THE MANAGEMENT OF EATING DISORDERS AND OBESITYdownload.e-bookshelf.de/download/0000/0068/55/L-G...The Management of Eating Disorders and Obesity, Second Edition, edited by David J

THE MANAGEMENT OF EATING DISORDERS AND OBESITY

SECOND EDITION

Goldstein_2nd_FM_Final 11/2/04, 2:46 PM1

NUTRITION ◊ AND ◊ HEALTH

Adrianne Bendich, Series Editor

The Management of Eating Disorders and Obesity, Second Edition, edited by David J.Goldstein, 2005

Preventive Nutrition: The Comprehensive Guide for Health Professionals, Third Edition,edited by Adrianne Bendich and Richard J. Deckelbaum, 2005

IGF and Nutrition in Health and Disease, edited by M. Sue Houston, Jeffrey M. P.Holly, and Eva L. Feldman, 2005

Nutrition and Oral Medicine, edited by Riva Touger-Decker, David A. Sirois, andConnie C. Mobley, 2005

Epilepsy and the Ketogenic Diet, edited by Carl E. Stafstrom and Jong M. Rho, 2004Handbook of Drug–Nutrient Interactions, edited by Joseph I. Boullata and Vincent T.

Armenti, 2004Nutrition and Bone Health, edited by Michael F. Holick and Bess Dawson-Hughes,

2004Diet and Human Immune Function, edited by David A. Hughes, L. Gail Darlington,

and Adrianne Bendich, 2004Beverages in Nutrition and Health, edited by Ted Wilson and Norman J. Temple, 2004Handbook of Clinical Nutrition and Aging, edited by Connie Watkins Bales

and Christine Seel Ritchie, 2004Fatty Acids: Physiological and Behavioral Functions, edited by

David I. Mostofsky, Shlomo Yehuda, and Norman Salem, Jr., 2001Nutrition and Health in Developing Countries, edited by Richard D. Semba and

Martin W. Bloem, 2001Preventive Nutrition: The Comprehensive Guide for Health Professionals, Second Edition,

edited by Adrianne Bendich and Richard J. Deckelbaum, 2001Nutritional Health: Strategies for Disease Prevention, edited by Ted Wilson and

Norman J. Temple, 2001Clinical Nutrition of the Essential Trace Elements and Minerals: The Guide for Health

Professionals, edited by John D. Bogden and Leslie M. Klevey, 2000Primary and Secondary Preventive Nutrition, edited by Adrianne Bendich

and Richard J. Deckelbaum, 2000The Management of Eating Disorders and Obesity, edited by David J. Goldstein,

1999Vitamin D: Physiology, Molecular Biology, and Clinical Applications,

edited by Michael F. Holick, 1999Preventive Nutrition: The Comprehensive Guide for Health Professionals, edited by

Adrianne Bendich and Richard J. Deckelbaum, 1997


THE MANAGEMENT

OF EATING DISORDERS

AND OBESITY

SECOND EDITION

Edited by

DAVID J. GOLDSTEIN, MD, PhDDepartment of Pharmacology and Toxicology, Indiana UniversitySchool of Medicine and PRN Consulting, Indianapolis, IN

Foreword by

ALBERT J. STUNKARD, MD

Weight and Eating Disorders Program, Department of Psychiatry,University of Pennsylvania School of Medicine, Philadelphia, PA


© 2005 Humana Press Inc.999 Riverview Drive, Suite 208Totowa, New Jersey 07512

www.humanapress.com

All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher.

All papers, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of thepublisher.

Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information publishedand to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections anddosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, asnew research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactionsconstantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any changein dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is anew or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies forindividual patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration statusof each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissionsor for any consequences from the application of the information presented in this book and make no warranty, express or implied, withrespect to the contents in this publication.

Cover design by Patricia F. ClearyProduction Editor: Robin B. Weisberg

For additional copies, pricing for bulk purchases, and/or information about other Humana titles,contact Humana at the above address or at any of the following numbers: Tel.: 973-256-1699;Fax: 973-256-8341; E-mail: [email protected] or visit our Website at www.humanapress.com

This publication is printed on acid-free paper. ∞ANSI Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials.

Photocopy Authorization Policy:Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients is granted by HumanaPress, provided that the base fee of US $25.00 per copy is paid directly to the Copyright Clearance Center (CCC), 222 Rosewood Dr.,Danvers MA 01923. For those organizations that have been granted a photocopy license from the CCC, a separate system of paymenthas been arranged and is acceptable to the Humana Press. The fee code for users of the Transactional Reporting Service is 1-58829-341-6/05 $25.00.

Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1

eISBN 1-59259-865-X

Library of Congress Cataloging-in-Publication Data

The management of eating disorders and obesity / edited by David J. Goldstein.-- 2nd ed. p. ; cm. -- (Nutrition and health) Includes bibliographical references and index. ISBN 1-58829-341-6 (alk. paper) 1. Eating disorders. 2. Obesity. [DNLM: 1. Bulimia--therapy. 2. Anorexia Nervosa--therapy. 3. Obesity--therapy. WM 175 M266 2005]I. Goldstein, David J. (David Joel), 1947- II. Series: Nutrition and health (Totowa, N.J.) RC552.E18M364 2005 616.85'2606--dc22

2004009971


Series Editor’s Introduction

v

The Nutrition and Health Series of books have had great success because each volumehas the consistent overriding mission of providing health professionals with texts that areessential because each includes (1) a synthesis of the state of the science; (2) timely,in-depth reviews by the leading researchers in their respective fields; (3) extensive,up-to-date fully annotated reference lists; (4) a detailed index; (5) relevant tables andfigures; (6) identification of paradigm shifts and the consequences; (7) virtually no over-lap of information between chapters, but targeted, interchapter referrals; (8) suggestionsof areas for future research; and (9) balanced, data-driven answers to patient/healthprofessionals’ questions that are based on the totality of evidence rather than the findingsof any single study.

The series volumes are not the outcome of a symposium. Rather, each editor has thepotential to examine a chosen area with a broad perspective, both in subject matter as wellas in the choice of chapter authors. The editors, whose trainings are both research- andpractice-oriented, have the opportunity to develop a primary objective for their book,define the scope and focus, and then invite the leading authorities to be part of theirinitiative. The authors are encouraged to provide an overview of the field, discuss theirown research, and relate the research findings to potential human health consequences.Because each book is developed de novo, the chapters are coordinated so that the resultingvolume imparts greater knowledge than the sum of the information contained in theindividual chapters.

The Management of Eating Disorders and Obesity, Second Edition, edited by DavidJ. Goldstein clearly exemplifies the goals of the Nutrition and Health Series. The firstedition was widely acclaimed for its emphasis on data-driven clinical applications of thenewest scientific discoveries in the areas of bulimia, anorexia, binge eating, and thecomplex, chronic disease of obesity. Dr. Goldstein, who is an internationally recognizedleader in the fields of obesity and eating-disorder research, has enhanced the contents ofthe first edition even further with the addition of three timely, new chapters. The first twonew chapters cover the internet and its value in the education and potential treatmentof eating disorders in one chapter, and the use of the internet in education and treatmentof obesity in a second chapter. The third critically important chapter reviews the role ofhunger and satiety in obesity treatment. All of the original chapter authors, the mostauthoritative leaders in obesity and eating-disorder research, have updated the contentsand have included recent references, figures, and graphs. Thus, Dr. Goldstein has devel-oped a second edition that is destined to be the benchmark in the field because of itsextensive, in-depth chapters covering the most important aspects of eating disorders andobesity, with emphases on human physiology, treatment, and disease prevention.

The book chapters are logically organized to provide the reader with a basicunderstanding of the clinical conditions of bulimia nervosa, anorexia nervosa, andobesity in the first chapter of each of the book’s three major sections. Each section also


contains chapters that address treatment options as well as prevention strategies. Thislogical sequence of chapters provides the latest information on the current standards ofpractice for clinicians, related health professionals including the dietitian, nurse, pharma-cist, physical therapist, behaviorist, psychologist, and others involved in the team effortrequired for successful treatments. This comprehensive volume also has great value foracademicians involved in the education of graduate students and postdoctoral fellows,medical students, and allied health professionals who plan to interact with patients witheating disorders including obesity.

Cutting-edge discussions of the roles of growth factors, hormones, cellular and nuclearreceptors and their ligands, gene promoters, adipose tissue, and all of the cells directlyinvolved in fat metabolism are included in well-organized chapters that put the molecularaspects into clinical perspective. Of great importance, the editor and authors haveprovided chapters that balance the most technical information with discussions of itsimportance for clients and patients as well as graduate and medical students, healthprofessionals, and academicians.

Separate chapters in the three sections include specific, detailed information on thecounseling of patients with bulimia and the pharmacological treatment of bulimia. Thereis a unique chapter that looks at the role of nutrition and dietary factors in the preventionof eating disorders. The anorexia section includes four chapters devoted to basic infor-mation, treatment strategies, detailed information on pharmacological therapies, and thenew chapter on internet resources. The third section is the largest and contains threechapters on general aspects of obesity including the etiologies of obesity, medicalconsequences of obesity, as well as benefits of weight loss and a very practical chapteron binge eating in the obese.

Thirteen chapters are devoted to the treatment of obesity. These include an overviewof current treatment options as well as a discussion of future treatments that are alreadyin development. Critical to any weight-reduction program is exercise, and there is acomprehensive chapter on the role of physical activity, exercise, and nutrition in weightcontrol. The importance of a team approach to the treatment of obesity as a chronicdisease is extensively discussed in the chapter on lifestyle modification in the treatmentof obesity. Specific treatment modalities are reviewed in separate chapters on very low-calorie diets, pharmacotherapies, combination therapies, the potential for genetic inter-ventions, the new chapter on hunger and satiety, and surgical interventions that arediscussed in detail, including drawings that depict the specific types of surgeriescurrently available. Each of these chapters presents an objective evaluation of thetreatment and identifies the positives and negatives that have been seen during clinicalstudies, as well as cumulative data derived from clinical practice.

The final four chapters in the obesity treatment section examine the clinical experi-ences in a comprehensive weight-management program, the importance and value of amultidisciplinary team in the management of obesity, the potential for the internet to helpin obesity treatment, and a most candid chapter on the barriers to obesity treatment. Thefinal book chapter reviews the most medically relevant alternative to treatment–preven-tion of obesity—and examines the signs that could alert the health professional to thepotential for the development of obesity, as well as outlines the steps to take to helpprevent the overweight patient from moving to frank obesity.

vi Series Editor’s Introduction


There is a clear, data-driven message throughout the obesity section of the volume thatobesity is a chronic disease. As with hypertension that can be controlled by drug therapy,so with obesity—therapy cannot stop once a particular weight-loss goal is reached. Likehypertension that reappears without chronic treatment, obesity can easily reappear if nottreated as a chronic disease.

Detailed tables and figures assist the reader in comprehending the complexities of thedisturbances in eating behaviors. Modulators of eating responses that are covered in thissection include adrenergic receptors, cholecystokinin, γ-aminobutyric acid, histamineand serotonin receptors, insulin, leptin, neuropeptide Y, galanin, ghrelin, growthhormone, as well as substances that can be consumed in diet and/or supplements such ascaffeine, ephedrine, aspirin and lithium, olestra, and yohimbine. Novel treatment optionsthat are of great interest to clients and patients are included in several chapters that reviewmore than 50 therapeutic agents. In-depth descriptions of behavioral modificationprograms, mental states, evaluation tools for documentation of patient eating habits, andmany other valuable treatment aids are included in numerous chapters. Thus, TheManagement of Eating Disorders and Obesity, Second Edition is focused on answeringquestions commonly asked by clients and patients about why some diets do not work andwhy some “professional” sources advocate certain products that are available over thecounter but may not “work.” The overriding goal of this volume is to provide the healthprofessional with the balanced documentation to assure the client/patient that eatingdisorders and obesity are complex states that transcend the simplistic view of just losinga few pounds.

Hallmarks of all chapters include bulleted key points at the beginning of each chapteras well as a detailed table of contents; complete definitions of terms with the abbrevia-tions fully defined for the reader and consistent use of terms between chapters. There arenumerous relevant tables, graphs, and figures as well as up-to-date references; allchapters include a conclusion section that provides the highlights of major findings. TheManagement of Eating Disorders and Obesity, Second Edition contains a highlyannotated index and within chapters, readers are referred to relevant information in otherchapters.

This important text provides practical, data-driven resources based on the totality ofthe evidence to help the reader understand the basics, treatments, and preventivestrategies that are involved in bulimia, anorexia, and obesity. The overarching goal of theeditor is to provide fully referenced information to health professionals so they may havea balanced perspective on the value of various treatment options that are available todayas well as in the foreseeable future.

In conclusion, The Management of Eating Disorders and Obesity, Second Edition,edited by David J. Goldstein provides health professionals in many areas of research andpractice with the most up-to-date, well-referenced and easy-to-understand volume on theimportance of identifying and treating those already suffering from bulimia, anorexia,and/or obesity as well as providing strategies to prevent the development of these chronic,serious diseases. This volume will serve the reader as the most authoritative resource inthe field to date and is a very welcome addition to the Nutrition and Health Series

Adrianne Bendich, PhD, FACN

Series Editor

Series Editor’s Introduction vii


Foreword

The 6 years since the publication of the first edition of The Management of EatingDisorders and Obesity has seen a sea change in our view of obesity. At the time of thefirst edition, obesity was still viewed as a fairly simple problem, with unfortunate, but notnecessarily dire, consequences. Since that time, the importance of obesity has broken intoour general awareness and into the medical literature in particular. The enormousincrease in obesity, to the extent that two-thirds of Americans are overweight or obese, is nowtermed an “epidemic.” This epidemic is destined to become even more severe as the hugeincrease in childhood obesity has its impact on obesity in later life. The serious healthconsequences of obesity are being increasingly recognized and Syndrome X has becomea household word.

This situation in the treatment of obesity is a major reason for the consternation causedby the removal of fenfluramine from the market just as the first edition of this volume waspublished, because fenfluramine was the most effective pharmacological agent for thetreatment of obesity yet employed and was a sound basis for medical treatment of thedisorder. No other medication for obesity has yet taken its place.

In the face of the uncontrollable increase in obesity, the public is turning increas-ingly to popular fads. The explosion of interest in the Atkins Diet, and “low carbs”illustrates a near hysteria on the part of the general public. Forty million Americans aresaid to be currently following the not entirely benign Atkins Diet. In these frantic days,an important task of the practitioner is to forestall the more needless, and even harmful,results of the hysteria.

As befits an epidemic, public health efforts are being introduced in increasing measureto schools, communities, and in public communication, as through the internet. The focusof these methods is on the favorable changes in lifestyle that may help to prevent obesityfrom developing, control it when it develops, and, in some cases, reduce it. As outlinedin Food Fight by Brownell and Horgen (1), the beginning of this effort is to think differ-ently about foods, not as “good” or “bad,” but in total calories of food intake. Next, publichealth and medical efforts should be combined to increase physical activity and toestablish simple but sound eating habits that include smaller portion sizes. Theseactivities had not been ones that, until now, the practitioner would have been able topursue under the circumstances prevailing because they require services that had not beenreimbursed. Awareness of the epidemic nature of obesity has led to the salutary conse-quence of the US Food and Drug Administration labeling obesity “a disease.” This long-delayed action has important consequences. It makes it possible for the treatment ofobesity to be reimbursed. For the first time, practitioners may be able to devote the timenecessary for the successful treatment of obesity. Furthering at the individual level theefforts made at the public health level means that the practitioner can, for the first time,be able to advise patients on favorable lifestyle changes.

ix


x Foreword

The eating disorders, in contrast to obesity, have been the subject of only modestchange since the first edition of this volume. The greatest improvement has been in themanagement of bulimia nervosa. Intensive research has produced improvements in boththe pharmacological and behavioral treatments of bulimia nervosa, and in their combi-nation. The treatment of bulimia nervosa is still largely the province of specialistsdevoted to treatment of the disorder. But there is a critical role for the clinician in diag-nosing it and referring patients for treatment. The earlier the treatment begins, the betterits results, both in the short term and in the long term. Patients with bulimia nervosashould not be allowed to suffer without the effective help that is now available.

Binge-eating disorder has received increasing attention in recent years and it is nowrecognized as a widespread problem. A number of studies of pharmacological and psy-chological treatment have shown that these agents improve the symptoms of binge eating.This improvement, however, has not produced weight loss and the usefulness of thisdiagnosis has been questioned (2).

The problem of anorexia nervosa is the most challenging among the eating disorders.Despite continuing research, little progress in treatment has been made. The most effec-tive treatment for anorexia nervosa may well be Russell’s (3) decades-old program offamily therapy for young anorectics. As with bulimia nervosa, the practitioner can pro-vide a valuable service in identifying patients with anorexia nervosa and carrying out thedifficult task of getting them into treatment. The current status of the disorder is welldescribed in the four chapters devoted to it.

Albert J. Stunkard, MD

Weight and Eating Disorders ProgramDepartment of Psychiatry

University of Pennsylvania School of MedicinePhiladelphia, PA

REFERENCES

1. Brownell KD, Horgen K. Food Fight. Contemporary Books, Chicago, IL, 2004.2. Stunkard AJ, Allison KC. Binge eating disorder: disorder or marker? Int J Eat Disord 2003;34:5107–

5116.3. Russell GFM, Szmukler GI, Dare C, Eisler I. An evaluation of family therapy in anorexia nervosa and

bulimia nervosa. Arch Gen Psychiatry 1987;44:1047–1056.


Preface

xi

The first edition of The Management of Eating Disorders and Obesity was publishedin 1999, just after the removal of fenfluramine and dexfenfluramine from the marketbecause of the association of their use with development of valvular heart disease (1).Dr. Albert J. Stunkard expressed the possibility that drug therapy would come to a“screeching halt” and that legal actions would cause prescribers to avoid obesity pharmaco-therapies and cause pharmaceutical companies to discontinue development of futureobesity therapies. Prescription of drugs for obesity treatment did decrease and the USFood and Drug Administration required additional evidence of safety prior to approvalof new anti-obesity agents for marketing, but drug development did not stop. To thecontrary, our improving understanding of the genetic basis of eating behaviors hasexpanded the number of molecular targets for obesity pharmacotherapies, and manynovel molecular entities are being evaluated. Recently, the effects of ephedrine and similarcompounds on blood pressure and the risk of stroke (2,3) have been more generallyrecognized, and ephedrine-containing products have been withdrawn from the market.

In 1999, I noted that eating disorders and obesity were common and their prevalencewas increasing. Unfortunately, this trend has continued to the degree that obesity has beencalled an epidemic (4). In 2004, the obesity-related mortality rate nearly overtook that ofcigarette smoking. Underlying this increase in obesity is the abundance and variety offood, as well as the commercialization of the food industry, promoting more eating, largerportions, and high caloric density foods. Threats of litigation of “fast food” chains andsocial pressures may have encouraged these companies to add more healthful items totheir menu and many have added low carbohydrate selections in an effort to capitalize onthe recent trend for low carbohydrate diets. This is discussed in Chapter 19.

Obesity and associated diseases continue to cost society more than $100 billion indirect and indirect health costs annually. Treatment of eating disorders and obesitycontinue to be suboptimal. All tend to be best managed by experts and for obesity,maintenance of weight loss continues to be challenging, even in the best medicallymanaged centers.

Associated with obesity is a societal stigma that leads in part to the emphasis on beingthin and adds pressures toward attainment of lean body habitus, thus enhancing thedevelopment of the potentially life-threatening anorexia nervosa and bulimia nervosa.These eating disorders and obesity are disorders of ingestion—either too much or toolittle, too much control or too little, with purging behavior or without. All have significanthealth, social, and psychological consequences.

That is the bad news. So what is the good news? There is increasing awareness abouteating disorders and their predispositions. Efforts are expanding on prevention, earlyidentification, and intervention of eating disorders. Clinicians are developing treatmentstrategies incorporating newer technologies, including the internet, which might eventu-ally reduce the cost while improving access to and effectiveness of therapy. Regarding


xii Preface

obesity, there is greater focus on prevention, and strategies for prevention are beingevaluated. Researchers are identifying the effects of maternal behaviors during preg-nancy that “imprint” the fetus for increased postnatal weight gain and obesity-associateddisease complications. As we learn about such effects, we may be able to recommendbehaviors for pregnant women that would reduce the future risk for their infants. Increas-ing pressure for companies to improve the ingredients in their prepared foods has ledmany to respond in positive ways. School lunches have been placed under more scrutiny.Schools are attempting to educate students about nutrition and are attempting to encour-age better eating and increased activity and exercise. More is understood about effectivemethods for maintenance of reduced weight and these methods are being incorporatedinto therapeutic programs. The molecular basis of obesity is being more effectivelyprobed and many neuroendocrine mediators have been identified.

This second edition follows the structure of the first edition in that it consists of threemajor sections, one each for bulimia nervosa, anorexia nervosa, and obesity. Each sectioncontains brief, practical, and timely reviews of the disorder or aspects of management.The reviews have been updated to incorporate recent findings and new chapters havebeen incorporated. The goal remains to provide assistance to practitioners who want torealize the maximal impact when caring for patients with eating disorders or obesity. Notonly are present therapies described, but developing therapies are identified as well.

The unifying principle underlying the treatment of eating disorders and obesity is theestablishment of healthful behaviors and the ideal of also attaining a healthy weight. SoDrs. Romano and Blackburn and colleagues discuss the health consequences of bulimianervosa (Chapter 1), anorexia nervosa (Chapter 5), and obesity (Chapter 10). Then Dr.Busk and colleagues discuss the health benefits of increased activity and exercise (Chap-ter 13). Increasing activity is important in alleviating the health consequences of obesityeven without weight loss, as it has been identified as one of the behaviors that makeweight maintenance more likely.

The treatment of the eating disorders can be challenging. Drs. Mitchell and CookMyers discuss the nonpharmacological therapy of bulimia nervosa (Chapter 2) and Dr.Hsu discusses the strategy for treatment of anorexia nervosa (Chapter 6). Dr. Hudson andhis colleagues and Dr. Kaye review the research on the pharmacotherapy of bulimianervosa (Chapter 3) and anorexia nervosa (Chapter 7). They provide their experiencesand strategies for treatment.

Ultimately, we should be trying to prevent the development of eating disorders and ifthey occur, we should attempt early treatment before the conditions become refractoryto treatment. Once we have successfully treated the patient, we need to prevent relapse.Dr. Rock (Chapter 4) discusses the effects of nutrition on the development of eatingdisorders and how modification of nutrition can assist in preventing the development of,improving the treatment of, and preventing relapse of eating disorders.

Dr. Marcus (Chapter 11) provides an overview of binge-eating disorder. This is a morerecently defined diagnosis that has had increasing research interest since the first edition.Dr. Marcus reviews much of the research related to treatment of binge-eating disorderand places this into perspective.

Dr. Foreyt and colleagues (Chapter 12) look at the present status of obesity and lookforward to how today’s needs may be met in the future. Part of the cause of obesity is the


underlying genetics of the individual that becomes permissive for weight gain in anenvironment of excess (5). As noted earlier, imprinting of the fetus and other environ-mental effects may also predispose individuals toward weight gain. These and othereffects are discussed by Dr. Atkinson (Chapter 9).

Despite concerns about withdrawal from the market of obesity medications or greaterregulatory restriction on obesity pharmacotherapy and despite possible increased stigma-tization of obesity pharmacotherapy, two new obesity pharmacotherapies, orlistat andsibutramine, were approved for marketing in the United States, as is discussed by Dr.Bray (Chapter 16). New treatments continue to be explored and some of these have novelmechanisms that were not anticipated in 1999. Several of these may be approved formarketing during the next several years. Two that are anticipated in the near term areciliary neurotrophic factor and rimonabant. In addition, some treatments are being usedin combination with greater success than provided by individual agents, much asfenfluramine in combination with phentermine provided greater efficacy than did eitheragent individually (4,6) . Drs. Atkinson and Uwaifo report on use of combination therapyin Chapter 17. Combinations of drugs are used in other branches of medicine to improvecontrol of disease or to lower blood pressure, cholesterol, control diabetes, and so on. Itis reasonable to believe that use of medications with different mechanisms of action couldproduce better weight control. This greater efficacy led to the popularity of the fen-phencombination for weight reduction and other combinations are in use at present. Suchcombinations have not been adequately studied in large controlled trials, but we shouldexpect such studies in the future.

The genetics of obesity has been further elucidated since the first edition and Dr.Fernandez (Chapter 18) provides an update on these findings and how they might relateto future therapeutics. He also attempts to address the genetic perspective on the role ofenvironment and how to use genetic tools to better understand the interaction of natureand nurture.

Surgical solutions for obesity have, on average, resulted in greater and more sustainedweight loss than other treatments. Recognition of this has led to increased interest andutilization of this alternative. Surgical therapy continues to generate media interest. Thesurgical procedures continue to be refined and developed to maximize weight loss andminimize adverse consequences. Dr. Shikora (Chapter 20) discusses these surgicaltechniques and management of the post-surgery patient.

Weight loss can be attained with very low calorie diets, discussed by Dr. Phinney(Chapter 15), and by calorie restricted diets with modification of lifestyle and eatingbehaviors, discussed by Drs. Fabricatore and Wadden (Chapter 14). Very low caloriediets require special monitoring to avoid problems. Dr. Phinney discusses this manage-ment. After initial weight loss, postreduction maintenance strategies are critical to pre-vent regain of weight. Dr. Fabricatore and Wadden discuss strategies for weightmaintenance.

The low carbohydrate diet, commercialized by Dr. Atkins, and its variants, includingthe South Beach Diet, have become very popular. Recent research has provided scientificinformation from randomized clinical trials about the effects of a low carbohydrate diet.Michael Penn and I have summarized this information and provide it in the context of therole of hunger and satiety in the management of obesity (Chapter 19). We provide a

Preface xiii


xiv Preface

hypothesis regarding the way the low carbohydrate diet may operate and note that weshould expect that claims about diets and treatments should be tested scientifically.

A book on treatment would not be complete without covering the practical aspects ofsetting up and organizing the treatment practice. Drs. O’Neil and Rieder (Chapter 22)discuss the organization and use of a multidisciplinary program for treatment of obesityand Drs. Loper and Lutes (Chapter 21) discuss the practicalities of office practice andshare their recent experience. Dr. Frank discusses the issues that prevent patients fromachieving success in their effort to lose weight (Chapter 24). An enhanced understandingof these barriers to successful treatment will serve us well in our efforts to improve careof the obese patient.

The internet has provided access to information and treatment resources and poten-tially will provide a cost-effective adjunct to traditional therapy for patients with eatingdisorders and obesity. Internet resources are presented for eating disorders (Chapter 8)and obesity (Chapter 23). Although the use of the internet in therapy is very limited todate, we can expect the use of this medium to increase. It is hoped that providing thisresource will benefit practitioners, particularly those in areas where consultant resourcesare limited. Although the Internal Revenue Service has just included the treatment ofobesity as a tax deductible medical expense, it is still not covered by most health insurancepolicies and cost continues to be an issue. Indirect cost is also problematic in thatintensive therapy is best and potentially entails missing work or obtaining child care. Useof the internet might alleviate some of this burden as well.

It is anticipated that incorporation of this information will enhance the effectivenessof practitioners in their management of patients with eating disorders and obesity.

I thank the Series Editor, Dr. Adrianne Bendich, Humana Press, and Paul Dolgert fortheir assistance in making this edition a reality. I also thank the chapter authors for theircontributions.

David J. Goldstein, MD, PhD

REFERENCES

1. Connolly HM, Crary JL, McGoon MD, et al. Valvular heart disease associated with fenfluramine-phentermine. N Engl J Med 1997; 337:581–588.

2. Shekelle PG, Hardy ML, Morton SC, et al. Efficacy and safety of ephedra and ephedrine for weight lossand athletic performance. J Am Med Assoc 2003; 289: 1537–1545.

3. Bent S, Tiedt TN, Odden MC, Shlipak MG. The relative safety of ephedra compared with other herbalproducts. Ann Intern Med 2003; 138:468–471.

4. Weintraub M, Hasday JD, Mushlin AI, Lockwood D H. A double-blind clinical trial in weight control.Use of fenfluramine and phentermine alone and in combination. Arch Intern Med 1984; 144:1143–1148.

5. Kahn RC. The role of obesity in diabetes mellitus. Curr Opin Endocrinol Diabet 1996; 3:1–2.6. Weintraub M. Long-term weight control study: conclusions. Clin Pharmacol Ther 1992; 51:642–646.


xv

Contents

Series Introduction ......................................................................................................... v

Foreword ....................................................................................................................... ix

Preface ........................................................................................................................... xi

Contributors ............................................................................................................... xvii

PART I. BULIMIA NERVOSA

A. GENERAL INFORMATION

1 Bulimia Nervosa ......................................................................................... 3Steven J. Romano

B. TREATMENT

2. Counseling Patients With Bulimia Nervosa ............................................ 13Tricia Cook Myers and James E. Mitchell

3. Pharmacological Therapy of Bulimia Nervosa ....................................... 23James I. Hudson, Harrison G. Pope, Jr., and William P. Carter

C. PREVENTION

4. Prevention of Eating Disorders: A Nutritional Perspective .................... 41Cheryl L. Rock

PART II. ANOREXIA NERVOSA


5. Anorexia Nervosa ..................................................................................... 61Steven J. Romano

B. TREATMENT

6. Treatment of Anorexia Nervosa ............................................................... 71L. K. George Hsu

7. Pharmacological Therapy for Anorexia Nervosa .................................... 85Walter H. Kaye

8. The Internet and Eating Disorders ........................................................... 97David J. Goldstein

PART III. OBESITY


9. Etiologies of Obesity .............................................................................. 105Richard L. Atkinson


xvi Contributors

10. Medical Consequences of Obesity and Benefits of Weight Loss ......... 119Lalita Khaodhiar and George L. Blackburn

11. Obese Patients With Binge-Eating Disorder ......................................... 143Marsha D. Marcus and Michele D. Levine

B. TREATMENT

12. Overview and the Future of Obesity Treatment .................................... 161Lisa Terre, Walker S. C. Poston II, and John P. Foreyt

13. The Role of Physical Activity, Exercise, and Nutrition in the Treatment of Obesity ............................................................... 181Edward T. Mannix, Helmut O. Steinberg, Stacey Faryna, Jodi Hazard, Reed J. Engel, and Michael F. Busk

14. Lifestyle Modification in the Treatment of Obesity .............................. 209Anthony N. Fabricatore and Thomas A. Wadden

15. Very Low-Calorie Diets ......................................................................... 231Stephen D. Phinney

16. Pharmacotherapy of Obesity .................................................................. 241George A. Bray

17. Combination Therapies for Obesity ....................................................... 277Richard L. Atkinson and Gabriel Uwaifo

18. Genetics and Potential Treatments for Obesity ..................................... 293José R. Fernández and David J. Goldstein

19. The Role of Hunger and Satiety in Weight Management ..................... 307Michael Penn and David J. Goldstein

20. Surgical Interventions for the Management of Obesity ........................ 327Scott A. Shikora, David Smith, and Julie J. Kim

21. Clinical Experience in a Comprehensive Weight-Management Center ................................................................................................... 347Judy Loper and Richard A. Lutes

22. The Multidisciplinary Team in the Management of Obesity ................ 355Patrick Mahlen O’Neil and Sherry Rieder

23. The Internet and Obesity Treatment ...................................................... 367David J. Goldstein

24. Barriers to Treatment ............................................................................. 375Arthur Frank

C. PREVENTION

25. Prevention of Obesity ............................................................................. 399Barbara C. Hansen

Index ........................................................................................................................... 413


Contributors

RICHARD L. ATKINSON, MD • Obtech Inc., Richmond, VA and Obesity Institute, MedStarResearch Institute, Washington, DC

GEORGE L. BLACKBURN, MD, PhD • Center for the Study of Nutrition Medicine,Department of Surgery, Beth Israel Deaconess Medical Center, Harvard MedicalSchool, Boston, MA

GEORGE A. BRAY, MD • Pennington Biomedical Research Center, Louisiana StateUniversity, Baton Rouge, LA

MICHAEL F. BUSK, MD, MPH • The National Institute for Fitness and Sport, Divisionof Pulmonary, Allergy, Critical Care and Occupational Medicine, and Departmentof Cellular and Integrative Physiology, Indiana University School of Medicine,Indianapolis, IN

WILLIAM P. CARTER, MD • Biological Psychiatry Laboratory, McLean Hospitaland Department of Psychiatry, Harvard Medical School, Belmont, MA

REED J. ENGEL, MD • The National Institute for Fitness and Sport, Indianapolis, INANTHONY N. FABRICATORE, PhD • Weight and Eating Disorders Program, Department

of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PASTACEY FARYNA, RD • Division of Endocrinology and Metabolism, Indiana University

Department of Medicine, Indianapolis, INJOSÉ R. FERNÁNDEZ, PhD • Division of Physiology and Metabolism, Department

of Nutrition Sciences and Section in Statistical Genetics, Departmentof Biostatistics, University of Alabama at Birmingham, Birmingham, AL

JOHN P. FOREYT, PhD • Behavioral Medicine Research Center, Department of Medicine,Baylor College of Medicine, Houston, TX

ARTHUR FRANK, MD • The George Washington University Weight ManagementProgram, Washington, DC

DAVID J. GOLDSTEIN, MD, PhD • Department of Pharmacology and Toxicology, IndianaUniversity School of Medicine and PRN Consulting, Indianapolis, IN

BARBARA C. HANSEN, PhD• Obesity and Diabetes Research Center, Departmentof Physiology, University of Maryland School of Medicine, Baltimore, MD

JODI HAZARD, MS • The National Institute for Fitness and Sport, Indianapolis, INJAMES I. HUDSON, MD, ScD • Biological Psychiatry Laboratory, McLean Hospital

and Department of Psychiatry, Harvard Medical School, Belmont, MAL. K. GEORGE HSU, MD, FRC PSYCH • Department of Psychiatry, Tufts-New England

Medical Center, Boston, MAWALTER H. KAYE, MD • Anorexia and Bulimia Nervosa Research Module, Department

of Psychiatry, University of Pittsburgh Medical Center, Western PsychiatricInstitute and Clinic, Pittsburgh, PA

xvii


JULIE J. KIM, MD • Center for Minimally Invasive Obesity Surgery, Departmentof Surgery, Tufts-New England Medical Center, Boston, MA

LALITA KHAODHIAR, MD • Center for the Study of Nutrition Medicine, Departmentof Medicine and Surgery, Beth Israel Deaconess Medical Center, Harvard MedicalSchool, Boston, MA

MICHELE D. LEVINE, PhD • Western Psychiatric Institute and Clinic, Universityof Pittsburgh Medical Center, Pittsburgh, PA

JUDY LOPER, PhD, RD • Central Ohio Nutrition Center, Inc., Columbus, OHRICHARD A. LUTES, MD • Central Ohio Nutrition Center, Inc., Columbus, OHEDWARD T. MANNIX, PhD • The National Institute for Fitness and Sport, Division

of Pulmonary, Allergy, Critical Care and Occupational Medicine, and Departmentof Cellular and Integrative Physiology, Indiana University School of Medicine,Indianapolis, IN

MARSHA D. MARCUS, PhD • Western Psychiatric Institute and Clinic, Universityof Pittsburgh Medical Center, Pittsburgh, PA

JAMES E. MITCHELL, MD • Neuropsychiatric Research Institute, Departmentof Neuroscience, University of North Dakota School of Medicine and HealthSciences, Fargo, ND

TRICIA COOK MYERS, PhD • Neuropsychiatric Research Institute, Departmentof Neuroscience, University of North Dakota School of Medicine and HealthSciences, Fargo, ND

PATRICK MAHLEN O’NEIL, PhD • Weight Management Center, Department of Psychiatryand Behavioral Sciences, Medical University of South Carolina, Charleston, SC

MICHAEL PENN, RPH • Indiana University School of Medicine, Indianapolis, INSTEPHEN D. PHINNEY, MD, PhD • University of California Davis School of Medicine,

Sacramento, CAHARRISON G. POPE, JR., MD • Biological Psychiatry Laboratory, McLean Hospital

and Department of Psychiatry, Harvard Medical School, Belmont, MAWALKER S. C. POSTON II, PhD, MPH • Department of Psychology, University

of Missouri-Kansas City and Mid America Heart Institute, Kansas City, MOSHERRY RIEDER, PhD •Weight Management Center, Department of Psychiatry

and Behavioral Sciences, Medical University of South Carolina, Charleston, SCCHERYL L. ROCK, PhD, RD • Department of Family and Preventive Medicine, University

of California, San Diego, La Jolla, CASTEVEN J. ROMANO, MD • Pfizer, Inc. and Department of Psychiatry, New York University

School of Medicine, New York, NYSCOTT A. SHIKORA, MD, FACS • Center for Minimally Invasive Obesity Surgery,

Department of Surgery, Tufts-New England Medical Center, Boston, MADAVID SMITH, MD • Center for Minimally Invasive Obesity Surgery, Department

of Surgery, Tufts-New England Medical Center, Boston, MAHELMUT O. STEINBERG, MD • Division of Endocrinology and Metabolism, Department

of Medicine, Indiana University School of Medicine, Indianapolis, INALBERT J. STUNKARD, MD • Weight and Eating Disorders Program, Department

of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA

xviii Contributors


LISA TERRE, PhD • Department of Psychology, University of Missouri-Kansas City,Kansas City, MO

GABRIEL UWAIFO, MD • Obesity Institute, Medstar Research Institute, Washington, DCTHOMAS A. WADDEN, PhD • Weight and Eating Disorders Program, Department

of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA

Contributors xix


Chapter 1 / Bulimia Nervosa 1

BULIMIA NERVOSAI

1_01_Roma_001_012_F 10/08/2004, 1:15 PM1


3

From: The Management of Eating Disorders and Obesity, Second EditionEdited by: D. J. Goldstein © Humana Press Inc., Totowa, NJ

1 Bulimia Nervosa

Steven J. Romano

KEY POINTS

• Symptoms of binge eating and purging associated with bulimia nervosa arecommon, especially in teenage and young adult women, but males are alsoaffected. Dancers, gymnasts, models, and wrestlers have high prevalence ofbulimia nervosa.

• Diagnostic criteria have been established in the Diagnostic and StatisticalManual of Mental Disorders (DSM) by the American Psychiatric Associa-tion. Diagnosis can be difficult because patients may not complain of thecondition or admit to the behaviors.

• Bulimia nervosa is commonly associated with psychiatric comorbiditiessuch as depression and anxiety. Substance abuse is common.

• Medical complications can be life threatening.

1. INTRODUCTION

This chapter focuses on the psychiatric presentation, prevalence, and medical com-plications associated with bulimia nervosa and highlights comorbid psychopathology(Table 1). A more extensive discussion of etiological factors and treatment approachescan be found elsewhere in this text (see Chapters 2, 3, and 4).

Bulimia nervosa, like anorexia nervosa (see Chapter 5), represents a clinical syn-drome with multiple factors that contribute to its etiology and affect clinical presen-tation. The term bulimia is from the Greek meaning “ox-hunger” and is an aptdescription of a primary feature of the disorder, binge eating. Interestingly, althoughStunkard (1) described binge eating in obese patients decades ago, bulimia as part ofa clinically distinct syndrome affecting normal-weight individuals and coupled withcompensatory mechanisms to guard against weight gain, was not described in themedical literature until much later. At that time, Russell (2) put forth criteria forbulimia nervosa that included urges to engage in periods of overeating, attempts toavoid the “fattening” effect of food through vomiting or use of purgatives, and, similarto the central psychological feature of anorexia nervosa, the presence of a morbid fearof becoming fat. The latter feature underscored the anxiety and avoidance behaviorthat are an integral part of the syndrome. Bulimia nervosa was once postulated to be

1_01_Roma_001_012_F 10/08/2004, 1:15 PM3

4 Part I / Bulimia Nervosa

an affective subtype (a mood disorder), in part because of the preponderance of depres-sive features frequently accompanying the disorder’s clinical presentation. The resultsof antidepressant treatment studies illustrating a specific response of bulimic symptomsstrengthened that opinion. Nevertheless, newer information has led to an evolution inconcept, and bulimia nervosa is now considered a primary eating disorder distinct fromanorexia nervosa.

Since the initial description of bulimia nervosa, there has been an explosion of infor-mation, in both scientific and lay literature, regarding the apparent surge in bulimic-related behaviors. The recognition of the extent of eating-disorder behaviors in certainpopulations, such as college-aged women, and the description of a significant level ofcomorbid psychiatric symptomatology have led to advances in both the understanding ofthe biological underpinnings and efficacious approaches to treatment.

2. PREVALENCE

As the syndrome of bulimia nervosa was described in the medical literature only in thelate 1970s and was not incorporated into the DSM until 1980, prevalence studies are few.Furthermore, the diagnostic criteria for bulimia nervosa have evolved to more specifi-cally describe the symptoms of binge eating as part of a syndrome associated with purgingand nonpurging compensatory behaviors and criteria for frequency and chronicity (illus-trated in Table 2) (3). Thus, the early prevalence studies reflect the prevalence of specificbehaviors, such as binge eating or, in a smaller number, vomiting. Those studies weregenerally in subpopulations, such as college-aged females. Thus, they do not accuratelyassess the prevalence of the syndrome of bulimia nervosa, as outlined in current diagnos-tic research criteria, in the general population.

Focusing on specific populations, a number of studies utilizing DSM-III criteriafound the prevalence of bulimia to be approx 4 to 9% in high school- and college-agedstudents (4–7). Prevalence studies of binge eating in special populations describedlevels of disordered eating as high as, for example, 90% in ballet dancers (8). A studythat focused on the assessment of vomiting in college students described a prevalenceof 9.9% (9), and another study that examined attendees at a family-planning clinic founda prevalence of 2.9%.

Family studies in bulimia nervosa support a familial contribution. Increased rates ofthe eating disorders, including bulimia nervosa, were assessed by Strober (10) in a studycomparing first- and second-degree relatives of anorexic patients with the relatives of acontrol group of non-anorexic, psychiatrically ill patients. More recent reports by

Table 1Chapter Overview

1. Introduction2. Prevalence3. Psychiatric Comorbidity4. Clinical Description5. Differential Diagnosis6. Medical Complications7. Conclusion

1_01_Roma_001_012_F 10/08/2004, 1:15 PM4


Lilenfeld et al. (11), Strober et al. (12), Stein et al. (13) further confirm that bulimianervosa, as well as anorexia nervosa, is strongly familial. A number of studies indicatedincreased rates of affective disorders in the families of patients with anorexia nervosa andbulimia nervosa (14–17). More studies need to be conducted to better elucidate familialpatterns, clarify genetic variants, and to explore a potential link between bulimia andaffective disorder. Regarding the latter, possible heritable biological vulnerability to aspectrum of psychopathology may exist to explain the observed increase in the incidenceof affective disorder in families of bulimic patients. Functional dysregulation of seroto-nin, a potent neurohormone involved in both mood and appetitive behavior, may repre-sent an etiological link and, along with potential disturbances in other neurotransmittersystems, is a focus of research interest.

Similar to anorexia nervosa, bulimia nervosa predominantly affects young women,although the age of onset tends to be later in adolescence. In contrast to anorexia nervosa,many patients with bulimia nervosa present in their 20s and 30s, often after havingsuffered with the disorder for a number of years. Although college-educated whitefemales are most often described, clinical experience has appreciated a greater degreeof heterogeneity than that generally regarded in anorexia nervosa, a situation that mayreflect the relatively high incidence of dieting in populations at risk. Males appear to beaffected more frequently by bulimia nervosa than by anorexia nervosa, representingperhaps as many as 10 to 15% of cases.

The prevalence and incidence data available on bulimia nervosa, although limited,provide a clue as to those populations most at risk for the development of clinicallysignificant disturbances. In general, the single most important factor leading to an eatingdisorder is dieting, but significant sociocultural influences affect weight- and body-

Table 2Diagnostic and Statistical Manual of Mental Disorders Criteria for Bulimia Nervosa

A. Recurrent binge eating characterized by both1. Eating an amount of food that is definitely more than most people would eat

i. During a similar time intervalii. Under similar circumstances

2. Having a sense of lack of control overi. Amount of food eatenii. Ability to stop eating

B. Recurrent inappropriate compensatory behaviors intended to prevent weight gain1. Self-induced vomiting2. Misuse of laxatives, diuretics, enemas, other medications3. Fasting4. Excessive exercise

C. Binge eating and compensatory behaviors occur at least twice a month for at least 3 mo.D. Self-image is unduly influenced by body shape and weightE. These behaviors do not occur exclusively during episodes of anorexia nervosa

Purging Type: During current episodes, the patient regularly engages in purging activities.Nonpurging Type: During current episodes, the patient does not regularly engage in binge eating or

purging, but uses other behaviors such as fasting or excessive exercise.

1_01_Roma_001_012_F 10/08/2004, 1:15 PM5


change behavior. Particular antecedents to dieting, such as equating beauty with thinnessand viewing attractiveness as a prominent measure of success, both incorporated asvalues in Western society, represent such sociocultural influences and are more likely toaffect young women. Dieting in this group is also peer-supported, leading to the persis-tence of periods of nutritional deprivation and subsequent development of disorderedmeans of managing food intake in those unable to sustain restrictive dieting. Given theprevalence of dieting in this culture and the fact that dieting is considered the most potentstressor contributing to the development of an eating disorder in an otherwise vulnerableindividual, the group at risk is expanding and represents a spectrum of personality typesfrom a range of socioeconomic backgrounds. Of course, in those professions that are mostlikely to stress the aforementioned values, such as professional modeling, acting, anddance, a higher incidence of bulimia nervosa can be expected. In addition, professionsthat espouse body-change behavior in the service of improved performance, such ascertain sports, would likely support the development of this disorder. Regarding thelatter, wrestling is one of the few areas in which males are significantly influenced.

3. PSYCHIATRIC COMORBIDITY

Comorbid psychiatric symptomatology is frequently encountered in patients withbulimia nervosa. Affective symptoms are particularly common, as are features of anxietyand impulsivity. Some comorbid symptoms can be associated more directly with theprimary eating disorder, whereas others may represent coexistent syndromes. The lattergenerally require thorough evaluation and subsequent management in order to enhancetreatment response of the primary eating disorder.

The significance of depressive features presenting in a majority of patients withbulimia nervosa was evident in the earlier conceptualization of this syndrome as anaffective subtype. This diagnostic construct was buttressed by the effectiveness of anti-depressant treatment strategies (see Chapter 3). Currently, depressive features are mostoften viewed as secondary to the eating disturbance and often become less severe orabate with the treatment and resolution of the bulimic behaviors. The etiology of depres-sive symptoms in this setting may be, in part, physiological and linked to the negativeeffects and consequences of malnourishment and purging behaviors. In the case of some,for whom bulimia evolves into a strategy for reducing stress or moderating negativeaffective states such as anxiety or depression, depressive symptoms can emerge follow-ing control of bulimia. In other words, bulimia may be initially employed as a weight-reducing strategy but develop into a defense in the psychological sense, whereby removalof the behavior results in the emergence of negative affects previously held in check.This is more often the case in individuals manifesting significant comorbid characterpathology. In others, affective symptoms may predate bulimia nervosa and represent aseparate and primary psychiatric disorder.

Anxiety features are commonly associated with bulimia. Phobic avoidance of certainfood items or meals is clearly an aspect of the primary eating disturbance, as is the anxietyassociated with the ingestion of unwanted food or following a binge when the ability topurge is obstructed or delayed, as in the case of social interruption. Generalized anxiety,panic attacks, or obsessive–compulsive features may also be evident, with obsessive–compulsive features most often associated with eating or weight- and shape-relatedconcerns. Certainly, the aforementioned anxiety symptoms can be evidence of other

1_01_Roma_001_012_F 10/08/2004, 1:15 PM6


primary psychiatric disorders and should be thoroughly evaluated and pursued during aninitial psychiatric evaluation.

Impulsivity is often observed in bulimic individuals and is a dimensional feature thatseems to distinguish the personalities of patients with bulimia from those with restrictinganorexia. Impulsivity in this regard may speak to the presence of a personality disorderas described in the fourth edition of the DSM. Especially apparent are traits associatedwith the dramatic cluster, which include borderline and histrionic personality disorders.Impulsivity may also be evidenced by certain concomitant behaviors, including sub-stance abuse, sexual promiscuity, or shoplifting.

The rates of comorbid psychopathology have been assessed by a number of research-ers and confirm many of the aforementioned clinical impressions. Lifetime rates of majordepression in bulimia nervosa have been reported to be from 36 to 70% (18–20). Thesignificance of concurrent depressive symptomatology at the time of presentation is wellrecognized and affects between one-third and one-half of the patients. The intensity ofthe depressive episode at presentation may influence the initial management of the indi-vidual with bulimia, which is addressed in more detail elsewhere in this text.

Supporting the clinical description of features associated with impulsivity and anxietyin many patients presenting with bulimia nervosa, the rates of personality disorders in boththe dramatic cluster and the anxious cluster have been reported to be relatively high. In amore recent study, Braun et al. (21), employing the Structured Clinical Interview forDSM-Personality (SCID-P) diagnostic interview, established that one-third of the indi-viduals in the bulimic subgroups met the criteria for a dramatic cluster personality disor-der. One-third of those met the diagnosis for borderline personality disorder. In addition,one-third of the individuals in the bulimic subgroups met the criteria for a personalitydisorder in the anxious cluster, most often avoidant or obsessive–compulsive personalitydisorders. Interestingly, the rate of personality disorders from the anxious cluster wassimilar to the rate seen in the anorexic restrictor group. Previous studies assessing the rateof personality disorders in patients with bulimia nervosa revealed a wide range of findings.Specifically, the percentage of patients with at least one DSM-III-R personality disorderhas been reported as 77% (22), 69% (23), 62% (24), 61% (25), 33% (26), and 28% (27).

The rate of substance abuse, including alcoholism, in patients with bulimia nervosa hasbeen reported in a number of studies, and it varies from 18 to 33% (28–30). In all thesestudies, the rates in the bulimic groups were significantly greater than those for the controlgroups. More recently, Braun et al. (21) found that all bulimic subgroups had significantlyhigher rates of substance abuse in comparison with a subgroup of anorexic restrictors.

Given the breadth of psychopathology encountered in patients with bulimia nervosadiscussed above, it may be helpful to consider an underlying biological disturbance orvulnerability that may contribute to the development of various behavioral outcomes.For example, the neurotransmitter serotonin has been implicated in several functionalareas, including appetitive behavior, mood and affect modulation, and impulsivity, andserotonergic dysfunction has been proposed in the etiology of a spectrum of obsessive–compulsive syndromes. A disturbance in the functioning of serotonin neurotransmis-sion or pathways could thus influence the modulation of normal behavior or thedevelopment of pathological symptomatology, leading to various clinical presentations.Further research will help elucidate the possible links that may underlie the comorbidpresentation of bulimia and various other psychiatric conditions.

1_01_Roma_001_012_F 10/08/2004, 1:15 PM7


4. CLINICAL DESCRIPTION

The disorder of bulimia nervosa affects approx 2 to 3% of young women, althoughbulimic behaviors, as described earlier, may be encountered in many more. Such behav-iors are generally precipitated by periods of restrictive dieting. Individuals with bulimiaengage in regular episodes of binge eating, followed by compensatory behaviors that arean attempt to counteract the weight-gaining effect of ingested calories. Binge eating ischaracterized by the rapid consumption of large amounts of food over a distinct periodof time, usually 1 to 2 hr. Binge eating is associated with the sense of losing control andis often followed by feelings of guilt or shame. Frequently, other dysphoric affectivestates, such as depression or anxiety, follow the binge eating and purging. Some patientsreport alleviation of dysphoria or even emotional numbing immediately following theepisode, although this is short-lived. During a binge, an individual may consume a fewthousand calories or more. Some individuals describe trigger foods, often a fatteningsweet, such as chocolate, precipitating a binge, although the overall content of foodconsumed, by macro-analysis of nutritional content, varies. The bulimic individualalmost exclusively binge eats in private, as the behavior of grossly overeating is humili-ating. In this setting, embarrassment can lead to varying degrees of social avoidance andisolation.

Contributing further to avoidant behavior is the need to compensate for consumption,frequently in the form of purging. Most bulimic individuals induce vomiting during orafter a binge, and some bulimic individuals use laxatives or diuretics alone. Recognizingthe various compensatory behaviors encountered in this disorder, two subtypes aredelineated: purging and nonpurging. Nonpurging compensatory behaviors include com-pulsive exercising and restrictive dieting or fasting between binges. In many individualswith bulimia nervosa, a variety of purging behaviors are utilized following binge eatingin a desperate effort to avoid weight gain.

Another characteristic of bulimia nervosa is dissatisfaction with one’s body shape orweight. For many, this may evolve into a significant degree of obsessional preoccupation.This is coupled with a self-evaluation that is overly influenced by these physical charac-teristics. Such overly critical self-evaluation can have a profound effect on self-esteem,as evidenced, in part, by the majority of patients presenting with comorbid depressivesymptomatology. A notable degree of impulsivity is encountered in many individualswith bulimia nervosa, and associated behaviors reflecting this characterological dimen-sion include, in some, substance abuse, sexual promiscuity, and stealing or shoplifting.

5. DIFFERENTIAL DIAGNOSIS

Few medical or psychiatric disorders present in such a manner as to confound thediagnosis of bulimia nervosa. Frequently, it is the finding of certain physical signs orsymptoms in a young woman, who does not admit to binge-eating or purging behaviors,that leads the clinician on a search for some other primary medical diagnosis. Usually,the complaints are a direct result or consequence of self-induced vomiting and diureticor laxative use. Signs and symptoms associated with gastritis, esophagitis, dehydration,or electrolyte disturbances lead to consultation with primary care physicians or to emer-gency room visits, postponing psychiatric consultation and evading more primary inter-ventions.

1_01_Roma_001_012_F 10/08/2004, 1:15 PM8


Because significant affective symptoms frequently accompany the presentation ofbulimia nervosa, and because bulimic individuals may initially be hesitant to admit to theextent of their eating-disorder behaviors, one needs to distinguish an eating disorder froma primary depressive disorder. Although antidepressants are effective treatment for bothdisorders, the treatment of bulimia generally requires a multimodal approach with morespecific attention paid to particular eating-related behaviors and cognitions in order toachieve and sustain a marked improvement (see Chapter 2). Treatment of the associateddepressive symptoms alone, without recognition of the underlying eating disorder, willlead to suboptimal management of both disturbances, with probable persistence ofbulimia. One needs also to recognize or rule out personality disorders, because certainfeatures associated with bulimia nervosa, such as impulsivity, may be seen as evidenceof primary character pathology and limit further evaluation of disordered eating. Suchpatients may be initially referred for more dynamic psychotherapy, which may notaddress specific bulimic symptoms as appropriately as is generally required to effect amarked change. Importantly, one must distinguish bulimia from anorexia. If the patientis underweight and amenorrheic, and is binge eating and purging, she has anorexianervosa, binge–purge subtype, rather than bulimia nervosa.

6. MEDICAL COMPLICATIONS

The majority of medical complications caused by bulimia nervosa are consequencesof purging behaviors. Self-induced vomiting can lead to gastritis, esophagitis, periodon-tal disease, and dental caries, the latter caused by the corrosive effect of acidic stomachcontents on the dental enamel. Gastric dilitation and gastric or esophageal rupture are raremedical emergencies that may lead to shock. Metabolic alkalosis with the developmentof clinically significant hypokalemia in patients who vomit is not unusual, and serumelectrolytes will reveal typical indices. Electrocardiogram changes in this setting carrysignificant import, because arrhythmias can lead to cardiac arrest if hypokalemia andrelated disturbances are not effectively corrected. Use of diuretics can cause similarelectrolyte disturbances. Metabolic acidosis can be encountered in those who use largenumbers of stimulant-type laxatives. Dehydration, sometimes requiring intravenoushydration, can accompany each of the aforementioned purging behaviors. More oftenassociated with bulimic behaviors are general physical complaints, such as fatigue andmuscle aches. Although becoming less frequently encountered in clinical practice, long-term use of the emetic syrup of ipecac can lead to myopathies, including, most seriously,cardiomyopathy. The latter is not an infrequent cause of death in patients abusing thistoxic substance.

7. CONCLUSION

Patients with bulimia nervosa or exhibiting the spectrum of eating-disorder behaviorsassociated with this syndrome have become increasingly common in clinical practice.This apparent increase in bulimic symptomatology has stimulated research interest that,in turn, has informed treatment strategies. Given the significant psychiatric and medicalmorbidity encountered in patients with bulimia nervosa, efforts should be made toimprove recognition and ensure proper referral. The development of effective psycho-therapies and adjunctive pharmacological treatments, in conjunction with the public’s

1_01_Roma_001_012_F 10/08/2004, 1:15 PM9


growing awareness, should encourage more individuals to present for management oftheir disorders. Further exploration into the biological underpinnings of bulimia, con-tinued assessment of treatment outcome, and attempts to identify predictive patientcharacteristics should lead to more specific tailoring of therapy and enhancement oftreatment response.

REFERENCES

1. Stunkard AJ. The current status of treatment of obesity in adults. In: Stunkard AJ, Stellar E, eds. Eatingand Its Disorders. Raven, New York, NY, 1984, pp. 157–174.

2. Russell GFM. Metabolic, endocrine and psychiatric aspects of anorexia nervosa. Sci Basis Med AnnuRev 1969; 14:236–255.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, DSM-IV.American Psychiatric Association, Washington, DC, 1994, pp. 549–550.

4. Stangler RS, Printz AM. DSM-III: Psychiatric diagnosis in a university population. Am J Psychiatry1980; 137:937–940.

5. Johnson CL. Bulimia: A descriptive survey of 316 cases. Int J Eat Disord 1982; 2:3–16.6. Pyle RL, Mitchell JE, Eckert ED, Halvorson PA, Neuman PA, Goff GM. The incidence of bulimia in

freshman college students. Int J Eat Disord 1983; 2:75–86.7. Carter JA, Duncan PA. Binge eating and vomiting: A survey of a high school population. Psychol

Schools 1984; 21:198–203.8. Abraham SF, Mira M, Llewellyn-Jones D. Eating behaviors amongst young women. Med J Austr 1983;

2:225–228.9. Halmi KA, Falk JR, Schwartz E. Binge-eating and vomiting: a survey of a college population. Psychol

Med 1981; 11:697–706.10. Strober M. A family study of anorexia nervosa. Paper presented at the International Conference on

Anorexia Nervosa and Related Disorders. Swansea University College, Wales, UK, 1984.11. Lilenfeld LR, Kaye WH, Greeno CG, et al. A controlled family study of anorexia nervosa and bulimia

nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity. Arch GenPsychiatry. 1998; 55:603–610.

12. Strober M, Freeman R, Lampert C, Diamond J, Kaye W. Controlled family study of anorexia nervosaand bulimia nervosa: evidence of shared liability and transmission of partial syndromes. Am J Psychia-try. 2000; 157:393–401.

13. Stein D, Lilenfeld LR, Plotnicov K, et al. Familial aggregation of eating disorders: results from acontrolled family study of bulimia nervosa. Int J Eat Disord. 1999; 26:211–215.

14. Winokur A, March V, Mendels J. Primary affective disorder in relatives of patients with anorexianervosa. Am J Psychiatry 1980; 137:695–698.

15. Hudson PL, Pope HG, Jonas JM, Todd D. Family history study of anorexia nervosa and bulimia. Br JPsychiatry 1983; 142:133–138.

16. Gershon ES, Schreiber Jl, Hamovit JR, Dibble ED, Kaye W, Nurnberger JI, et al. Clinical findings inpatients with anorexia nervosa and affective illness in their relatives. Am J Psychiatry 1984; 141:1419–1422.

17. Rivinius TM, Biderman J, Hertzog DB, et al. Anorexia nervosa and affective disorders: a controlledfamily history study. Am J Psychiatry 1984; 141:1414–1418.

18. Piran, N, Kennedy S, Garfinkel PE, Owens M. Affective disturbance in eating disorders. J Nerv MentDis 1985; 173:395-400.

19. Walsh BT, Roose SP, Glassman AH, Gladis M, Sadik C. Bulimia and depression. Psychosom Med 1985;47:123–131.

20. Laessle R, Kittl S, Fichter M, Wittchen HU, Pirke KM. Major affective disorder in anorexia nervosa andbulimia: a descriptive diagnostic study. Br J Psychiatry 1987; 151:785–789.

21. Braun DL, Sunday SR, Halmi KA. Psychiatric comorbidity in patients with eating disorders. PsycholMed 1994; 24:859–867.

22. Powers PS, Coovert DL, Brightwell BR, Stevens BA. Other psychiatric disorders among bulimicpatients. Compr Psychiatry 1988; 29:503–508.

1_01_Roma_001_012_F 10/08/2004, 1:15 PM10


23. Wonderlich S, et al. DSM-III-R personality disorders in patients with eating disorders. Int J Eat Disord1990; 9:607–616.

24. Gartner AF, Marcus RN, Halmi KA, Loranger AW. DSM-III-R personality disorders in patients witheating disorders. Am J Psychiatry 1989; 146:1585–1591.

25. Schmidt MB, Telch MJ. Prevalence of personality disorders among bulimics, non-bulimic binge eatersand normal controls. J Psychopath Behav Ess 1990; 12:170–185.

26. Ames-Frankel J, Devlin NJ, Walsh BT, et al. Personality disorder diagnoses in patients with bulimianervosa: clinical correlates and changes with treatment. J Clin Psychiatry 1992; 53:90–96.

27. Herzog DB. Are anorexic and bulimic patients depressed. Am J Psych 1984; 141:1594–1597.28. Hatsukami D, Eckert E, Mitchell JE, Pyle R. Affective disorder and substance abuse in women with

bulimia. Psychol Med 1984; 14:701–704.29. Mitchell J, Hatsukami D, Eckert E, Pyle R. Characteristics of 275 patients with bulimia. Am J Psychiatry

1985; 142:482–485.30. Bulik C. Drug and alcohol abuse by bulimic women and their families. Am J Psychiatry 1987; 144:

1604–1606.

1_01_Roma_001_012_F 10/08/2004, 1:15 PM11

Chapter 2 / Counseling Patients With Bulimia 13

13

From: The Management of Eating Disorders and Obesity, Second EditionEdited by: D. J. Goldstein © Humana Press Inc., Totowa, NJ

2 Counseling PatientsWith Bulimia Nervosa

Tricia Cook Myers and James E. Mitchell

KEY POINTS

• The first step of treatment is careful evaluation of physical, behavioral, andpsychiatric status of the patient.

• The patient needs periodic monitoring of physical, behavioral, and psychiat-ric status as part of therapy.

• Counseling includes self-monitoring, prescription of regular and balancedmeals, and behavioral and cognitive therapy.

1. INTRODUCTION

This chapter is designed to provide an introduction to the basic principles of counsel-ing outpatients with bulimia nervosa who are being seen in a general medical setting. Asummary of these principles and chapter outline is presented in Table 1. The purpose isnot to make psychiatrists or counselors out of family physicians or other generalists, butrather to improve patient care and to briefly review some basic principles that can beuseful in an office setting when working with these patients. Emphasis is placed on a fewissues that may significantly increase the likelihood that cases of bulimia nervosa will bedetected and that individuals with bulimia nervosa will become engaged in treatment andwill take the first steps in the process of recovering from this disorder.

2. ASSESSMENT OF THE PATIENT

The first step for the physician is a thorough assessment of the patient. In the case ofan individual with bulimia nervosa, this requires a detailed assessment of the variousnormal and abnormal eating and eating-related behaviors that may be present (1). Thisassessment (see also Chapter 1) will lead the physician logically into treatment planning.Here, we discuss the issues that should be addressed in the assessment.

2.1. WeightA careful weight history is essential. This includes an assessment of the patient’s

current height and weight (and calculations of the percent of ideal body weight), as well

1_02_Mitch_013_022_F 10/08/2004, 1:18 PM13


as high and low weight during adulthood, and, in particular, any history of being mark-edly overweight or underweight. Also, a family history of obesity is useful informationin that there is a high heritability for adult body weight. As a corollary, it is very usefulto evaluate how these patients feel at their current weight in general, and how they feelabout specific body parts in particular. Many patients with eating disorders are veryconcerned about body weight, but others worry specifically about certain body parts,particularly their waist, hips, buttocks, and thighs. It is of note that these are the areas withwhich many young women in the general population are dissatisfied even if they are ofnormal weight.

2.2. Meal PatternIt is useful to sketch out the meal pattern, including what the patient is eating and the

frequency and timing of meals and snacks. Obtaining a specific dietary history is gener-ally superior to a generalization about “usual” intake. Does the intake appear adequate?Most individuals with eating disorders markedly restrict food intake when not bingeeating, and important goals of treatment are not only to suppress or eliminate bingeeating, but also to increase the number of regular meals and snacks as a way of minimizingthe dietary restriction that leads to binge eating.

Table 1Chapter Overview

1. Introduction2. Assessment of the Patient

2.1. Weight2.2. Meal Pattern2.3. Eating-Related Behaviors2.4. Associated Psychiatric Problems2.5. Current Symptoms2.6. Screening

3. Medical Monitoring3.1. Laboratory Evaluation Electrolytes3.2. Dehydration

4. Specific Counseling Strategies4.1. Self-Monitoring4.2. Prescription of Regular, Balanced Meals

4.2.1.Flexibility4.2.2.Sympathetic But Firm Approach

4.3. Behavioral and Cognitive-Behavioral Counseling4.3.1.Concentrate on success4.3.2.Teach Normal Weight Expectations4.3.3.Maintain an Active Lifestyle4.3.4. Identify Cues4.3.5.Highly Structured Counseling

4.4. Self-Help Manuals and Internet-Based Counseling5. Medications and Referral for Counseling6. Conclusion

1_02_Mitch_013_022_F 10/08/2004, 1:18 PM14

Documents

THE MANAGEMENT OF EATING DISORDERS AND OBESITYdownload.e-bookshelf.de/download/0000/0068/55/L-G...The Management of Eating Disorders and Obesity, Second Edition, edited by David J