prognosis • At this time, no treatment for anorexia is completely effective. • Many remain very thin and displayed characteristics of the disorder, including perfectionism and drive for thinness, that keep them at risk for recurrence of the eating disorder. • Recovery can take between 4 and nearly 7 years. • Comorbid disorders increase for poor outcome. • Risk of Death • Death rates ranging from 4% to 20%. • The risk for early death is twice as high in bulimic anorexics as it is in the anorexic-restrictor types. • Increased suicide rates.

  15. Bulimia Nervosa • Core Characteristics • Recurrent episodes of binge eating • Eating in a discrete period of time (i.e. 2hrs) an amount of food that is definitely larger than most people would in similar circumstances A sense of lack of control over eating during the episode • Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or medications, fasting, or excessive exercise • Both behaviors occur on average at least twice a week for 3 mos • Self-evaluation unduly influenced by body shape and weight • Two Types: • Purging Type • Non-purging type

  16. Bulimia Nervosa • Associated Features • Comorbid Conditions • Anxiety disorders (esp. GAD) • Substance use disorders • Personality disorders (esp. Cluster B – emotional, dramatic, emotional, erratic) • Behavioral Patterns • Purging types show greater physical and psychological dysfunction • Preoccupation with efforts to conceal disorder and master impulse to binge • Binge episodes usually involve intake of about 1000 calories approx. 14 times per week

  17. Bulimia Nervosa • Specific Risk Factors • Personality Characteristics • Long-standing pattern of excessive perfectionism • Negative self-evaluation • Maturity fears • Impulsivity • Family Patterns • High parental expectations • Other family members dieting • Higher criticism by family members about shape, weight, or eating • Decreased allowance for autonomy

  18. Bulimia Nervosa • Treatment • Antidepressants • Cognitive-Behavioral Therapy • Clearly superior to medication • Emphasis on normalizing eating patterns • Temporal regularity • Social eating • Focus on distorted cognitive patterns • Dichotomous thinking

  19. Bulimia Nervosa • Prognosis • Less major health problems associated with bulimia, where normal weight is maintained • In general, the outlook is better for bulimia than for anorexia. • Mortality rate about 1% for those in treatment; 20% have life-long patterns of disorder • Physical Effects • Teeth erosion, cavities, and gum problems • Loss of fluid and low potassium levels • Acute stomach distress, rupture of the esophagus, or food pipe

  20. Boys and Body Image • Growing awareness regarding the pressure men and boys are under to appear muscular. • Many males are becoming insecure about their physical appearance as advertising images raise the standard and idealize well-built men. • Alarming increase in obsessive weight training and the use of anabolic steroids and dietary supplements that promise bigger muscles or more stamina for lifting. • Number of boys affected is increasing and that many cases may not be reported, since males are reluctant to acknowledge any illness primarily associated with females.

  21. Part II - Obesity:An EpidemicCurrent TreatmentsA New Approach: BCT

  22. Obesity Trends* Among U.S. AdultsBRFSS, 1985 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  23. Obesity Trends* Among U.S. AdultsBRFSS, 1986 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  24. Obesity Trends* Among U.S. AdultsBRFSS, 1987 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  25. Obesity Trends* Among U.S. AdultsBRFSS, 1988 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  26. Obesity Trends* Among U.S. AdultsBRFSS, 1989 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  27. Obesity Trends* Among U.S. AdultsBRFSS, 1990 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  28. Obesity Trends* Among U.S. AdultsBRFSS, 1991 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  29. Obesity Trends* Among U.S. AdultsBRFSS, 1992 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  30. Obesity Trends* Among U.S. AdultsBRFSS, 1993 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  31. Obesity Trends* Among U.S. AdultsBRFSS, 1994 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  32. Obesity Trends* Among U.S. AdultsBRFSS, 1995 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  33. Obesity Trends* Among U.S. AdultsBRFSS, 1996 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  34. Obesity Trends* Among U.S. AdultsBRFSS, 1997 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  35. Obesity Trends* Among U.S. AdultsBRFSS, 1998 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  36. Obesity Trends* Among U.S. AdultsBRFSS, 1999 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  37. Obesity Trends* Among U.S. AdultsBRFSS, 2000 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  38. Obesity Trends* Among U.S. AdultsBRFSS, 2001 Source: Mokdad A H, et al. J Am Med Assoc1999;282:16, 2001;286:10.

  39. A National Crisis • The rates of overweight and obese individuals have been steadily climbing. • Rates of obesity alone have doubled in the last decade. • 1998, the World Health Organization labeled Obesity “an Epidemic.” • 65% of the population are now either overweight or obese (2004). • The trend is continuing with no end in sight.

  40. Who is Overweight or Obese? • Height-Weight Tables>120% desirable weight • BMI (kg of body weight / height (in meters) squared) Normal < 25 kg/m2 Overweight 25-30 Class I Obesity 30-34.99 Class II Obesity 35-39.99 Class III Obesity >40 • Percent Fat>25% males; >32% females • Waist Circumference>40 in. males; >35 in. females

  41. Physical & Emotional Burdens • Risk of major chronic diseases increases with increases in BMI and central obesity: Metabolic Syndrome Cardiovascular Diseases Type 2 Diabetes Cancers Osteoarthritis Sleep Apnea Gall bladder Disease Psychological Disorders Social and Employee Discrimination

  42. The Financial Burden • $100 billion dollars spent annually on obesity-related health care utilization. • $329.2 billion dollars spent in 2002 on CVD-related illness. • $50 billion dollars spent annually on diet related products.

  43. The Ultimate Cost • Direct link between Obesity and Years of Life Lost (Fontaine et al, 2003) • Young adults with morbid obesity had a 22% reduction in life span. • Ethnic differences in optimal BMI • 23 to 25 for Caucasian (men and women) • 23 to 30 was optimal for African American (men and women). • Obesity-related illness accounts for >280k deaths annually (Manson, 2003) • Obesity mortality is positively correlated with CVD mortality • 950,000 people die each year from cardiovascular disease (CDC, 2003)

  44. US Cardiovascular Disease Rates Deaths in the Thousands Cardiovascular disease mortality trends for males and females in the United States, 1979-2000. Reprinted from the American Heart Association.

  45. Explanation Biological Psychological Social Engel, 1977, 1980; Schwartz, 1982

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