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Welcome to PsychEd, psychiatry podcast for medical learners by medical learners. This is the first of a two-part episode on the topic of eating disorders. In part one, we'll be covering diagnosis, an approach to initial assessments, predisposing factors and explanatory models for the development of eating disorders, and medical complications.
In part two, we'll delve into an exploration of eating disorder treatment.
I'm Dr. Lucy Chen. I'm a staff psychiatrist at the Centre of Addiction and Mental Health. It's been a while since I've last hosted a podcast and it's lovely to be back, especially joined by a couple of very lovely and brilliant residents.
We have Nikhita Singhal.
Hi, I'm Nikhita. I'm a second year psychiatry resident at the University of Toronto and very excited to be co-hosting this episode.
Yes.
And then we have also Vanessa Aversa and I believe this is your very first podcast. Experience.
Yes, thanks Lucy. I'm Vanessa. I'm a third year psychiatry resident at the University of Toronto and I'm excited to join in today.
Great. And our esteemed guest for today is Dr. Randy Staab. He's a staff psychiatrist at Trillium Health Partners and the lead of the eating disorders program at Credit Valley Hospital.
Thank you very much for having me here today.
Yeah, that's great. So I have had the absolute pleasure to train under Dr. Staab as a senior resident and that was clearly very inspiring. I work primarily with women with a trauma history on an inpatient unit at ChemH and there's certainly a lot of comorbid eating disorders.
And I work closely with a dietician on the team and I feel like I wouldn't have a lot of confidence working with this patient population if I hadn't done the elective with Dr. Staab and very excited to have him on the podcast.
The learning objectives of this episode are as follows. By the end of this episode, you should be able to recognize the clinical features of various eating disorders using DSM-5 diagnostic criteria, identify predisposing factors using a biopsychosocial framework, list common comorbid psychiatric conditions associated with eating disorders and identify and describe the medical complications of eating disorders.
So Dr. Staab, I guess, you know, a very natural kind of question to begin with would be what exactly is an eating disorder? How do we define that?
Sure, so eating disorders are very, you know, complex biological brain disorders. They're, you know, they are complex illnesses that involve an unhealthy relationship with food, eating and body image or body size. They're definitely not a lifestyle choice, right?
So, you know, sometimes in the media they're portrayed as being sort of frivolous, you know, lifestyle choices or something, but these are definitely really important biologically brain based disorders. And they can be quite difficult to treat because of all of the medical comorbidities and the psychiatric comorbidities that go along with them. In fact, anorexia nervosa has the highest mortality rate out of any mental illness.
And could you tell us a bit about the different types of eating disorders?
Sure. So there's a bunch of them in DSM-5. So the ones that we can talk about today are anorexia nervosa, or AN, bleme nervosa, or BN, binge eating disorder, or BED, and then avoidant restrictive food intake disorder, or RFID, and other specified eating disorders, and then unspecified eating disorder.
So despite a number of common psychological and behavioral features, these disorders differ substantially in terms of clinical course, outcome and treatment needs. You know, people with eating disorders display a broad range of symptoms that frequently kind of occur along a continuum between those with anorexia nervosa, bulimia and other eating disorders. So usually weight and shape preoccupation and excessive self-evaluation based on weight and shape are the primary symptoms for all eating disorders, but not exclusively.
And most people don't try to set out to develop eating disorder on purpose. It just kind of gradually develops over time as people get more and more obsessed with dieting and weight loss. So anorexia nervosa are AN, right?
So, you know, the main criteria is restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health. So just as a general ballpark figure in the eating disorder world, we kind of use like a body weight less than approximately 85% of expected or usually less than about a BMI of 17.5. That's not an absolute number.
So, you know, that's just a general ballpark sort of guideline. When you start to make the diagnosis, and this could be weight loss or failure to make expected weight gain during a period of growth in adolescents or teenagers. So it has to be quite a substantial level of emaciation.
And then secondly, they have an intense fear of gaining weight or becoming fat or persistent behaviors that interfere with weight gain. So often ironically, the fear of becoming fat and body image disturbance often actually gets worse and intensifies the more the weight is lost with anorexia, which is very different from like an average, routine sort of dieter. Many people in the world might go on a diet here and there, but some of the anorexia kind of they keep dieting, it's never good enough when they reach a weight goal, they may feel happy or kind of be in control for a short period of time, but then they keep setting their weight goals lower and lower and it's never kind of good enough.
“Man, ironically, let's say if somebody started at 130 pounds, let's say hypothetically, right? They started to die, they started to lose weight, they get down to 120 pounds, they might feel good and kind of happy and in control for a short period of time, but then they lose more weight, they diet more extremely, they exercise more or start to engage in purging behaviors, right, they get down to 115 pounds, 110 pounds, they keep pushing it, it's never good enough. Eventually when they get down to quite low, let's say 100 pounds hypothetically, ironically, they often feel worse about their body image at like 100 pounds than when they did, when they started off the whole dieting process at like 120 or 125, which is very different from an average dieter, right?
So that's when the distortion starts to get worse and worse. Not everyone with anorexia has this intensive fear of gaining weight or becoming fat with this body image disturbance, the majority do, but maybe 10 or 15% of people don't. And it's more around, you know, difficulties with control or having a difficult time changing their habits or maybe related to sort of like religious aestheticism or things like that.
There could be other sort of motivations behind it, but the bottom line is that they have other persistent behaviors that interfere with weight gain. And then, so moving on with the criteria. So there's a disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight and shape on self evaluation.
So really most of their self worth is determined by weight and shape, and they really see weight loss as an impressive achievement and weight gain as an unacceptable failure of control. Or the persistent lack of recognition of the seriousness of the current low body weight. So there often tends to be a lot of denial and a lot of resistance with anorexia nervosa.
And often they seek treatment more in the prompting of their friends or their family or their doctor, their therapist, and they often kind of feel like people are exaggerating, that it's not such a big deal, that they're fine, they can take care of it on their own. So there is a lot of often denial and resistance that goes along with the disorder. In the Eating Disorders program, we do these sort of like self-esteem pies.
And a regular person, hypothetically, let's take myself for instance, if we were to do a self-esteem pie, picture a kind of a circle and then picture a pie divided up into, let's say, eight or 10 pieces. Part of people's healthy self-esteem would be divided into a lot of different areas. So, someone's self-esteem could be related to their work or their family, their wife, their spouse, their children, maybe their hobbies, some of their clubs that they're involved with or their spirituality, traveling or books or friends and family.
So there could be lots of different things that contribute to how you feel about yourself and your self-esteem. Whereas at some of the anorexia nervosa, most of their self-esteem and how they feel about themselves is really related to weight and shape and volumage, the number on the scale and how much fat they can pinch on their abdomen, which is obviously very unhealthy. It's not a very balanced way of living your life because if one thing happens, if you gain one pound or you gain a quarter of an inch, then your whole world is ruined, right?
Your whole day is destroyed because it's built on kind of a very shaky foundation. In the past, in DSM three and four, they used to include loss of menstrual periods as a criteria for anorexia nervosa, but that was dropped in DSM five because it's not a very sensitive or specific criteria. Some women lose their periods when they're actually at normal weight.
And then some women maintain their periods even though they're at a very low weight. And it doesn't really count when people are just going through puberty because sometimes their periods can be kind of hit and miss. Or if they're on birth control or have an IUD that can kind of alter it, or if they're going through menopause, or obviously, you know, for boys or for men, that criteria doesn't count.
So for that reason, you know, that criteria was dropped a number of years ago. So for anorexia nervosa, there's two different subtypes. There's the restricting subtype.
That's the one that most people in society would think about when they think about anorexia nervosa. So people who died in the extreme and have excessive exercise to lose weight. And then there's also the binging and purging subtype.
So people who have all the criteria of anorexia that we just mentioned. And then on top of that, they also have regular episodes of binging and purging as well. And then, you know, the severity is based on their weight.
So the severity of the BMI. So a milder form of anorexia also would be a BMI greater than 17. Moderate would be a BMI between about 16 and 17.
You know, severe between 15 and 16. And then extreme would be less than 15, which is obviously worse, you know, prognosis, more complications. So about 10 to 15% of people with anorexia will die from the disorder.
On long-term follow-up studies, it may go as high as even 18 to 20% when people have had chronic anorexia for more than 20 years. So pretty disturbing, you know, that so many, you know, young, talented, often, you know, smart, sophisticated young people are dying from this disorder.
Yeah, thank you so much for that, Dr. Staab. You really kind of painted a clear picture. And I think a lot of times, yeah, there's like these very clear like media images of what anorexia is.
And it's good to know that it's kind of quite multifaceted. I liked how you also mentioned, you know, how for some people it's, you know, there's cultural factors here too. There's sort of a diverse range of people that can find themselves with this disorder and there's different types of contributions.
For sure. Yeah, I mean, it's not, there are, you know, there are specific criteria, but people also have their own individual personalities and their own, you know, upbringing and life experiences that they bring that can, you know, manifest in a various of different ways, right? So just one little sidebar note too, like the term anorexia is a little bit of a misnomer because in medicine, right, if you look up the term anorexia, it means, you know, loss of appetite, which these patients often don't usually lose their appetite.
Maybe in the very end stages or late stages of disorder, it's just that they often have a very good appetite. It's just that they're not giving into their appetites, right? And then because of the high levels of denial and resistance, they're often not complaining about the symptoms, right?
They're not walking into a doctor's office, you know, complaining about weight loss and emaciation and the symptoms that we're talking about. These are symptoms that are seen by, you know, their clinicians or their friends or their family more often.
I think this is a natural segue to kind of then talk about bulimia nervosa and the differences between anorexia and bulimia.
Sure. So for bulimia nervosa, so again, in the general public, if you know, people think about bulimia, they think about vomiting, but actually for bulimia nervosa, you have to have binge eating and some type of compensated behavior, which may or may not be vomiting, right? So to qualify as binge eating, it has to be eating in a specific period of time, a very, very large amount of food, right?
So this is way more than people would eat under usual circumstances. So, you know, sometimes when I go to a party or whatever, you know, people will say to me, Oh, Dr. Staab, you have to help me for my binge eating or something, right? And then I'll just say, oh, you know, what did you eat last night or something, right?
And they'll say, oh, I binged because I had one extra piece of pizza, or, you know, I had an extra bowl of potato chips or something like that. So that doesn't qualify as a binge, right? But usually for research purposes, it would need to be a minimum of extra 1,000 calories in one sitting.
And that's not like 1,000 calorie, like a large meal. That would be 1,000 calories on top of a person's regular meal plan. And it's usually eaten very quickly, usually less than two hours, usually less than about a half an hour actually.
People are eating it very quickly, almost in a frenzy, they feel out of control. And it's often all the sort of high fat, high calorie, high carbohydrate foods that they would normally never allow themselves to eat, right? So it's kind of like a lot of cakes and cookies, ice cream, chips, fast food, sort of all the forbidden foods that they would never normally allow themselves to eat.
And then they also have a lack of control over it. So there's a feeling that once the binge has started, that they feel that it can't stop, that it has to kind of just like run its course. And then they also have recurrent inappropriate compensator behaviors to prevent weight gain.
So after a binge, people with bulimia feel horrible. They feel a lot of guilt and anxiety and disgust and shame. And then to try to undo the binge, they will engage in either purging through vomiting or laxatives or diet pills, diuretics, enemas, other medications or fasting, or sometimes excessive exercise as well.
And the binge eating inappropriate compensator behaviors have to occur both on average at least once a week for three months, right? So if there's a teenage girl who, you know, goes to a party one night and maybe drinks a bit of extra beer, and then, you know, it feels disinhibited and binges and purges one time, that wouldn't count as bleeding nervosa. It has to be an ongoing regular pattern for it to qualify.
People with bleeding nervosa, their self-velation is also unduly influenced by weight and shape as well. So they have basically the same underlying psychopathology as with anorexia nervosa as well. They have an intense drive to lose weight and extreme body dissatisfaction as well.
And the disturbance does not occur exclusively during anorexia nervosa. So if you're underweight and you meet criteria for anorexia nervosa, then that kind of trumps the diagnosis for bulimia nervosa. So sometimes medical students, it can be a bit confusing why, you know, when does someone anorexia or bulimia?
So if you're underweight and, you know, under BMI of let's say 17.5 approximately, and you're binging and purging regularly, then you would meet criteria for anorexia nervosa binge purge subtype. And if you're normal weight or above average in weight, and you're binging and purging regularly, then you might create criteria for a bulimia nervosa.
Yeah, that's really important to highlight. And yeah, like I guess some of the ways that I conceptualize this, yeah, bulimia is more of a disorder of chaotic eating, right? And then anorexia is more so restricted eating to the point of, you know, severe significant emaciation or low body weight.
Yes, although about half of them do have chaotic eating with bingeing and purging as well. I mean, the binge is not to get too technical, but some of the binges that are seen with anorexia nervosa tend to be smaller than with bulimia nervosa often because, and they're doing, you know, they're purging out more of the calories obviously just to maintain a low body weight.
And then I guess some things that I also kind of picture or kind of use to kind of differentiate between these disorders, also like their comorbidities. Anorexia with more comorbidity with cluster C, sort of OCPD obsessiveness, like, you know, harm avoidance traits.
Yes.
And the bulimia more cluster B borderline personality, substance abuse can kind of risk taking traits.
Definitely. Yeah, so with anorexia and also we see, you know, very high levels of perfectionism, you know, obsessive compulsive personality traits. They often are very rigid and harm avoidant and have a need for exactness and perfectionism and conform to authority.
They tend to be often, I mean, this is a stereotype, but they often can be quite hardworking and diligent and responsible. They often are quite modest and earnest and very sensitive to criticism and have high levels of anxiety and often a lot of social anxiety too. They often tend to be and have more sort of sexual disinterest as well and be very obsessional as well.
With bulimia nervosa, like you said, Lucy, with bulimia nervosa, people tend to be more, you know, have more dysphoric moods, have more, you know, difficulties with interpersonal stressors and can be more labile, they can be more thrill seekers and have more sort of, you know, novelty seeking behaviors with bulimia nervosa.
Yeah, so then why don't we move on to binge eating disorder?
Sure, so binge eating disorder, we don't actually treat binge eating disorder here at the Trillium Health Partners Credit Valley Program because the treatment approach is actually quite different than what you would use with anorexia and bulimia nervosa. So for binge eating disorder, people also have recurrent episodes of binge eating. So the same type of binges that you would have in bulimia nervosa that we just talked about.
So eating a very large amount of food in a short period of time, feeling out of control. And then the binge eating episodes are associated with three or more of the following. So eating much more rapidly than normal, eating until they're feeling uncomfortably full, often they feel really sick by the end of it.
Eating large amounts of food when not feeling physically hungry. Eating alone because they feel embarrassed by how much they've eaten. So again, a lot of shame and guilt and anxiety goes along with it.
And then feeling disgusted with oneself, depressed or very guilty afterwards. They also have a lot of market distress regarding binge eating. And the binge eating also occurs at least once a week on average for three months.
So again, not just one isolated episode on Christmas Eve or something like that. And they don't, I think the important distinction with bulimia, they don't have recurrent inappropriate compensator behaviors, right? So they binge eat and then they do not purge, they do not vomit.
They do not try and get rid of the calories afterwards. And often, you know, afterwards they feel really sick and disgusted and horrible, guilty, awful. Yeah, and that often, because they're binging a large quantity of the food, often that can lead to weight gain over time, often leading to, you know, metabolic problems, obesity, problems with type two diabetes, cholesterol, et cetera.
So with anorexia nervosa and bleeding nervosa, we didn't mention, but it's more like 10 to one women to men. Whereas for binge eating disorder, it's a little bit more evenly split between men and women. It's about more like 60% women and 40% men, something like that.
And they tend to be slightly older, more in the late 20s or 30s. And they also tend to have a lot of comorbid conditions as well. So depression, anxiety, social anxiety and things like that as well.
And the severity for binge eating disorder is based on the number, frequency of binge eating episodes.
And Dr. Staab, is there sort of a bit more motivation in this population with respect to engagement and treatment or?
There is, yup. So actually both. So yeah, binge eating disorder, there tends to be more, there's less denial than with anorexia nervosa.
The same with bleeding nervosa as well, right? So with anorexia nervosa, sometimes there's a lot of denial. People have no idea there's something wrong.
They feel like, you know, other people are just unfairly criticizing them. And maybe other people have the problem or other people are jealous of them or something. Whereas bleeding nervosa and binge eating disorder, there's a lot more insight, right?
They still may have a lot of shame and not be open to talk about it because they feel so, you know, guilty and ashamed. But in their heart, they know there's something wrong. Like if you're binging on, you know, 10 donuts, or you feel disgusting afterwards, you know that there's a problem, right?
Or people are binging and then vomiting. They know that there's something wrong. They may not be still so keen to get help in the beginning stages, but there is more motivation to change because they really feel disgusted and actually hate the symptoms.
They really can't stand the symptoms. They're disgusted by them.
Okay, so maybe now we should move on to ARFID or avoidant restrictive food intake disorder. And I find this disorder very interesting because I see so many different manifestations of it.
Okay, sure. Yes, it's quite a heterogeneous disorder, right? So this disorder just sort of arrived on the scene in DSM-5.
It was known as a whole host of different sort of other disorders before. So it is quite a mouthful to say. So avoidant restrictive food intake disorder.
So it is also an eating or feeding disturbance, which leads to significantly low body weight or significantly nutritional deficiencies, dependence on enteral feeding or oral supplements. And it also markedly interferes with their psychosocial functioning. So it can present in a lot of different ways, right?
So some people with ARFID present with like, choking phobias or like a swallowing phobia or a vomiting phobia, or they're concerned about, if they had a really bad gastroenteritis, maybe they're worried about if they eat, they're gonna get like food poisoning or bloating or cramping or stomach pain. So they often have like unusual eating habits, but they don't have that dry for thinness or body image distortion that you see with anorexia nervosa typically, right? So, you know, they may be, you know, have lost 30 pounds over the year, but they're desperate to gain it back.
They don't like being skinny. They don't like being underway. They don't admire their bones.
That they don't look at themselves in the mirror and, you know, are fearful about eating a cheeseburger or something. It's more about, you know, their fear of swallowing or nausea or the sensory effects of food. They're very sensitive to tastes, things like that, but they actually don't like being skinny and underweight.
They actually would prefer to gain weight. So just to continue with our for the criteria. So it's not better explained by lack of available food or other sort of associated cultural sanctioned practice.
It does not occur exclusively during the course of anorexia nervosa or bulimia nervosa. And it's not attributable to some other sort of concurrent medical condition. So it's not better explained by another mental disorder as well, right?
So it's not related to, you know, Crohn's disease or, you know, celiac disease or some other sort of medical condition like, you know, malabsorption syndrome or hyperthyroidism or something else that causes weight loss.
I do wonder though, about sort of comorbidity, right? So, you know, in autism spectrum disorder, there's a lot of, you know, preoccupation with different textures of food, you know, or maybe they're only eating one food group or even less. And so, you know, or even in, you know, specific phobia of choking.
So I suppose that RFID is a comorbid disorder to some of those presentations.
Often, yes. So it can be like, it's quite heterogeneous, right? So RFID, like, you know, people with anorexia, often when you speak to them, you feel like you're almost speaking to like, you know, a bunch of people who are related or something, right?
They all seem like sisters of the same person in some ways. Whereas some of the RFID, they seem very different, right? You can have people who have like, you know, a fear about eating, you know, crunchy foods, or they're gonna choke on it or something, or fear some people are, you know, they'll only eat white foods or something like that.
And they have like autistic spectrum. They only eat like chicken nuggets and French fries and rice or something like that. You know, whereas like someone with anorexia wouldn't be caught, you know, wouldn't probably touch French fries or chicken nuggets with a 10 foot pole.
These people would just eat one thing and maybe higher in fat, but ultimately it does lead to some nutritional deficiencies because they're just kind of just eating like one thing all the time.
This is also very interesting disorder in the landscape of, you know, current people engaging in very extreme health practices. And I say, health practices in quotes, right? Like the carnivore diet or, you know, people only eating, you know, like fruits, literally only fruits.
Yeah, because again, they're not getting the proper variety, right? It can lead to nutritional deficiencies and you know, problems obviously. A lot of these people that we see here at the clinic with ARFID, they have also had a lot of anxiety.
So these tend to be really, I mean, people that interact with somebody and also have a lot of anxiety, but these people tend to be like, you know, very worried, anxious kids. And then something happens where maybe they had one bad experience where they ate, I don't know, they ate pizza one time and, you know, got food poisoning or got diarrhea or something. And then they're like scared about getting that again.
And then they start restricting their food more and more and more and more to the point when they're only eating like three things or something like that, right? So they tend to be really highly anxious, highly worried and ruminating all the time and are kind of looking for danger all the time in their environment or within themselves.
So that's a great summary of RFID. And then our final category is other specified feeding or eating disorders. And I guess this just sounds like a mishmash of things, but maybe you can break it down and make sense of diagnosis.
Sure. So other specified eating disorder. So it's kind of broken down into sort of five different subcategories.
And again, it's very heterogeneous. So you have to say when you're diagnosing someone, like you would say, you know, other specified eating disorder dash atypical anorexia nervosa, or whatever is the subcategory. Because just by itself, it wouldn't really mean that much.
So this is sort of a grab bag of people who have significant eating problems that cause a significant distress or impairment in the person's functioning, but it doesn't meet criteria for anorexia or bulimia or BED or RFID like we talked about already. So some examples might be sort of like atypical anorexia nervosa. So people who have significant weight loss for whatever reason, but their weight may be within a normal range, right?
So we see people sometimes who start off with obesity and let's say they go from 200 pounds down to 125 pounds. And for all intents and purposes, their eating habits and their fear of foods and their exercise and their, the caloric intake is basically like that as someone with anorexia, but they're actually at a normal BMI. Their BMI may be, you know, 20 or 21, but they've lost a huge amount of weight.
So they would still qualify as having, you know, quite an eating disturbance. So, but then you qualify as, you know, atypical anorexia nervosa. Someone with bleeding nervosa who may be just sort of sub-threshold as well, where they have binge eating and inappropriate compensated behaviors, but it's less than the average than once a week for three months.
Someone with binge eating disorder of low frequency or limited duration. So again, they're having binge eating episodes, but maybe it's just once or twice a month instead of once a week on average for three months. And then purging disorder.
So people who are just purging regular meals, right? So they're not binging and they're just purging like a regular lunch or a regular dinner routinely. And then night eating syndrome is people have recurrent episodes of eating in the nighttime.
You know, often most of their food intake happens and then we eat hours in the morning at two or three in the morning and they're awake. It's not that they're like, you know, they're not sleepwalking or something like that.
I suppose, yeah, it's sort of sub threshold criteria for some of the disorders we already talked about.
Exactly, yeah, pretty much.
And then just in addition to maybe and purging disorder and night eating syndrome.
Yes, exactly, yeah.
Yeah, and then there's, I guess, I guess there's another final category in the DSM-5, this unspecified eating or feeding.
Yeah, and that's again, just kind of a grab bag for anyone who has significant eating pathology and causes distress and impairment, but it doesn't meet any other criteria of things we've talked about already. So some people who kind of go on these fads or kicks and have eating disorder symptoms for a while and then they eat normally, or they do this for a couple of weeks in the summer, then they get over it, or people who have chewing and spitting symptoms, or basically for anyone who has significant pathology, but doesn't meet criteria for the other disorders we've already talked about.
Yeah. So, this makes me just think about, when I guess a resident is to approach a patient and having some of these diagnostic criteria in mind, right? How would they begin to take a history to get sufficient data to like substantiate a diagnosis?
Like what, maybe you can give us a little bit of like a, kind of a general approach to taking an eating disorders history.
Sure, so I think, you know, some of the main points to clarify would be, you know, definitely to get their weight and their height and their BMI to kind of see where they're at, to maybe look if they've had some large weight fluctuations over the last year or two, you know, maybe what's their highest weight they've ever been, what's the lowest weight they've ever been, has their weight been stable, are there a lot of fluctuations? Maybe to do a typical sort of daily food intake about what they eat on a typical day gives you a sense of kind of what their eating is like. Do they engage in symptoms of binging, vomiting, laxatives, dipels, diuretics, chewing and spitting?
How much exercise do they do? Is their exercise kind of compulsive? You know, do they have a lot of guilt or shame or anxiety with eating?
Do they spend a lot of their day thinking about issues related to food, weight, shape, body image, binging, purging, et cetera? You know, what are their menses like and, you know, how do they feel about their body image? Do they do a lot of body checking or mirror checking in the day?
Do they place a lot of their self-esteem onto their body image, right? How would they feel if they were to gain five pounds? I guess, you know, a lot of people maybe wouldn't be too happy to gain five or 10 pounds, I'm not sure if we can catch them all, but someone with an eating disorder would be solely devastated and floored if they were to step on the scale and gain five pounds, whereas most of us may not be too keen on it, but it wouldn't destroy our entire day or our entire week or something like that.
So those would be some of the main points, and then obviously clarifying some of their comorbid conditions, commonly depression or anxiety or substance or OCD, and then also some of their medical history as well, can be important, especially if you're concerned about someone who's been underweight or having, you know, a lot of binge purge symptoms as well.
Thanks, Dr. Staab, for going through this with us. One of the questions that I had was related to some of your discussion around how a lot of the patients with anorexia and nervosa experience high levels of denial and resistance related to their illness. And I can see how maybe in treating or assessing some of these patients, you know, the goals of the patient and the goals of the health care provider are kind of at odds.
And so I was wondering if you sort of have any thoughts about certain strategies that residents might be able to use either in the initial assessment or later on in treatment in terms of engaging these patients in care.
Sure. I mean, that's the that's probably the toughest or one of the toughest jobs of that I have to do and our team does here at Credit Valley is trying to motivate, you know, trying to motivate someone who maybe doesn't see they have a problem or doesn't really want change or doesn't really want to get better. You know, sometimes I see people in the clinic at the first consultation.
And the first thing that they'll say, I'll say, you know, hi, I'm Dr. Staab. I'm just going to take your history and, you know, run run through some of these questions. And the first thing that they'll say is, I don't want to be here.
Right. And I'll say, okay, well, can you tell me why you end up coming? And I'll say, oh, I came here because my mom made me.
Right. So sometimes just try to roll with some of the resistance and just say, okay, well, you know what, let's just try and get a history today. It's up to you if you want to get any help or not.
Or if you want to, you know, work on anything or change anything in the future. But why don't we just get a history so that we have a baseline and we have it documented. And then it's totally our choice.
I think giving them the control, you know, it's totally our choice if you want to do anything about this or or pursue any treatment in the future. So just letting them know, I guess just that you're going to get a history to start off with and that there's no, you know, except in rare instances where you might have to certify someone, you wouldn't say that. But, you know, the vast majority of people eating disorders, you're not going to certify in forced treatment.
So just letting them know that this is just an assessment, we're just going to get some history to start off with. And maybe at the end, if you can try to try to develop some discrepancy between maybe what are some of their future goals, and where they are right now, and are their current behaviours, and their current health status and mental health status, are they consistent with, you know, going to university and getting a job and perhaps getting married or having kids or being able to travel or just being able to be free and go to a party and eat food and, you know, partake with friends and family and just to try to develop some discrepancies between where they would like to be in five years from now and where they are currently. “You know, sometimes you get people to do certain exercises like writing a letter to their eating disorder or looking at the pros and cons of their eating disorder or, you know, if their eating disorder is working so well for them, would they recommend it to their friend or to their family member or their daughter or if they had an imaginary person with it, if it's working so well for them, is this something they would recommend to everyone?
Usually the answer would be no, because they often tend to be unhappy and quite miserable and often quite hate themselves deep down. And so they would see, you know, they often tell patients and family members often what we see as being the problem, you know, we see the extreme dieting behaviors and binge purging behaviors and other extreme behaviors being the problem. The patient who suffers from anorexia may actually see those as being the solution to the problem, right?
So it can be a difficult task to try to bring someone into the light and hopefully change some of these behaviors to become healthier and more moderate and less extreme. But it is a difficult task, just again, similar in some ways to someone with alcoholism or substance abuse, who may not see that they have a problem and, you know, get off my case. I don't need the help.
It can be a difficult job sometimes to help them get treatment and work towards change. Sometimes it takes people kind of falling on their face and unfortunately having complications or hitting kind of rock bottom sometimes for them to access the help or the care that they need.
Thanks Dr. Staab. So it really sounds like in cases where, you know, you might not need to certify a patient necessarily reinforcing autonomy and also trying to align some of the patient's goals with the health care provider's goals can sometimes be helpful in terms of engaging them.
Yeah, even just to get a history, just to say we're just going to do a history today. You know, if you don't want to have your mom come in at the end of the session, it's up to you if they're an adult, right? We don't have to have your mom come in to the session afterwards.
It's totally confidential. Whether you want to do anything to pursue after this is up to you. You know, we have a lot of different treatment options.
So you know, we have an intensive treatment option. We'll talk about that later. But you know, there's inpatient care, day hospital care, but there's just some minor, sometimes just some really small little, little interventions like going to an education group or, you know, seeing a dietician a couple of times.
There are just some very small little interventions that maybe don't involve a lot of change. It just involves education or developing some insight.
That's really helpful, Dr. Staab. Yeah, thank you. Thank you for walking us through it.
Can we maybe delve into a bit how eating disorders actually develop?
Sure. So there's no like one single pathway to developing an eating disorder, right? There's a lot of different, we consider it to be multifactorial, right?
So there's, you know, there's biological factors, there's psychological factors, there's, you know, family factors and cultural factors. We see, you know, predisposing factors, precipitating factors, perpetuating factors. So we see people who often present with a lot of similar constellation of symptoms, but they all come from different, you know, cultural backgrounds, socioeconomic backgrounds.
They have had different life histories and different friends and, you know, lots of different experiences often, which again, shape how the disorders come to fruition, so to speak. So I guess we'll start off maybe sort of biologically. The more time I spend in eating disorders, the more sort of like biological genetic factors, how important they become.
So, you know, if I would have been giving this podcast, let's say, you know, 25, 30 years ago, we probably would have thought more that psychological and socio-cultural factors would have been the most important determinant. But now in 2021, there's a consensus more that really, you know, genetics and biology and neurotransmitters play the most important role, we would say. So people with eating disorders, there's people with anorexia nervosa, I guess we'll start with.
There's definitely an increased incidence of anorexia nervosa in families where you see higher rates of depression, eating disorders, anxiety disorders, obsessive compulsive disorder and obsessive compulsive personality disorders or styles within the family. You know, there's a very high concordance rate of anorexia nervosa in monozygotic twins. It's about 50% concordance, which is way higher than you would expect in the general population, right?
In the general population anorexia, thank goodness is still quite rare, right? It's talking maybe 0.5 or 1% of young girls have anorexia nervosa. Whereas if you have an identical twin with anorexia nervosa, your chance of getting it would be about 50%.
So about 100 times higher for someone with exactly the same genetics. But the thing is, it's not 100% concordance. So there are certain, you know, protective factors that could help a person not develop anorexia nervosa, even if they may have the genetic setup that they would be genetically loaded for, is what I'm trying to say.
In terms of bleeding of also again, again, more and more studies are proving that genetic factors are really important for bleeding of also as well. There's definitely a higher rates of bleeding of also in families that have also eating disorders, depression, mood disorders, substance abuse and obesity tends to be tends to run more in the families with bleeding of also. And you know, there's more and more genetic studies coming out.
There's a really big one being done by the Price Foundation. It's a multi-centre site trial. I think they have over like 14,000 samples or something now.
And they've located a numerous different sort of genetic loci that are of importance, right? So it's not a simplistic thing where, you know, you know, your grandmother has anorexia nervosa, and then your mother has anorexia nervosa. And then the daughter has anorexia nervosa, right?
It's not a sort of simplistic thing like that. There may be, let's say, hypothetically, you know, 10 or 15 different genetic markers that increase the risk for anorexia nervosa. And then, you know, the roll of the dice, you know, the person develops like, you know, 10 of them, they may be at higher risk of let's say depression, they may be at higher risk of anxiety and perfectionism and low self-esteem and obsessive compulsive features and, and then poor body image and that sort of sets them up, including other life experiences that kind of, you know, shape them into to go down that road.
That's really interesting. It's sort of it sounds like it's sort of the traits that that lead a patient to go down that path a little bit more easily.
Exactly. Yeah, for sure. You know, there are some brain differences between people with anorexia nervosa and blemium nervosa and sort of, you know, regular controls.
There's some interesting work being done looking at the insula and the limbic system. So things that are, you know, I'm not an expert in these things, but there's more and more studies being shown that they're definitely this is a brain disorder, right? This isn't just sort of, you know, a fad that has gone too far or something like that, right?
There are definitely sort of strong biologically genetically determined underpinnings to both anorexia nervosa, bleeding nervosa and other eating disorders.
Yeah, we'll talk more about kind of like medical sequelae, but also, you know, there are definitely brain changes that are reflective of malnutrition.
For sure. Yep. So about 50% of people with anorexia nervosa actually have a brain shrinkage, right?
And their brains, you know, they have enlarged ventricles and enlarged sulci from emaciation and malnutrition. About half of them will then, you know, half of those then will, when they, with recovery, will normalize again. But about a quarter of them end up staying kind of shrunken down, which is a bit disturbing.
And we're not sure of the long term sequelae of that. But yeah, I know at SickKids, they were doing CT scans and MRIs of everyone that was going through for a while. We don't routinely do that here at Credit Valley or an adult program.
Because if we tell people, oh, your brain is shrunken down, they're like, okay, well, what do I do about that? Well, the treatment is to eat the food and to get healthy and get back to a normal weight. So it's not something that we would do routinely.
But I know that there are research studies that have shown that there are definitely malnourished brain changes that happen with anorexia nervosa, which is kind of scary.
But I guess, yeah, that's also part of psychoeducation with the patient, which is a way to get them to engage with education.
Yes, exactly. Because often they tend to be very determined and perfectionistic and have high standards. So realizing when something starts to impair your school, and my brain is shrinking down and my myelin is getting damaged, sometimes that can be a motivator to actually get help and get better.
Yeah, for sure. So maybe this is a good point to sort of switch gears and then talk about kind of like, I guess, the psychological more of the, I was going to say nature, but I mean, nurture sort of factors that the development of an eating disorder.
Sure. So I mean, there's a lot of psychological factors that can increase a person's risk of developing eating disorders. So having low self-esteem is definitely a risk factor.
Often people with eating disorders have low self-esteem and low feelings of control and a perceived lack of autonomy. Often they have issues with sexuality, a lot of depressive and anxiety symptoms often that come up in their teenage years. Sometimes in the family, we see certain sort of characteristics sometimes in patients with eating disorders.
So often in the families, there may be sort of like a lack of feeling of safety or a lack of acceptance or validation. They may feel that there's sort of a lack of conflict resolution in families or sort of low expression of emotion in families with anorexia nervosa. Sometimes there can be kind of enmeshment that you might see, particularly, I guess, in adolescent kids with eating disorders.
Sometimes you see sort of poor boundaries between parents and child and often sometimes families that can be kind of rigid and very black and white, that can reinforce that sort of black and white all or nothing thinking that you might see with both anorexia and bulimia. Sometimes in families you see sort of an over concern with weight and shape within the family that the mother is always dieting or there's pressure to lose weight all the time. Again, perfectionism within the family is quite common and there is a higher rate of early childhood sexual abuse in anorexia nervosa and bulimia nervosa as compared to the general population, right?
So a woman or a child who's been, you know, damaged or who's been sexually violated may turn to an eating disorder as a way of protecting herself or may have a way of appearing less feminine or less sexually attractive. You know, dieting or bingeing and purging may be a way of numbing painful emotions or PTSD symptoms or flashbacks or it may be a way to kind of control the body, purify the body or kind of punish her her body.
Yeah, for sure. I see a lot of this comorbidity on the women's inpatient unit. I work with women with trauma and there's lots of comorbidity with eating disorders and that's exactly it.
Like, you know, starvation almost allows them to kind of dissociate, right? And so they're not able to recall their trauma or cognitively participate in therapy, which is really disturbing for them because it evokes a lot of these memories.
Yes. I mean, unfortunately, fortunately or unfortunately, eating disorders do serve a lot of functions for people, right? And so, you know, with people with PTSD or trauma histories, it does, it can help to regulate emotions.
It's almost a way of like self-harming. It can calm people down. It can decrease nightmares and flashbacks and dissociations.
And then when people are in the refeeding process, unfortunately, some of the, you know, some of the nightmares, flashbacks and memories that have been numbed out or suppressed can start to come back. And that can be quite an unpleasant experience for a lot of people going through recovery. So again, that's like, that's one of the hard jobs of recovery is working on other coping skills to deal with the trauma, the abuse, the emotions without using your eating disorder as a crutch to get through.
Yeah, exactly. I feel like, you know, giving them a set of new skills and helping them practice them allows them to replace these maladaptive coping strategies with healthier ones.
Yeah, for sure. That's so important on the road to recovery.
And I guess, yeah, so we talked kind of about cultural factors and then also, you know, definitely some occupations, right? And, and activities like cheerleading or gymnastics, you know, elite athletics that can also sort of perpetuate a risk of developing an eating disorder.
Yep, yep. So definitely there is something in, you know, sort of, you know, our first world sort of westernized culture that increases the rate of eating disorder. So there are higher rates of eating disorders, you know, in Canada, United States, in Europe, than maybe in some less developed countries in Africa or some other places in the world.
And so I guess it often relates to the rate of dieting. So, you know, not necessarily, you know, I guess the more people that diet, the more people that will eventually take it to an extreme and will develop eating disorder, right? If we lived in a culture where nobody dieted, right, and it was kind of frowned upon, there would be much less rates of eating disorders, right?
Because there wouldn't be this cohort of people that again, then take it to an unhealthy level and become obsessed with it. So people that move, let's say from a lower developed developing country from Africa or from certain parts of Asia or South America to a developing a developed country, their rates of eating disorders increase then to the country that they migrate to. And then definitely, there are certain professions, you know, acting or gymnastics, ballet, you know, jockeys and men, anything where there's a strong emphasis on weight and shape and being thin to maintain your job or your career, where there's a lot of pressure, then obviously it's going to increase the rates of eating disorders.
And it also makes me think about like onset of an eating disorder. It's typically in young like an adolescence.
It does you typically so anorexia. Typically the onset is between about 12 and 20 years old during the adolescent teenage years. But like I said before, it's 10 times more common in women than in men.
We're bleeding of all sets, usually more in the later teenage years and early 20s. And again, much more common in women than as men as well.
And what are your thoughts Dr. Staab on kind of this correlation with adolescence? Is it because of puberty? Is it about self-identity during like, why is this sort of a vulnerable time to develop an eating disorder?
I mean, we don't know for sure, but it is it is a time of a lot of transitions, right? So, it's a time where autonomy, where, you know, autonomy and control goes more from the parents to the teenagers, the teenagers are making more decisions around their clothes or their hairstyle or their friends or their hobbies or whatever. And that can be a difficult negotiating, you know, time to negotiate for kids.
You know, there's hormonal changes happening at that time. There are increased rates of depression and anxiety and substance abuse around the same time as well. So any type of big change, again, for someone who's maybe very kind of rigid, controlling, you know, maybe can come across as being a bit willful.
Sometimes it can be hard to go through a big massive change, right? So one big massive change is going through puberty and adolescence. And then another time with another big spike with eating disorders is when people finish high school and then decide to move away from home or go to college, university.
That's also another time when we see a spike in eating disorders, probably related to all the changes that happen, people then being more independent with their eating and having less supervision. So I don't think we know for sure 100% why, but I think those are some theories about why it tends to occur predominantly during the teenage years. It's not always then, I have to say, though.
We do see people that develop eating disorders in their 20s and 30s. So it's not absolutely in the teenage years, but that tends to be the highest risk time. I think one thing I'll just say as well is, so we talked about a lot of predisposing factors.
So in terms of precipitating factors, any type of change or stress or loss, can often see that triggers the on-seminary disorder. That could be sometimes a really big stressor, could be sexual abuse or rape or something like that or molestation, or it can be a lot of stresses that just pile up, like maybe not doing as well in school on an exam, or being shunned by some friends, or some teasing or bullying, or a move or a divorce in the family, or other stressors that pile up that lead the person to feel out of control, or that they may try to latch on to something to try to desperately feel more in control, and try to feel like they're to boost their self-esteem. Unfortunately, it's not a good long-term solution, of course.
I think the thing that's important to remember as well is eating disorders do occur in all cultures, in all countries, in all socioeconomic status levels, and all professions, right? Because sometimes there's a bit of a stereotype that, you know, anorexia only occurs in white, wealthy, you know, perfectionistic upper class people or something, which is not true, right? So we see anorexia and bulimia in all different ethnicities and cultures and sexualities and socioeconomic status in all different countries, right?
“So even in countries in Africa or the Middle East or Asia where thinness is not viewed as an ideal, where it's actually considered to be kind of maybe unattractive or kind of ugly, that eating disorder still exists, right? Even in, you know, places where, you know, Bedouin tribes in the Middle East, where people have never seen one television show or one Hollywood movie, they've never seen one Vogue magazine or any, they've had no exposure to Western culture one bit, they're living, you know, in a tribe somewhere, their eating disorders still happen, anorexia and bulimia. So it's not, there definitely are, you know, biological factors that happen outside, completely outside of other socio-cultural factors.
That's really interesting, Dr. Staab. And, you know, I think that's great for us to kind of keep in mind. So, you know, that when we're approaching a patient, you know, irregardless of how they're presenting, like, you know, we should ask about eating disorders and we shouldn't discount someone just based on, you know, how they appear.
For sure, definitely. Yeah. And the majority of people with eating disorders are normal weight, right?
So I think that's important to also remember that, you know, people with anorexia nervosa are obviously underweight, but the majority of people with eating disorders in the world, right, which would be, you know, bleeding nervosa, binge eating disorder, and other specifying disorders, most of them are either, you know, normal weight or above average weight. So the majority of people are not underweight. So that's also important to remember.
Yeah, and I'll say like, I also do just general, you know, outpatient consultations and assessments. And, you know, prior to maybe my elective with you, I probably wouldn't have regularly asked about eating disorders. It's a lot more common than the people might think.
You know, I would say. So always have your antenna up for sure, you know, with like, you know, younger teenage girls are in their 20s. But keep your antenna up all the time for everyone.
But I think even more so in when you see young females who are struggling with, you know, body image or self-esteem, depression, anxiety, et cetera.
OK, so why don't we move on to some of the medical medical and physical complications of eating disorders?
Sure. So, yeah. So eating disorders can affect, you know, every organ system, every part of the body from the top of your head down to the tips of your toes, from the effects of starvation and or bingeing and purging.
So it's important to remember that even when people have normal electrolytes or a normal ECG or normal vital signs, that they still could be suffering quite a lot and be at quite a high medical risk. Because sometimes things can happen suddenly out of the blue and people can still die even with normal, you know, supposedly normal testing. So just, I guess, starting off with the cardiac system.
So, you know, when the body, when the human body is starved or malnourished, it tends to focus calories and energy on the things to keep you alive, right? So other things in the body tend to get a bit neglected. So things like your skin or your hair or your fingernails or teeth or things like that tend to get neglected, where it tries to focus energy on like your heart and your liver and your brain, things like that.
When people are malnourished, the body tries to conserve energy, your metabolism slows down, right? So your heart rate slows down, your blood pressure slows down, which is great to conserve energy. But if it becomes too low, you can start to get symptoms, right?
So you can get low blood pressure, can lead to dizzy spells, fainting spells. People can get like chest pains. If your heart rate becomes too low, it can lead to really deadly arrhythmias, again, fainting spells or dizzy spells or even cardiac arrest.
The effects of purging in combination with being underweight and having a low heart rate can be really deadly. That's actually the number one cause of death in eating disorders, is from cardiac abnormalities. The highest risk of death is actually people who are underweight who are also bingeing and purging as well.
Often people get edema, which can either be due to heart failure or typically, if they're dehydrated for a long period of time from purging, and then they stop purging, let's say if they come into a program, they can have rebound fluid edema because their bodies are hanging on to fluids because they have aldosterone or antidiuretic hormone circulating in their body for a few weeks, or from just generalized protein malnutrition. They can have low hemoglobin, low red blood cells, low white blood cells, low albumin, just low protein in general, can lead to edema because of fluid and electrolyte disturbances. Then moving on to the endocrine system.
Again, most hormones go down when people are malnourished or starving themselves. Eastergene, progesterone, testosterone, right sex hormones go down, which can lead to either irregular menstrual periods or complete cessation of their menstrual periods, which puts them at risk of things like osteoporosis or osteopenia can lead to bone loss. It's kind of like the body's protective mechanism in the body.
So it's kind of the body's way of saying like, you know, this woman is not healthy enough to get pregnant or to carry a pregnancy to full term. So we're going to kind of like shut down the whole thing to preserve energy to not lose blood, which is in short supply, lose protein. So it's kind of the body's protective mechanism to prevent a pregnancy.
Having said that though, we always tell people even if they haven't had their period in a long time and they are sexually active, that they still should use some type of birth control because sometimes accidentally, you know, an egg can just kind of pop out and can get fertilized. So I have seen that a couple of times in my over 20 year career where people have not been menstruating for long periods of time and they're being sexually active and they accidentally get pregnant. And if you do get pregnant in the middle of an eating disorder, it's not a great idea.
So there's definitely, you know, higher rates of pregnancy complications, premature babies, low birth weight babies, lower APGAR scores. There's more C-sections and more stillbirths. So definitely not a great idea to get pregnant in the middle of anorexia nervosa or bulimia nervosa.
We always tell people when they finish our program, when they finish our day program, that if they can, to try to wait at least a year after they finished our day program to repair the damage they've done to their body, hopefully. And also just psychologically to get more settled and feel more comfortable with their body image changes. So people with anorexia nervosa sometimes have to gain 20 or 25 pounds in our program to get to a healthy weight.
And then the average woman when she's pregnant may gain another 25 or 30 pounds, which can be very difficult and unsettling for someone with anorexia. So we usually try and get them to weight a year so their body image kind of feels a bit better. They feel a bit more settled.
They've had some redistribution before they try to get pregnant. When people have recovered from their eating disorder, so they get to a decent weight, they stop symptoms of binging and purging or laxatives and excessive exercise, their fertility does go back to normal. I think that's important for patients to know and doctors, that they haven't permanently damaged their ovaries or their fallopian tubes or something.
That is reversible and their fertility will go back to normal for a woman of their age, right? That's important for people to know.
In terms of the thyroid gland, so often people's thyroids will kind of shut down when people are malnourished or very emaciated and underweighted. It's kind of the body's protective mechanism to lower their metabolism, to lower your thyroid, so that you decrease sort of energy expenditure to kind of conserve energy. And then again, with refeeding and weight gain, often their thyroid levels will just return to normal.
So it's not something that you need to treat with Synthroid or thyroxine or something like that. Again, that would actually increase their metabolism and lead to more weight loss. And it can be a medication that can often be abused by people with eating disorders for weight loss purposes.
So it's definitely not something we want to give to people when they're in the middle of their eating disorder.
And this also just makes me think of patients with type 1 diabetes and like, I guess, omitting their use of insulin, right? As a way of losing weight.
Yeah, that's a big problem. So it's such an easy way to lose weight, right? You can eat whatever you want and then just not take your insulin and spike your sugars really high and not absorb the food or the glucose.
It's very deadly, right? It's a very deadly practice, but we do see this on our clinic quite a bit. Right now in our intensive program, we actually have two patients with type 1 diabetes.
Patients with type 1 diabetes have much higher rates of eating disorders than the general population because it is such a quick and easy way in some ways to lose weight. Again, very deadly, very dangerous, but very difficult for some of these patients to give up.
Interesting. And then I guess something that's been always counterintuitive to me that sometimes in extreme starvation states, like the cholesterol levels could be high.
Yeah, which is quite unusual sometimes, right? So sometimes again, from starvation can put a bit of a strain on your liver and it can actually churn out more cholesterol. So sometimes people are very emaciated, very underweight.
They're not, they wouldn't touch a steak or a fatty food to, if their life depended on it. And they're eating like a lot of fruits and veggies and whatever, but they can have high cholesterol from their liver kind of churning out excessive lipids and cholesterol and fats. So just moving on in terms of different systems.
So muscular skeletal system, again, so muscle wasting again from protein, malnutrition, excessive exercising, and again, bone difficulties. Most of the medical complications that I'm gonna talk about today are reversible, which is the good news. Unfortunately, bone problems like osteopenia and osteoporosis are often not reversible.
So usually for people who are, let's say, above the age of 30, it can be quite difficult to actually improve your bone mineral density. Even if people make a full recovery, they get to a good healthy weight and their periods come back. Sometimes it can be quite difficult to increase your bone mass after the age of 30.
I've seen younger patients, you know, when they're teens and twenties, who've gone from osteopenia, osteoporosis back to normal, right, they get to a healthy weight, their periods come back and then five or six years later, we test their bone density and it's actually normalized, which is amazing, it's a miracle, which you would never see in an older woman postmenopausal. But it can be quite difficult for patients to do that in the 30s and 40s to really improve their bone mass. You can prevent further deterioration, which is a good motivator, but sometimes it can be hard to increase their bone mass.
So yeah, often these patients, the risk factors for osteoporosis are being at a low body weight or being at a low BMI, not having your period for more than six months, having a low dairy intake, having low calcium and vitamin D intake, being Asian is a risk factor. Obviously nothing you can do about that, right? Having a family history puts you at higher risk, having low protein intake.
And then some of the things that you can influence would be like your caffeine intake, right? Caffeine is not good for bone mass or alcohol intake. Alcohol or smoking or steroids as well can be damaging to bone.
So trying to minimize other exposure and other risk factors where possible.
Okay, maybe move on to the gastrointestinal system.
Right, so there can be a lot of GI complications with eating disorders. So in general, people with anorexia have also had very slow gastric emptying. So slow stomach emptying, which can lead to like nausea, bloating, cramping, fullness, burping, gas, you know, so it can feel quite uncomfortable when they're trying to refeed and trying to eat a bit better because they get all these GI symptoms all the time.
So just normalizing eating will eventually normalize that. So just eating proper breakfast, lunch, dinner, snacks, eating properly for a couple of weeks or months will eventually hopefully normalize their delayed stomach emptying. There are some medications that we sometimes prescribe that may help a bit with that, like Domperidone or Metoclopramide can sometimes speed up gastric motility.
Constipation is very common with both anorexia nervosa and bulimia nervosa from not enough food intake, or it can be from laxative abuse, can make the bowels kind of lazy. So that often again normalizes just by proper eating again. Sometimes we give them things like a fiber supplement or coles or a stool softener or laxadate to kind of get them going.
We don't recommend any purgative laxatives in people with eating disorders. So we don't recommend, you know, X lax or Senacot or Correctol or, you know, those typical kind of like life brand generic ones, anything with Sena because they can make the bowels a bit lazy when they're abused. And often these patients take too much of them for the feeling of weight loss, right?
They do not, laxative do not cause real weight loss. They just cause a lot of water and feces and salts, but you're not actually losing real weight, right? So that's important, I think, a distortion often to correct with these clients.
And then again, from chronic purging that you would see either with anorexia or bulimia can lead to damage to your esophagus, it can lead to ulcers, it can lead to erosion of your gums and your teeth, damage to your enamel. If people have chronic vomiting for many, many years, they can actually get a condition at the base of their esophagus called Barrett's esophagus, which is like neoplastic changes to the cells in the base of your esophagus, which can actually lead to cancer, which can obviously lead to death, right? Which is very disturbing.
I've seen a couple of patients who've had that. They were chronic vomiters for 15 years or something like that, and then they developed this other disorder, which was sad. Yeah, and then just chronic malnutrition and bingeing and purging can place a strain on your pancreas, right?
It can lead to pancreatitis, it can lead to hepatitis. And I've seen gallbladder problems again from weight fluctuations and from chronic malnutrition and bingeing and purging, gallstones. That's great.
So I think we already talked a little bit about the neurological system and the impacts in terms of the enlarged ventricles and the myelin sort of wasting, anything else within the neurological system?
So just commonly, people often get headaches quite commonly, low blood sugars again can lead to sort of brain fog or even seizures, numbness and tingling quite commonly, or muscle spasms from electrolyte disturbances, low potassium or low magnesium or low phosphate can lead to that. Yeah, and just again, just poor memory and poor concentration, just feeling like your brain is kind of in a fog because of lack of nutrition, lack of glucose or poor, you know, low blood pressure, low heart rate. And then moving on to the kidneys.
So again, either the extremes can cause kidney damage. So dehydration can lead to kidney problems or over-hydration. Sometimes patients will drink, you know, liters and liters of like, you know, six liters of water a day and two liters of coffee.
And that can lead to damage or diuretics can lead to kidney damage. It can lead damage the kidney's ability to concentrate urine, can lead to kidney stones, and then other sort of dermatological problems. So again, skin can become very dry and flaky, can lose its kind of like elasticity.
People can get kind of color discolorations to their skin, more bruising and bleeding to their skin. They can, you know, their nails become kind of brittle and cracked or their hair becomes dry and get more split ends. Again, just from lack of nutrition, you know, the things like your hair and nails and skin kind of get neglected and don't grow as fast and more of your hair cells go into like a dormant stage.
So they get more damaged. And then those things, again, all of those things kind of reverse with hopefully proper eating, getting to a proper weight and stopping bingeing and purging. Yeah.
And Dr. Staab, thank you so much for going through all that. I think this is all important because I think this is sometimes information we can present to a patient. They are sometimes fully aware of the impacts of longitudinal impacts of their eating disorder and how it's actually affecting their health and their body.
Yes. And sometimes this can be the motivating factor to get them in the door for treatment, right? So you know, they may be sort of, you know, in denial for years.
And then all of a sudden they, you know, slip on some ice and they break their pelvis, right? And they're 30 years old and the doctor tells them they have severe osteoporosis and they can't believe it because they had no idea, right? Or they, you know, are walking down the street and have a seizure because their blood sugar is one, right?
You know, we've seen these things happen and then people hopefully get more motivated and have some more insight to get some help of, you know, before some major catastrophe happens that's not reversible, right? So hopefully.
And I guess just very quickly going back to my law, my previous question that I kind of banked for this would be just, you know, what would be typical blood work that you would do when you have a patient that you're suspicious of having, you know, an eating disorder?
Sure. So we do a pretty broad, a broad array of blood work here at Credit Valley. So we do a CBC quite typically, right?
Extracting sugar or random sugar, you know, electrolytes, CK, we often measure to kind of look at their muscle breakdown of people are exercising like maniacs. Sometimes that's really elevated liver enzymes we commonly do. We often check their iron, their calcium, magnesium, phosphate.
They can be low or they can also be influenced by refeeding syndrome. We often check their amylase. Those would be, I think, the main things that kind of stand out that we check here, B12.
Extracting sugar or random sugar, you know, electrolytes, CK, we often measure to kind of look at their muscle breakdown of people are exercising like maniacs. Sometimes that's really elevated liver enzymes we commonly do. We often check their iron, their calcium, magnesium, phosphate.
They can be low or they can also be influenced by refeeding syndrome. We often check their amylase. Those would be, I think, the main things that kind of stand out that we check here, B12.
And I guess thymine.
Thymine, yeah. And again, we often test thyroid levels as well. If their thyroid comes back low, we don't jump the gun and recommend treatment.
Again, if we have to like you treat people, you treat the individual, you don't treat their blood tests, right? So you don't just treat low, you know, an elevated TSH or something. You have to you have to treat the individual.
And just quickly for audience members that aren't aware about of of refeeding syndrome, you know, quickly from my understanding, it's you know, when a patient's been starved for a long period of time, and they suddenly have a surge of sort of caloric intake, the body produces a lot of ATP, and it could use up a lot of phosphate, and that could cause a plummet in phosphate, which could lead to, you know, rhabdomyolysis, coma, seizure.
Yes, yes, it's a very, it's a rare but very, it's a life threatening constellation of symptoms, syndrome. So just like you, just like you said, Lucy, so when people have been starved for a very, very long period of time, their bodies stop using sort of glucose as the primary energy source, and they start to use more protein and fat, which is not supposed to be the case, right through ketogenesis. And then if they come into a program or they go somewhere and they start eating better, their bodies have more glucose, they get this surge of insulin, and their body is trying to repair itself.
So they have a dramatic increase in the need for things like phosphate, magnesium, potassium and calcium, and they get kind of like sucked into intercellularly. And you can get a big drop in phosphate is the primary indicator, but also you can get a big drop in magnesium and potassium as well. So you need to check their electrolytes pretty frequently when they first come in for reheating, especially if they're really emaciated or on the feeding tube, or they could be at high risk of repeating syndrome for the first couple of weeks.
So you want to monitor that pretty closely. It's usually treated quite easily by giving them supplements. In severe cases, you might want to reduce their caloric intake a bit, and maybe even shift some of their calories more to protein and less a little bit with carbohydrates.
But it's usually, as long as it's recognized early, and it can be treated quite well.
This brings us to the end of part one of our Eating Disorders episode. Listeners stay tuned for part two, which will cover eating disorder treatment. PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Dr. Lucy Chen, Dr. Vanessa Aversa and Dr. Nikhita Singhal. The audio editing was done by Drs. Vanessa Aversa and Nikhita Singhal, and the show notes were completed by Dr. Vanessa Aversa. Our theme song is Working Solutions by Olive Musique.
A special thanks to our incredible guest, Dr. Randy Staab, for serving as our expert for this episode. You can contact us at psychedpodcast.gmail.com or visit us at psychedpodcast.org. Thank you so much for listening.