Handbook of Eating Disorders - part 5 doc

MEDICAL COMPLICATIONS 183 OBESITY More than half of all US adults are classified as overweight (BMI > 25 kg/m 2 ) and one in three is considered to be obese (BMI > 30 kg/m 2 ). The rate of obesity has increased by 50% over the past 20 years in the USA (Yanovski & Yanovski, 1999), but a similar increase has been shown world wide. For example, the MONICA study and more recent studies in England (see Seidell & Rissannen, 1998) have demonstrated that the percentage of obesity in Europe has also undergone a sharp increase, making obesity the most common nutritional disease in industrialised countries. Binge eating disorder (BED), which is classified as an ‘eating disorder not otherwise specified’ in the DSM-IV (APA, 1994), has been described as the most relevant eating disorder for overweight individuals. It has been estimated, that approximately 20–30% of overweight persons seeking help at weight loss programmes are classified as binge eaters (Spitzer et al., 1993). This is one of the reasons why mental health professionals need to know about the highly prevalent condition of obesity (Devlin et al., 2000). Excess weight increases the risk of other severe illnesses, including hypertension, dia- betes, coronary heart disease (CHD) and some forms of cancer. Any treatment approach must recognise that obesity is a chronic, stigmatised, and costly disease. Recently, major advances have been made in identifying the components of the homeostatic system which regulate the control of food intake and body weight (Schwartz et al., 2000). The identifica- tion of obesity-related genes and hormones as well as the development of new drugs raises hope for the treatment of this serious epidemic. HEALTH RISKS ASSOCIATED WITH OBESITY In clinical practice, body fat is most commonly estimated by using the body-mass index (BMI = kg/m 2 ). A graded classification of overweight and obesity using BMI values pro- vides valuable information about increasing body fatness. A World Health Organisation (WHO) expert committee has proposed a classification for overweight and obesity based on the BMI with the following cut-off points (Table 10.2). There are a number of recent studies which demonstrated a close relationship between BMI and the incidence of type 2 diabetes, hypertension, coronary heart disease and cholelithiasis (Willett et al., 1999). This Table 10.2 Cut-off points proposed by the WHO expert committee for the classification of body weight Body mass index (kg/m 2 ) WHO classification Popular description <18.5 Underweight Thin 18.5–24.9 — Healthy, normal, acceptable 25.0–29.9 Grade 1 overweight Overweight 30.0–39.9 Grade 2 overweight Obesity ≥40.0 Grade 3 overweight Morbid obesity The data presented in this table reflect knowledge acquired largely from epidemiological studies in developed countries (adapted from Kopelman, 2000). 184 STEPHEN ZIPFEL ET AL. relationship is approximately linear for a range of BMI less than 29 kg/m 2 , but the risks are greatly increased for both genders above this cut-off. In addition, waist circumferences and waist-to-hip ratio provide measures for assessing upper body fat deposition. The waist circumference in particular is associated with the risk of CHD, hypertension, and blood lipid levels. Lean et al. (1995) demonstrated cut-offs for gender-specific waist circumferences associated with increased risk for metabolic complications. An expert panel on overweight has recently suggested that increased risks of metabolic complications exist if waist cir- cumference is greater than 102 cm in men and 89 cm in women (for review, see Willett et al., 1999). Han et al. (1995) found that, in men, a waist circumference of 94 to 102 cm was associated with a relative risk of 2.2 of having one or more cardiovascular risk factors, and in women a circumference of 80 to 88 cm was associated with a relative risk of 1.6. Metabolic Complications Obesity is characterised by elevated fasting plasma insulin and exaggerated insulin response to an oralglucose load. Particularly upper body obesity is associated with measures of insulin resistance. The different fat depots vary in their response to hormones that regulate lipolysis, such as noradrenaline and cortisol. As a consequence, the elevated abdominal adipose tissue contributes to an exaggerated release of free fatty acids (FFA). This elevation of FFA leads to an inappropriate maintenance of glucose production and impaired hepatic glucose utilisation responsible for an impaired glucose tolerance. Prospective studies confirm a close relationship between increasing body fat and type 2 diabetes. In women, the risk for diabetes after adjustment for age for those with a BMI of 35 or greater was increased 93-fold, compared with women with a BMI of less than 21 (Colditz et al., 1995). Similar results had been demonstrated for obese men. Cardivascular Complications Kopelman (2000) summarises the changes and impairment of cardiovascular function in obesity. Progressive weight gain is accompanied with an increase in blood volume. As a consequence, there is an increase in the heart’s pumping capacity and cardiac output. A combination of elevated circulatory preload and after load led to left ventricular (LF) dilatation and hypertrophy. In the long run, the combination of systolic and diastolic dys- function can lead to clinically significant heart failure. In the Framingham Heart Study, Kim et al. (2000) demonstrated, that body weight was directly related to an increase in the prevalence of coronary heart disease, particularly in men. In addition, the often marked systemic vascular resistance seen in obese individuals results in a marked rise in blood pressure (hypertension) and concentric LV hypertrophy. As a consequence, these factors are responsible for an increased risk of morbidity and mortality from CHD or sudden death, due to ventricular arrhythmia. This may also be due to an increase in sympathetic and de- crease in parasympathetic nervous tone (Rosenbaum et al., 1997). Other mediators, such as altered rates of blood flow, altered thrombocyte function, as well as hyperinsulinaemia or sleep apnoea may be important cofactors. Calle et al. (1999) demonstrated the risk of death from cardiovascular diseases throughout the range of moderate to severe obesity for both men and women in all age groups. The risk associated with a high BMI is greater for MEDICAL COMPLICATIONS 185 whites than for blacks. A weight gain of 5–8 kg is associated with an increase for CHD of 25% (Willet et al., 1995) Additional Complications In addition to metabolic or cardiovascular impairments, individuals with a significant excess weight show obesity-related changes in respiratory function, particularly during sleep. Be- sides daytime somnolence, this sleep apnoea syndrome can cause pulmonary hypertension and is associated with an increased risk of myocardial and cerebral infarction. Studies have shown a positive association between obesity and osteoarthritis of the hand, hip and knee. The Framingham study demonstrated that a decrease in BMI of 2 units or more over 10 years decreased the odds for developing knee osteoarthritis by over 50% (Felson et al., 1992). There is evidence that obesity is associated with an increased risk for a gall bladder carcinoma in both sexes. In addition, a higher rate of breast carcinomas and endometrium carcinomas was found in female obese individuals. HEALTH RISKS ASSOCIATED WITH WEIGHT CYCLING Weight loss in overweight and obese individuals improves the physical, metabolic, en- docrinological and psychological complications. Intentional weight loss may also reduce obesity-related mortality. However, recent clinical guidelines, e.g. Obesity in Scotland (Scottish Intercollegiate Guidelines Network, 1996) have recommended that there should be a shift away from major weight loss to weight management and risk factor reduction. A modest weight reduction of 5–10 kg is associated with many beneficial health effects, including a fall of 10 mmHg systolic and 20 mmHg diastolic blood pressure, a decrease in fasting glucose levels of up to 50%, and a significant reduction in total cholesterol and LDL cholesterol. Modest weight reductions improve back and joint pain, lung function and reduce the frequency of sleep apnoea. Unbalanced ‘crash’ diets should be avoided, because of the high risk of weight cycling and protein depletion. Several prospective studies have outlined some disadvantages of weight loss including (a) an increased risk for women who lose 4–10 kg to develop a clinically relevant gallstone disease and (b) a loss of bone mass. These findings provide further support for the shift towards risk factor reduction and weight maintenance, rather than major weight loss. SUMMARY AND CONCLUSIONS Medical complications play an important role in patients with eating disorders. In particular the following patient groups are at high risk for medical complications: malnourished anorexic patients, bulimic patients with a severe symptomatology of bingeing and purging, patients with a somatic comorbidity (e.g. diabetes mellitus) as well as those individuals with a marked overweight or weight fluctuations. Therefore it is important to take a full medical history, including current medication. In view of the multiple physical problems which may occur, and their potentially serious consequences, it is advisable that all patients have a thorough physical examination, with a special focus on the cardiovascular system. In 186 STEPHEN ZIPFEL ET AL. addition there is general agreement, that particularly anorexic patients should have a range of screening investigations (e.g. full blood count, biochemical profile). An electrocardiogram (ECG) is mandatory in all patients with anorexia nervosa and for those eating-disordered patients with severe electrolyte disturbances. 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CHAPTER 11 Family, Burden of Care and Social Consequences Søren Nielsen Psychiatric Youth Centre, Storstrøm County Psychiatric Services, Næstved, Denmark and N´uria Bar´a-Carril Eating Disorders Unit, Institute of Psychiatry, London, UK SUMMARY What do we know? r High levels of distress—personal and intra-familial r Burden of care high—familial, psychiatric and somatic r Loss of productive years—through periods of illness and through premature death r ‘Stunting’—emotional, psychosexual, physical and vocational r Outcome depends on both patient and treatment factors—‘experts’ do make a difference What we need to know more about r Which patients and families benefit most from which type and dose of treatment r Outcome if treatment is refused, incomplete or prematurely terminated r Characteristics of cases untraced or refusing follow-up r Sibling’s roles in the disease process and in the treatment process r Consumer satisfaction—of patients as well as carers r Quality of life—with and without eating disorder INTRODUCTION The concept ‘burden of care’ has attracted only limited attention in the field of eating disorders (Treasure et al., 2001). It is clear from outcome studies that there is a lot of suffering in and around persons with eating disorders (Tolstrup et al., 1987; Ratnasuria Handbook of Eating Disorders. Edited by J. Treasure, U. Schmidt and E. van Furth. C  2003 John Wiley & Sons, Ltd. 192 SØREN NIELSEN AND N ´ URIA BAR ´ A-CARRIL et al., 1991; Crisp et al., 1992; Theander, 1970, 1992, 1996; Keller et al., 1992; Wentz, 2000). Personal reports clearly attest to this (MacDonald, 2000). Our aim is to look at the ‘burden’ from three perspectives: personal, familial and societal. We will attempt to outline what is known, and what deficits there are in our present knowledge. PERSONAL BURDEN Misery In the acute phase of the illness patients do seem to get some satisfaction from the anorectic way of life. However, later the costs become apparent in terms of loneliness, despair and intense mood swings. The rigid control of all aspects of life tends to kill life as other people know it, and indeed as the patient herself has known it. Despite all efforts, no success seems to be really satisfactory, further goals continue to loom on the horizon. No solutions are in sight, only problems. From an outsider’s—e.g. most therapists—perspective the condition is enigmatic. Many autobiographical accounts exist, a few of which can be found in authoritative texts, e.g. Haggiag (2000). Some emphasise the suffering brought about by treatment, rather than the suffering originating from the illness per se. This point of view is understandable, given the clinical accounts of some of the more drastic treatment approaches (e.g. Theander, 1970, esp. pp. 115–118; Morgan & Crisp, 2000). Stunting Social The ‘hibernation’ following from years of existence as a person with an eating disorder, with chronic malnutrition, a limited range of interests and few free choices, can lead to sequelae in many areas of life. The potential for development is seldom fulfilled. Anorexia nervosa can lead to developmental delay, emotionally as well as socially. Ratnasuriya et al. (1991) noted that many in their cohort did not obtain full independence, but stayed with relatives in a dependent relationship, with a limited range of interests, neither completing an education nor holding a job. Tolstrup et al. (1987) found a downward slide in social class in the probands from the initial evaluation to the first follow-up in 1981–1982. The long-term significance of this finding will be fully appreciated only after further follow-up interviews. We have reanalysed some of the published raw data from the interesting follow-up study from Sweden, in particular ‘the living situation’ given in Wentz (2000) using the program package StatXact4 (Cytel, 2000). The data set consists of singly ordered R × C tables, and consequently the Kruskall-Wallis test (Siegel & Castellan, 1988) is the relevant analytical tool. A smaller proportion of the AN group (study group) shared a flat, and more live alone than in the COMP group (comparison group). Similar numbers in both groups live with parents, and similar numbers are married/cohabitating in each group. At variance with Tolstrup et al. (1987) and Ratnasuriya et al. (1991), Wentz (2000) found no between-group differences in ‘occupation’ when the cohort was 24 years old, i.e. after 10 years of follow-up. [...]... 8 11 6 41 5 5 0 11.12; exact p-value 0.0008 Personal contacts at 10 years of follow-up 20 7 20 4 44 1 6 0 23.02; exact p-value 0.0000 Social activities at 6 years of follow-up 27 15 6 3 45 5 1 0 15. 81; exact p-value 0.0001 Social activities at 10 years of follow-up 23 14 12 2 42 5 4 0 15. 05; exact p-value 0.0001 a Reanalysis of published raw data from Wentz (2000), Paper III, Table 4, using the program... number of change points to the data in Figure 11.1 Degrees of freedom No of change points Residual SS 0 1a 2 3 5. 654 5 × 106 1.61 25 × 106 1.1894 × 106 1.0 656 × 106 a Stepwise F-test Num Den AICC 23.81 15. 95 10.77 2 4 6 19 17 15 3 15. 75 293.16 294.10 301. 95 Best model: AICC attains minimum The positive trend in Figure 11.3 is highly significant (t (df 21) = 10.69; p < 0.00001) Financial Burden The cost of. .. number of change points to the data in Figure 11.2 Degrees of freedom No of change points Residual SS Stepwise F-test Num Den AICC 0 1 2a 3 0.00728377 0.00188477 0.00102890 0.0009 852 5 27.21 25. 84 15. 98 2 4 6 19 17 15 − 155 .06 −179.89 −1 85. 87 −176.49 a Best model: AICC attains minimum 202 ´ ´ SØREN NIELSEN AND NURIA BARA-CARRIL Anorexia Nervosa Excess mortality is well established (Sullivan, 19 95; Møller-Madsen... significant overall aggregate SMR of 7.4 ( 95% CI: 2.9 to 14.9) changed to a non-significant SMR of 1 .56 ( 95% CI: 0.8 to 2.7) At present the evidence on mortality in bulimia nervosa is inconclusive Anorexia Nervosa and Bulimia Nervosa Jørgensen (1992; cited in Nielsen, 2001) report a crude mortality of 20% (5 of 25 probands) after a mean of 12 .5 years of follow-up SMR is 9.9 ( 95% CI: 3.2 to 23) These findings... Psykiatr Tidsskr., 42, 4 45 448 Butzlaff, R.L & Hooley, J.M (1998) Expressed emotion and psychiatric relapse: a meta-analysis Arch Gen Psychiat., 55 , 54 7 55 2 Colahan, M & Senior, R (19 95) Family patterns in eating disorders: going round in circles, getting nowhere fasting In G Szmukler, C Dare, & J Treasure (Eds.), Handbook of Eating Disorders Theory, Treatment and Research (pp 243– 257 ) Chichester/New York:... this field is found in Part I of the first edition of this handbook (Szmukler et al., 19 95) , and in Chapter 17 of this book The seminal works of Selvini-Palazzoli (1974) and Minuchin et al (1978) stimulated a lot of interest in the role of the family in the aetiology of these disorders Unfortunately this led to families suffering and experiencing guilt and blame Some of the concepts of Minuchin et al (1978)... levels of psychological distress, and highlighted the need of further research into carers’ distress in the area of eating disorders Siblings Although it is very likely that siblings of eating- disordered patients may also feel the strain of the eating disorder, little is known about the extent of the effect that the eating disorder may have on them Roberto (1988) and Colahan and Senior (19 95) in Chapter... in Denmark during the period 1970–1987 Acta Psychiatr Scand., 94, 454 – 459 Newton, T., Robinson, P & Hartley, P (1993) Treatment for eating disorders in the United Kingdom Part II Experiences of treatment: A survey of members of Eating Disorders Association Eat Disord Rev., 1, 10–21 Nielsen, S (2001) Epidemiology and mortality of eating disorders Psych Clin North Am., 24, 201–214 Nielsen, S., Emborg,... for the treatment of patients with eating disorders (revision) American Psychiatric Association Work Group on Eating Disorders Am J Psychiat., 157 , 1–39 Attia, E., Haiman, C., Walsh, B.T et al (1998) Does fluoxetine augment the inpatient treatment of anorexia nervosa? Am J Psychiat., 155 , 54 8 55 1 Bacaltchuk, J., Hay, P & Mari, J.J (2000) Antidepressants versus placebo for the treatment of bulimia nervosa:... al (2001) Influence of psychiatric disorder on the controlling behaviour of mothers with 1-year-old infants A study of women with maternal eating disorder, postnatal depression and a healthy comparison group Br J Psychiat., 179, 157 –162 Steinhausen, H.-C (19 95) The course and outcome of anorexia nervosa In K Brownell & C.G Fairburn (Eds), Eating Disorders and obesity: A Comprehensive Handbook (pp 234–237) . activities at 6 years of follow-up 27 156 3 455 10 15. 81; exact p-value 0.0001 Social activities at 10 years of follow-up 2314122 4 254 0 15. 05; exact p-value 0.0001 a Reanalysis of published raw data. Results of fitting an increasing number of change points to the data in Figure 11.1 Degrees of freedom No. of change points Residual SS Stepwise F-test Num. Den. AIC C 0 5. 654 5 × 10 6 3 15. 75 1 a 1.61 25. role of the family have changed over time, as almost all aspects of our understanding of the eating disorders. A good introduction to this field is found in Part I of the first edition of this handbook