Eating Disorders

Zenebe k(B.Phar m, MSc,RPh)

Email: zenebekano21@gmail.com
 Introduction
2

 Eating disorders encompass several complex diseases that share

the pathologic feature of over-evaluation of body shape &
weight
 Exact etiology… unknown;
 however,it is most likely a combination of genetic, biologic,
developmental, and environmental factors
 societal, psychosocial factors
 Introduction ….
3

 Contributors to the eating disorders

 biological factors; genetic predisposition;
 predispositionto depression; dysregulation of hypothalamus;
serotonin imbalances;
 sociocultural and psychological factors
 pressures to be thin, cultural norms of attractiveness
 use of food as a way of coping
 over-concern with others’ opinions
 perfectionism (feel that anything less than perfect is unacceptable)
 Introduction ….
4

 Types .…
 Anorexia nervosa
 Bulimia nervosa
 binge-eating disorder
 Other specified and unspecified feeding and eating disorders
 Anorexia Nervosa
5

 A condition x/d by a focus on weight loss and thinness to

the extent that it becomes detrimental to health.
 It is a psychological disorder characterized by somatic
delusions that one is too fat despite being very thin.
 Management of AN is difficult,
 patients are often resistant to weight restoration plans
 psychiatric comorbidities exist in over 50% of those with AN
 Anorexia Nervosa/DSM-5
6

 Refusal to maintain body weight at normal weight for age and

height.
 Intense fear of gaining weight or becoming fat, even though
underweight.
 Distortions in the perception of one’s body weight or shape,
or denial of the seriousness of the current low body weight.
 Amenorrhea in females who have reached menarche,
 absence of at least three consecutive menstrual cycles
 Anorexia Nervosa ….
7

 Severity of AN is based upon …

 BMI in adults and BMI percentiles in children and adolescents.
 More common in girls and young women
 0.9% to 2% of women in US
 Psychiatric comorbidity is common,
 up to 75% of patients have a primary mood disorder
 lifetime
prevalence of OCD in patients with AN is as high as 40%
compared to 2.5% in the general population
 Anorexia Nervosa ….
8

 Specific risk factors for AN …

 being female,
 having a sibling with AN,
 the presence of mood disorders in family members
 presence of co-morbid anxiety, personality, or substance use
disorders
 Types of AN
9

 Restricting type
 restricting
food intake with no binge eating or purging behavior
over the past 3 months
 Simply refusing to eat as a way of preventing weight gain
 Some might go for days without eating
 Binge eating/purging type
 patientsregularly participate in bingeing or purging behaviors
over the prior 3 months
 e.g., self-induced vomiting, misuse of laxatives or diuretics
 Clinical presentation of AN
10

 Sign/Symptoms
 Patients have obsessions and fears about eating and gaining
weight.
 feeling full even when they have eaten very little food.
 Denial of symptoms, failure to recognize low body weight.
 Weakness, lethargy, amenorrhea, vomiting, restricted food intake,
inappropriate exercise, delayed sexual development,
osteoporosis, dry cracking skin, …
 Bulimia Nervosa
11

 A condition x/d by binge eating along with inappropriate

compensatory behaviors and methods to prevent weight gain.
 A disorder of eating in which the person alternates b/n strong
craving for food and feeling of intense dislike towards food
 Characterized by excessive eating followed by periods of
fasting or self-induced vomiting
 To meet DSM-5 criteria,
 the binges and compensatory behaviors must occur on average at
least once weekly for 3 months
 BN lifetime prevalence …1.5% of females and 0.5% of men
 Types of BN
12

 Non-purging type
 useof excessive exercise or fasting to control their weight but do
not engage in purging.
 Purging type
 people use self-induced vomiting or purging medications
 Clinical presentation of BN
13

 Patients binge eat and stop when they have abdominal pain or
self-induced vomiting.
 Severe dieting followed by binge eating episodes.
 They are concerned about their body image but do not have
the drive to thinness, which is a characteristic of AN.
 Self-evaluation is influenced by body shape & weight.
 Clinical presentation of BN
14

 Symptoms
 Patientsdo not eat regular meals and do not feel satiety at the end
of a meal.
 may use purging methods such as laxatives for weight control.
 They have guilt, depression after binges.
 Social isolation can result from frequent bingeing.
 Troubled personal relationships and substance abuse are common.
 Binge-eating disorder
15

 Patients with such disorder present with recurrent episodes of

binging without the compensatory behaviors associated with
AN or BN.
 Binge-eating episodes …. associated with at least 3 of the
following
 eating more rapidly than normal
 eating until feeling uncomfortably full

 eating large amounts of food when not physically hungry

 eating alone b/c of embarrassment of how much is being eaten

 feeling disgusted with oneself, depressed, or guilty after the

episode
 Binge-eating ….
16

 Severity of BED is determined by the number of binge-

eating episodes per week ….
 1-3 = mild
 4-7 = moderate
 8-13 = severe
 14 or more = extreme
 Other specified and unspecified feeding and eating
disorders
17

 In such cases, symptoms result in distress, but do not meet

full diagnostic criteria for any feeding or eating disorders.
 It includes ….
 atypical AN
 BN (lower frequency)
 BED (lower frequency)
 night eating syndrome
 Other specified and unspecified feeding and eating
disorders ….
18

 Night eating syndrome ….

 common in obesity clinic populations
 often accompanied by depressive symptoms
 itis repetitive night eating that includes eating after having been
asleep or excessive food consumption following evening meals
 Such patients benefit from antidepressant therapy
 sertraline 50 to 200 mg daily
 escitalopram 5 to 20 mg daily
19 Treatment
 Treatment
20

 Treatment goals ……
 reduce distorted body image
 restore and maintain healthy body weight
 establish normal eating patterns
 improve psychologic, psychosocial, and physical problems
 enhance compliance
 prevent relapse
 weight loss ….specific to BED
 Medications are rarely indicated as a sole treatment
 Treatments of AN
21

 Nonpharmacologic interventions ….1st-line

 CBT, interpersonal psychotherapy, nutritional counseling, family
therapy
 Initial treatment should aim at restoring a healthy weight and
treating food phobias.
 Most psychiatric symptoms, such as depression and anxiety,
diminish or disappear with weight restoration.
 Treatments of AN ….
22

 Oral refeeding …. initially with liquid formulas

 the most common approach to weight restoration
 Nasogastric refeeding …. preferred over IV bolus dosing in
severe cases
 TPN …..
 reserved for the management of severely malnourished patients
and if other refeeding methods fail
 Treatments of AN ….
23

 Current clinical evidence suggests a controlled weight gain of

0.9 to 1.4 kg per week in inpatient settings and 0.2 to 0.5 kg per
week in outpatient settings.
 Start refeeding at 30–40 cal/kg/day with slow titration (qod)
upwards until they begin to achieve target weight gain.
 Slow refeeding is important to minimize the risk of medical
and psychologic consequences.
 Treatments of AN/ Antidepressants
24

 Antidepressants ….
 currently have no role in the acute treatment of anorexia
 shouldbe initiated only if depression, anxiety, obsessions, or
compulsions persist after the target weight is achieved.
 SSRI antidepressants ….preferred, b/c they are better tolerated
and have greater CV safety than TCAs and MAOIs.
 Fluoxetine …. most widely studied SSRI in anorexia
 initiate
at low doses (20 mg/day) and increase to a maximum of 60
mg/day based on response and tolerability.
 Treatments of AN/ SGAs
25

 Increase weight and reduce comorbid anxiety and depressive

symptoms.
 Optimal treatment duration is unknown
 Risperidone 0.5 to 1.5 mg daily
 Olanzapine 2.5 to 15 mg daily
 Quetiapine 200 to 500 mg daily
 Treatments of AN ….
26

 Metoclopramide can be helpful in reducing bloating, early

satiety, and abdominal pain commonly found in anorexia, but
it does not affect weight gain.
 Low-dose, short-acting benzodiazepines (0.25 mg alprazolam
or 0.5 mg lorazepam) given before meals are useful when
severe anxiety limits eating.
 Estrogen replacement can be used, but restoring menses
through refeeding is a preferred approach to minimize bone
density loss.
 Treatment of Bulimia Nervosa
27

 The nondrug strategies used in bulimia are similar to those

used with anorexia, and they are equally critical to success.
 Nutritional counseling, planned meals, and self-monitoring
can help interrupt the binge–purge cycle.
 CBT combined with medication (e.g., fluoxetine)…. enhance
response.
 Antidepressants in Bulimia Nervosa
28

 Used in combination with nonpharmacologic approaches.

 toreduce depression, anxiety, obsessions, and impulsive
behaviors such as binge eating and purging, and improve eating
habits.
 SSRIs …the preferred agents
 Fluoxetine …the only FDA approved medication for
bulimia.
 Antidepressants in Bulimia Nervosa …
29

 Doses in the treatment of bulimia nervosa are similar to those

in patients treated for depression, though at the higher end of
the range.
 fluoxetine 60 mg/day is necessary for response
 The time for antidepressant onset of effect in bulimia is unclear.
 In the absence of data, the definition of a therapeutic trial from
the depression literature (4–8 weeks at a therapeutic dose)
should be used.
 Optimal duration of treatment after response is poorly defined,
although most clinicians treat for 9 months to 1 year.
 Mood Stabilizers (Lithium, Anticonvulsants)
30

 Lithium and anticonvulsants are reserved for bulimic patients

with a comorbid bipolar affective disorder.
 Target serum concentrations and doses are similar to those
used for patients with seizure or mood disorders.

 Lithium must be used cautiously, as fluid shifts related to

purging and laxative abuse increase the risk of toxicity.
 Mood stabilizers and anticonvulsants unacceptable to patients
in the long term …..due to their adverse effect of weight
gain.
 Binge eating disorder /treatment
31

 Antidepressants and appetite suppressants are the

pharmacologic agents with the greatest promise for short
term use.
 Antidepressants ….
 asmonotherapy at reducing binge eating and improving
depressed mood during the acute phases of the illness.
 can be used in combination with CBT to augment response.
 SSRIs are given at antidepressant doses.
 Binge eating disorder /treatment ….
32

 Topiramate 50 to 600 mg daily …. promotes weight loss.

 Sibutramine (10 to 15 mg/day) ….reduce weight and binge
frequency in obese BED patients
 Orlistat 120 mg given three times daily, along with a calorie-
restricted diet ….reduce weight in obese patients with BED.
 Obesity
33

 Obesity is a disorder that occurs as a result of an abnormal

energy balance, usually resulting from excessive caloric
intake and inadequate caloric loss.
 excess energy being stored as body fat.
 Causes of obesity
34

 Physiological factors: disturbances in the hunger and satiety

centers in the hypothalamus, effects on neurotransmitters,
neuropeptides and hormones that regulate food intake.
 Genetic predisposition together with environmental factors
 Metabolic abnormalities: hypothyroidism, diabetes, psychiatric
disorders, pregnancy, …
 Lifestyle factors: sedentary lifestyle, food intake patterns
 Psychological factors: cultural and socioeconomic influences
 Medications
 Cont’d
35

 Drugs that may cause weight gain

 Antidepressants (e.g. TCAs, SSRIs)
 Antiepileptics (e.g. gabapentin, valproate)
 Antipsychotics (e.g. olanzapine)
 Mood stabilizers (e.g. lithium)
 Insulin, Corticosteroids, etc
 Disorders associated with obesity
 Hypertension, Congestive heart failure, Hyperlipidaemia,
Diabetes, Gallbladder disease, Obstetric complications, …
 Obesity management plan
36

 Diagnosis:
 BMI – obesity 30 kg/m2, overweight 25–29.9 kg/m2
 Waist circumference men 102 cm, women 88 cm
 Investigations: blood pressure, blood tests (blood glucose,
lipid profile, thyroid function tests).
 Hypothyroidism is a potential cause for weight gain
 Smoking cessation for smokers
 Lifestyle and behavioral recommendations
 Lifestyle and behavioral recommendations
37

 A weight reduction program should include educating the

patient on evaluation of caloric content of food items.
 Patients should receive information on reducing fat and how to
avoid rapid reduction in body weight.
 Behavioral modification: patients should learn how to limit
eating in between meals and snacking on high-fat food items.
 Exercise recommendations
 At least three times a week for 30 minutes
 Schedule exercise sessions when they best fit into your lifestyle
 Pharmacotherapy and obesity
38

 Pharmacotherapy may be considered when:

 unsatisfactory response observed with reducing diet
 relapse is encountered after prolonged periods of progress

 An anti-obesity drug should be considered only for those with a

BMI of 30 kg/m2 or greater …..in whom at least 3 months of
managed care involving supervised diet, exercise and behavior
modification fails to achieve a realistic reduction in weight.
 Drugs should never be used as the sole element of treatment.
 Pharmacotherapy….
39

 Available drugs: orlistat, sibutramine (appetite suppressants)

 Orlistat
 Orlistatis a reversible inhibitor of GI lipases, which interferes
with hydrolysis of dietary fat.
 resulting in decreased absorption of ingested fat and is suitable
for patients who have a high intake of fat in their diet
 Orlistat capsules are taken with meals or up to 1 hour after
 Should be omitted if meals contain no fat
 Pharmacotherapy….
40

 Orlistat side-effects:
 interference with absorption of fat soluble vitamins, oily spotting in
feces, flatus and fecal urgency.
 Treatment should not usually continue beyond 1 year
 Sibutramine
41

 Used as appetite suppressant in the management of obesity.

 It inhibits the reuptake of 5-HT, NE and DA.
 It acts centrally, resulting in increased adrenergic and serotonin
activity leading to downregulation of adrenergic and serotonin
receptors. This causes a sensation of satiety.
 May be used as an adjunctive management of obesity in
patients with other risk factors such as type 2 DM and
dyslipidaemia.
 After initiating treatment, weight loss occurs slowly.
 Sibutramine….
42

 Side-effects:
 headache, dizziness, depression, anxiety, insomnia, hypertension,
constipation, dry mouth, nausea.
 Treatment should not be continued for more than 1 year
 Monitoring: blood pressure, pulse rate