Eating Disorders: The Weight of Food

US Pharm. 2013;38(9):HS3-HS11.

ABSTRACT: Eating disorders (i.e., anorexia nervosa, bulimia nervosa, binge eating disorder) involve abnormal eating behaviors and often include irregular thoughts towards food and distorted body image. Eating disorders are frequently kept secret by patients and may be intertwined with other psychiatric disorders, like depression, making the disease difficult to diagnose and treat. Signs and symptoms of eating disorders generally do not develop quickly, but rather reveal themselves over time, often resulting in long-term health consequences, including death. Both pharmacologic and nonpharmacologic treatment, including psychotherapy, should be considered on an individual basis.

Eating disorders afflict individuals who have severely disturbed eating behaviors, irregular thoughts towards food, and distorted body image. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) greatly expanded the definition of eating disorders, recognizing “Feeding and Eating Disorders” as an overarching category. It includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and unspecified feeding or eating disorder. This article will focus on anorexia nervosa, bulimia nervosa, and binge eating disorder. Eating disorders can lead to many health consequences and even death. Psycho-therapy and/or pharmacotherapy may be considered for treatment.

EPIDEMIOLOGY

Clinically significant cases of anorexia nervosa, bulimia nervosa, binge eating disorder, or unspecified eating disorders total nearly 30 million in the United States, with 20 million of those affected being women.¹ Due to the secretive nature of the disease, many cases are not reported. Therefore, actual case estimates may not be completely accurate. Western ideals of beauty have spread around the globe through the media and have resulted in a growing occurrence of eating disorders in non-Western countries.² Anorexia nervosa is the most common eating disorder among Non-Hispanic Whites in the U.S., while all other eating disorders experience similar rates of prevalence among ethnic groups.¹

According to one 2007 study, the lifetime prevalence estimates of eating disorders in the U.S. for anorexia nervosa, bulimia nervosa, and binge eating disorder are 0.6%, 1.0%, and 2.8%, respectively.³ Anorexia nervosa is the most common eating disorder among young women.² A marked increase in cases of girls between the ages of 15 and 19 years, a group already identified as high risk, has been seen over the last several decades.² This could mean either that the disorder is being detected earlier and/or occurs at an earlier age. The overall reported incidence of bulimia nervosa has seen a slight decrease in frequency since the early 1990s.² Binge eating disorder is more commonly found in those who are seeking weight loss treatment than compared to the general population.⁴

ETIOLOGY

An eating disorder is a physical and psychological condition in which the patient has severe disturbances in thoughts and emotions regarding food and, most importantly, eating behaviors. These individuals often become obsessed with food as well as body weight and image.⁵ This article describes three of the most common eating disorders recognized by the DSM-5: anorexia nervosa, bulimia nervosa, and binge eating disorder. It is common for other psychiatric disorders to accompany eating disorders. Depression occurs quite frequently among those with eating disorders, and there is an elevated risk for obsessive-compulsive disorder.¹ The incidence of major depressive disorder in anorexia nervosa, bulimia nervosa, and binge eating disorder has been found to be 39.1%, 50.1%, and 32.3% respectively.³ Compared to the general population, those with eating disorders are much more likely to have substance abuse disorders as well.¹ All eating disorders have been found to have an elevated risk of death, most markedly anorexia nervosa, which was found to result in more deaths than any other psychiatric disorder.^1,2

Anorexia Nervosa

Anorexia is the oldest recognized eating disorder, but its etiology is unclear.⁶ Persons afflicted with anorexia nervosa have below normal body weight due to undereating or the refusal of food, obsessive exercising, and laxative use.⁵ They also often have low self-esteem and body image—being very critical of their bodies and suffering from body dysmorphia, seeing themselves as overweight or being fat when they are, in fact, underweight, and may even be close to starvation.⁵ In patients with anorexia, there is an intense fear of weight gain and, therefore, drastic measures are taken to avoid this weight gain.⁵

The identification of biological and psychological risk factors are nonspecific and are unable to account for the fact that very few people who develop anorexia nervosa are able to fully recover.⁶ The level of anxiety or distress in anorexic patients immediately before a meal is often inversely related to the amount of calories consumed. It has been suggested that there are great emotional and cognitive factors that play roles in the development of the disorder and its persistence.⁶

Bulimia Nervosa

In contrast to anorexia nervosa, where patients are under-weight, patients with bulimia nervosa may be of normal weight, underweight, or overweight.⁵ Nonetheless, bulimics share many traits with anorexics, including body dysmorphia, an intense fear of gaining weight, perfectionism, and low self-esteem.⁵ Bulimia nervosa is characterized by frequent binge eating and the consumption of a large amount of food in a short time period.⁵ Bulimics often feel that they cannot control themselves during a binge and will later purge by vomiting or using laxatives to fight their fears of weight gain.⁵ The total calories consumed may often be in the thousands, and the food is commonly high in fat, sugar, and carbohydrates.⁵ Similar to anorexia nervosa, the etiology of bulimia nervosa is unclear, but it has been suggested that there may be both biological and psychological components.⁶ Some theories suggest that bulimics have disturbances in peripheral gastrointestinal (GI) signaling, causing the feeling of satiety to not develop appropriately or have excess gastric capacity, allowing them to consume a greater amount of food.⁶

Binge Eating Disorder

Patients with binge eating disorder will experience episodes of binging, often feeling out of control, and will consume large amounts of food in a short period of time, similar to bulimics.⁵ However, in contrast to bulimia, binge eaters do not try to rid themselves of the food consumed.⁵ This disorder may occur in normal weight, overweight, or obese individuals.⁷ Most patients with binge eating disorder have a long history of dieting and have feelings of desperation regarding their inability to control their food intake.⁷ The etiology of this disorder has not been widely studied, but it has been suggested to be linked to many social and psychological disorders such as depression, anxiety, and obesity.⁷

CLINICAL CHARACTERISTICS

The signs and consequences of eating disorders are most likely to develop over a length of time and have lasting health consequences (TABLE 1).^1,3 The key clinical characteristics that make eating disorders different, especially anorexia nervosa and bulimia nervosa, from other disorders with drastic weight changes is the distorted body image and obsession with weight.⁸

Anorexia Nervosa

Anorexia nervosa is identified by symptoms that are the result of malnutrition and the body trying to conserve energy by slowing down its processes.¹ Symptoms include the cessation of menstrual periods, a decrease in bone density—often resulting in osteopenia or osteoporosis, dry and brittle hair and nails, hair loss, and dry skin.^1,5 Patients may experience muscle weakness and loss, constipation, and dehydration.^1,5 If the dehydration becomes extreme, kidney failure may result.¹ Low blood pressure and bradycardia may occur, increasing the risk for heart failure, arrhythmias, and cardiac arrest.^1,5 A patient will often feel cold as body temperature drops, leading to the growth of lanugo, a fine layer of hair that will grow all over the body (including the face) to increase body temperature.^1,5 Patients may experience depression, lethargy, and avoid social situations that may expose their bodies.^1,5,7

Bulimia Nervosa

Those individuals struggling with bulimia nervosa may experience electrolyte disturbances, including losses of chloride, sodium, and potassium that result in an irregular heartbeat, heart failure, or death.^1,5 Less detrimental consequences include a chronically sore throat from purging, swelling in the neck, or a puffy face.⁵ Bulimics may develop gastroesophageal reflux disease (GERD) or the esophagus may become inflamed and even rupture due to frequent vomiting.^1,5 Tooth decay and staining occur as the enamel wears off from frequent exposure to stomach acid. Due to laxative abuse, bulimics may experience constipation, irregular bowel movements, or GI irritation. Other characteristics include peptic ulcers, pancreatitis, depression, and kidney problems.^1,5

Binge Eating Disorder

Patients with binge eating disorder often struggle with health problems associated with clinical obesity and are often overweight themselves.^1,5 Individuals may have unexpected weight gain, depression, and disturbances of body image as well.⁹ Consequences of binge eating disorder may include hypertension, hypercholesterolemia, hypertriglyceridemia, cardiovascular disease, hormone dysfunction, gallbladder disease, and type 2 diabetes mellitus, and frequently mirror consequences of obesity itself.^1,5,9 Binge eaters may experience social role adjustment issues, a decrease in health-related quality of life satisfaction, and increased medical morbidity and mortality.⁴

DIAGNOSIS

According to the DSM-5, there are specific diagnostic criteria for anorexia nervosa, bulimia nervosa, and binge eating disorder.⁴ The DSM-5 was the first to recognize binge eating disorder as a separate condition outside of eating disorder not otherwise specified (EDNOS).^4,8

Anorexia Nervosa

The diagnostic criteria for anorexia nervosa include three points. First, the patient has a significantly low body weight considering physical health, age, sex, and developmental trajectory due to the restriction of energy intake.⁴ Second, even though the individual is at a significantly low weight, he or she demonstrates an intense fear of weight gain or becoming “fat,” or displays behavior that persistently interferes with weight gain. Lastly, there is a persistent failure to recognize the seriousness of the individual’s own body weight, a strong emphasis is placed on body weight or shape upon self-evaluation, or a disturbance exists in the way in which the person perceives his or her body weight or shape.⁴

There are two subtypes of anorexia nervosa, restricting type and binge-eating/purging type.⁴ Restricting type involves the individual not being involved in binge eating or purging activities for the last 3 months, and weight loss is achieved primarily through fasting, dieting, and/or excessive exercise. Binge-eating/purging type occurs if the individual has taken part in recurrent episodes of binge eating or purging in the past 3 months.⁴

Bulimia Nervosa

To meet the diagnostic criteria, the recurrence of binge eating episodes (eating an amount of food larger than what an average person would consume during a   specific and discrete period of time) accompanied by a lack of control over eating must occur.⁴ Criteria also include regular behavior that compensates for binging such as vomiting, misuse of laxatives or other medications, excessive fasting or exercise, or diuretic use. The binging and purging must occur at least once a week for 3 months on average and may not occur only during periods of anorexia nervosa. The individual must be influenced by body shape and weight.⁴

Binge Eating Disorder

According to the DSM-5, binge eating disorder is diagnosed by recurrent binge eating episodes, which are characterized by eating a larger amount of food than an average person during a discrete period of time accompanied by the feeling of a loss of control over the food consumed during the episode.⁴ The episodes must also be associated with three of the following criteria: eating faster than normal, feeling uncomfortably full, eating large amounts of food when not hungry, eating alone out of embarrassment due to the amount of food being consumed, and feeling disgusted by oneself, guilty, or depressed after the episode. Diagnostic criteria also include the individual feeling distressed regarding the binge eating as well as binge eating occurring at least once a week for 3 months, on average. Lastly, the binge eating must not be associated with recurrent purging or inappropriate compensatory behavior that is found in bulimia nervosa and must not occur only during the course of anorexia nervosa or bulimia nervosa.⁴

TREATMENT

Treatment of eating disorders is difficult and often unsuccessful long-term. Patients who have eating disorders often struggle with them for the rest of their lives.¹

Anorexia Nervosa

Pharmacotherapy: Pharmacotherapy for anorexia nervosa is limited since most evidence does not support the use of medications to treat chronic anorexia nervosa, prevent relapse, or to restore weight.¹⁰ In addition, an adjustment in thinking and attitude towards the individual’s body and food must change for weight gain to occur.^10-12 Evidence is positive regarding the atypical antipsychotics, but this comes from many studies lacking controls.^10,12 However, there is some quality evidence that supports the use of olanzapine, which could be directly attributable to the fact that the medication causes weight gain as an adverse effect.^10,12 The tricyclic antidepressants are not recommended for use in anorexia nervosa, despite the frequent association with depression, due to limited beneficial evidence, the risk of fatal arrhythmias, and lethal overdose.¹² Evidence is lacking regarding the use of antidepressants for weight gain, but could be helpful for patients simultaneously experiencing depression.^10,12 Although fluoxetine is used off-label for the disease, it has demonstrated little success in weight restoration.^10,12 Traditional antipsychotics were once recommended but no longer are due to their side-effect profile.^10,12

In regard to the metabolic changes caused by the disease, patients who are extremely malnourished should be rehabilitated nutritionally with an increase in the intake of calcium, vitamin D, protein, fats, and carbohydrates, through the use of supplements, enteral nutrition, and in the most severe cases, parenteral nutrition as well.¹⁰ Supplementing zinc in the patient’s diet may be beneficial to aid in weight gain.¹⁰ Due to the nature of disease, anorexics often experience loss of bone mass, predisposing patients to osteopenia and osteoporosis. However, bisphosphonates and hormone treatment are not recommended at this time due to a lack of evidence displaying efficacy.^10,12

Nonpharmacologic Therapy: The American Psychiatric Association guidelines recommend that patients with anorexia nervosa who are not at an adequate weight should consider a hospital-based program for nutritional rehab.¹⁰ Nasogastric feeding is recommended when patients refuse to eat. Once the patient is no longer malnourished and begins to gain weight, psychotherapy may be started and can be helpful, although the evidence is weak in supporting it. In practice, a vast array of psychosocial interventions are recommended by clinicians to patients with eating disorders and many will utilize a combination of behavioral and dynamically informed interventions. Due to demonstrated benefit, it is strongly recommended that patients, especially children and adolescents, receive family-based therapy.¹⁰

Bulimia Nervosa

Pharmacotherapy: Antidepressants, specifically the selective serotonin reuptake inhibitors (SSRIs), are regarded as the most effective first-line medication therapy component to the treatment of bulimia nervosa.¹⁰ Fluoxetine is the only medication with a labeled indication for use in bulimia nervosa and has demonstrated quality evidence in its effectiveness.¹⁰ Additionally, tricyclic antidepressants have shown significant benefits in the treatment of bulimia, but due to their high risk profile and side effects, they are not often used first line.^10,12

Recently, topiramate has shown good evidence in its effectiveness at treating bulimia nervosa. However, topiramate use is only off-label and has a lengthy side-effect profile. One study involving topiramate compared to placebo in women with bulimia nervosa found that treatment resulted in a significantly greater difference of change in the frequency of binging/purging behavior, a significantly greater reduction in weight gain (this could be problematic if the patient is underweight), and demonstrated an improvement in self-evaluated health and social life.¹³ There have been some small studies and cases that have shown benefits of other agents, including baclofen, aripiprazole, oxcarbazepine, fluvoxamine, and imipramine, but more studies need to be completed before these agents are utilized consistently.^10,12

Nonpharmacologic Therapy: The central goal for patients with bulimia nervosa, like those with anorexia nervosa, is correcting malnourishment and normalizing eating habits.¹⁰ The most studied, and effective, treatment for bulimia nervosa has been shown to be cognitive behavioral therapy or interpersonal psychotherapy for those who do not respond to the cognitive behavioral approach. Patients with bulimia nervosa have shown positive responses to self-help programs where they may guide themselves through therapy workbooks and participate in much of the treatment individually. Family therapy, specifically for adolescents, has demonstrated beneficial effects as well.¹⁰

Binge Eating Disorder

Pharmacotherapy: There has been quality evidence to support the use of imipramine, sertraline, citalopram, and escitalopram in the treatment of binge eating disorder, although none are FDA approved for this indication.¹² However, sertraline, citalopram, and escitalopram have a lower risk-to-benefit ratio than imipramine and may be suggested first. Topiramate has also demonstrated effectiveness, but is not indicated for this purpose. Due to its side effect profile, this agent has only a moderate risk-to-benefit ratio. Inconsistent results have been seen regarding the treatment with fluoxetine, and more studies are needed.¹²

Nonpharmacologic Therapy: One of the common differences between obesity and binge eating disorder is that the rates of psychiatric comorbidities and long-term success of psychological treatments have been demonstrated in binge eating disorder.⁴ Patients with binge eating disorder are strongly advised to participate in cognitive behavioral therapy, as individuals or in a group.^10,11 Other forms of psychotherapy may be considered.

PHARMACIST INTERVENTION

Pharmacists are in a unique position to recognize signs of eating disorders. These include identifying patients who may purchase large quantities of diuretics, laxatives, or weight-loss agents frequently, or attempt refills prematurely. These patients may be questioned and referred to the Eating Disorder Resources sidebar below. It may be wise for pharmacists to have educational pamphlets or brochures available at the pharmacy for family members or patients with eating disorders. If patients are placed on medication for their eating disorder or for an associated psychological illness, it is important for the pharmacist to counsel the patient on the drug’s purpose and help monitor side effects. Pharmacists should be knowledgeable of nonprescription treatments utilized in the treatment of eating disorders (e.g., calcium, vitamin D) and be able to counsel patients on their use.

CONCLUSION

Eating disorders are silent and serious illnesses that can be difficult to diagnose and treat. Many cases are never reported, and the disorders may have lasting health consequences. A combination of psychotherapy and medication may be recommended once a patient is no longer in a malnourished state. Treatment will be most beneficial when the patient accepts and is ready to be treated and can admit to the problem. Pharmacists may be able to help identify this serious disease and provide patients with resources, while physicians should recommend treatment on a case-by-case basis.

REFERENCES

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10. Yager J, Devlin MJ, Halmi KA, et al. Guideline watch (August 2012): practice guideline for the treatment of patients with eating disorders, 3rd edition. APA Practice Guidelines. http://psychiatryonline.org/pdfaccess.ashx?ResourceID=5 391825&PDFSource=6. Accessed May 11, 2013.
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13. Nickel C, Tritt K, Muehlbacher M. Topiramate treatment in bulimia nervosa patients: a randomized, double-blind, placebo controlled trial. Int J Eat Disord. 2005;38:295-300.

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