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Body Image:
An Introduction to
Ana, Mia and Ed
Meera Beharry, MD
Adolescent Medicine
Department of Pediatrics
McLane Childrens Hospital Baylor Scott & White
Assistant Professor, Texas A & M
Objectives
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Understand common body image concerns
among adolescents
Know diagnostic criteria for eating disorders
Know when and how to refer
Understand the basics of treatment
Adolescence….
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Transition from child to adult
Physical maturation - puberty
Social maturation
Emotional maturation
How do you know what’s
normal?
http://www.teachertube.com/viewVideo.php?video_id=
7119
http://www.beautyredefined.net/photoshopping-altering-images-and-our-minds/
Quick facts
• The average American woman is 5’4” tall
and weighs 140 pounds.
• The average American model is 5’11” tall
and weighs 117 pounds.
• Most fashion models are thinner than 98%
of American women
• 25% of American men and 45% of
American women are on a diet on any
given day
http://www.nationaleatingdisorders.org
Epidemiology
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Anorexia Prevalence is 0.9% in women and
0.3% in men
Bulimia prevalence is 1.5% in women and
0.5% in men
The prevalence of EDNOS is 3.5% in women
and 2% in men
Onset of eating disorders
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Anorexia: mid-adolescent
Bulimia: late adolescence
However, a majority of patients report body
image concerns and disordered eating before
adolescence.
Goldstein, et al. Pediatrics in Review Vol.32 No.12 December 2011
Quick Facts
• Eating disorders have the highest
mortality rate of any mental illness.
• Over one-half of teenage girls and nearly
one third of teenage boys use unhealthy
weight control behaviors:
•
skipping meals, fasting, smoking cigarettes,
vomiting, and taking laxatives
• 42% of 1st-3rd graders want to be thinner
• 81% of 10 year old girls are afraid of
becoming fat
http://www.nationaleatingdisorders.org
Epidemiology: TX, YRBSS
2013 data
• Took diet pills without a doctor’s advice in
past 30 days
TX: 8.8% US: 5.0%
• Vomited or took laxatives to lose weight or
keep from gaining weight
TX: 5.8% US: 4.4%
• Did not eat for 24 or more hours in the
past 30 days to lose weight or keep from
gaining weight
TX: 12.2%
US: 13.0%
Criteria: Anorexia Nervosa
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Restriction
of energybody
intake
relative
toabove
Refusal
to maintain
weight
at or
normal
weight leading
for age and
Failure
requirements,
to a height;
significantly
lowto
make
expected
weight
gainofduring
a period of
body weight
in the
context
age, sex
growth,
leading trajectory
to body weight
less than
85%.
developmental
and physical
health
of expected.
Intense fear of gaining weight or becoming
overweight even though underweight
Disturbance in the way in which one’s body
weight or shape is experienced; undue
influence of body shape and weight on selfevaluation, or denial of the seriousness of
current body weight
Amenorrhea, in post-menarchal females
Anorexia Nervosa: Subtypes
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Restricting: during the current episode of AN
has not engaged in binge-eating or purging
behavior.
Binge-eating/purging type: During the
current episode of AN, the person has
regularly engaged in binge-eating or purging
behavior
Criteria: Bulimia Nervosa
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Recurrent episodes of binge eating
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Eating within a discrete time period an amount of
food that is definitely larger than what most people
would eat during a similar period of time under
similar circumstances
A sense of lack of control over eating during the
episode
Recurrent inappropriate compensatory behavior
to prevent weight gain
Above symptoms, occur on average every at
least once
twice a week for 3 months
Self-evaluation is unduly influenced by body
shape and weight
The disturbance does not occur exclusively
during episode of AN
Bulimia Nervosa: Subtypes
• Purging: patient regularly engages in
self-induced vomiting or use of
laxatives or diuretics
• Non-purging: patient uses other
inappropriate compensatory
behaviors (fasting, hyperexercising)
without regular use of vomiting or
medications to purge
Criteria: Binge Eating Disorder
•
Approved for inclusion in DSM-5 as its own
category of eating disorder.
• Recurring
episodestoofincrease
eating significantly
“This
change is intended
awareness of the
more food in a short period of time than most
substantial
between
binge
eating
peopledifferences
would eat under
similar
circumstances,
disorder
the common
of lack of
withand
episodes
markedphenomenon
by feelings of
control.
overeating.
While overeating is a challenge for many
•
Someone with binge eating disorder may eat too
Americans,
recurrent
binge
eating
less
quickly,
even when
he or
she is is
notmuch
hungry.
• The
have and
feelings
of guilt,
common,
farperson
moremay
severe,
is associated
with
embarrassment, or disgust and may binge eat
significant
physical
andbehavior.
psychological problems.”
alone
to hide the
•
This disorder is associated with marked
distress and occurs, on average, at least once
a week over three months.
http://www.dsm5.org/Documents/Eating%20Disorders%20Fact%20Sheet.pdf
Criteria: Other Specified Feeding
or Eating Disorder
Basically, disordered eating behavior that meets
some but not all of the criteria of the previously
mentioned disorders
• Atypical AN: weight is normal or above normal
• Bulimia nervosa (of low frequency or limited
duration)
• Binge eating disorder (of low frequency or
limited duration)
• Purging disorder: recurrent purging behavior to
influence shape or weight in the absence of
binge eating
Criteria: Unspecified Feeding or
Eating Disorder
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Symptoms of eating disorder are present and
cause clinically significant distress, but do not
meet the full criteria for feeding and eating
disorders.
To be used in situations in which the clinician
chooses NOT to specify the reason that the
criteria are not met and includes presentations
in which there is insufficient information to
make a more specific diagnosis (emergency
room).
Criteria: Body Dysmorphic Disorder
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Preoccupation with one or more perceived
defects or flaws in physical appearance that
are not observable or appear slight to others
At some point during the course of the disorder,
the individual has performed repetitive behaviors
(mirror checking, skin picking, etc.) or mental acts
(comparing appearance to others) in response to
the appearance concerns.
The preoccupation causes significant distress
or impairment in social occupational or other
important areas of functioning.
Preoccupation is not better explained by concerns
with body fat or weight in an individual who meets
diagnostic criteria for an eating disorder
Formerly known as dysmorphophobia
Criteria: FAT (Female Athlete Triad)
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Disordered eating
Osteoporosis
Amenorrhea
Among female athletes 5.9% met 2 of 3 criteria
and 1.2% met all three.
This is not a DSM 5 Dx
Physical Findings
Goldstein, et al. Pediatrics in Review Vol.32 No.12 December 2011
Diagnostic tools
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A great history
Review of growth charts
HEEADSS assessment
And maybe some screening tools….
Eating Disorder Screen in Primary
Care
ESP
• Are you satisfied with your eating patterns?
– A “no” to this question was classified as an abnormal
response
• Do you ever eat in secret?
– A “yes” to this and all other questions was classified as
an abnormal response
• Does your weight affect the way you feel about yourself?
• Have any members of your family suffered with an eating
disorder?
• Do you currently suffer with or have you ever suffered in the
past with an eating disorder?
SCOFF
• Do you make yourself Sick because you feel
uncomfortably full?
• Do you worry you have lost Control over how
much you eat?
• Have you recently lost more than One stone
(14 lb or 7.7 kg) in a three month period?
• Do you believe yourself to be Fat when
others say you are thin?
• Would you say that Food dominates your
life?
Eating Disorder-EAT
http://www.psychsupport.com.au/bundles/gppsui/assets/EAT26Test.pdf
http://www.eat-26.com/
Cases
Case # 1
A mother brings her 13 year old daughter in for
her annual sports physical. She has participated
in gymnastics since she was 3 years old. On
reviewing her growth chart you note that she
continues to follow along the 10% for height, but
has drifted down to below the 3% for weight. She
has not yet achieved menarche. Neither the
patient nor her mother are disturbed by this. They
are somewhat relieved, actually.
Case #1 continued
H: Lives with mother, father and 8 year old sister.
E: Getting straight A’s in everything. Recognizes
she cannot do gymnastics forever and would like
to become a doctor
E: Denies binging or purging behaviors, diet pill or
laxative use.
A: Gymnastics, connecting on the computer. She
doesn’t have time for anything else.
D: No substance use or abuse. Denies steroid
use
S: No history of sexual activity or abuse
S: No suicidal or homicidal ideation reported.
What else would like to ask?
Any tests?
Calculating ABW
• Square of the height in meters multiplied by
the 50th percentile BMI for age and sex.
• Males: ABW = 50 kg + 2.3 kg for each inch
over 5 feet.
Females: ABW = 45.5 kg + 2.3 kg for each
inch over 5 feet.
• Or Males: 106 pounds for 60 inches and 6
pounds for each additional inch
Females: 100 pounds for 60 inches in
height and 5 pounds for each additional
inch
Suggested Labs
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CBC
ESR
UA
Urine pregnancy
Chemistry including serum calcium, magnesium,
phosphorous and LFT’s
TFT’s*
Serum amylase---if vomiting (Lipase)
LH, FSH, estradiol and prolactin
EKG
Consider celiac panel, CPK
DEXA scan, If amenorrheic or suspecting
osteoporosis
MRI or CT for atypical presentations
Case # 2
A mother brings her 15 year old daughter in for
“behavior problems”. She asks to speak with you
before you go in to see the patient. You oblige
and mother tells you that she thinks her daughter
may be a lesbian because she found
questionable material on her computer. She
wants you to find out if she is gay and help treat
her.
HEE(?)ADSS
H: Lives with mother. Father and mother divorced when
patient was 9. She has occasional contact with him.
Mother has recently started dating again.
E: In 10th grade; getting all A’s; wants to be a fashion model
or fashion designer.
E: Would like to lose weight. She is currently 5’6” and 110.
She would like to be under 100 to help start her modeling
career. She skips breakfast because there is no time in the
morning, skips lunch because school food is “gross”; has a
bowl of cereal after school and “whatever mom makes” for
dinner. She denies binging or purging
A: No high risk activities disclosed
D: No substance use or abuse
S: No history of sexual activity. She reports no sexual
attractions.
S: No suicidal or homicidal ideation reported.
What do you think?
Thinspiration
Case # 3
You are seeing a 17 year old patient whose
mother thinks she is pregnant. She has been
hanging out a lot with lots of new people, staying
up late and having weird food cravings. Mother
heard her vomiting the other day. She wants you
to do a pregnancy test, no matter what!
HEEADS
H: Lives at home with her mother and father. Older
brother left for college last year.
E: Doing OK in 11th grade. Not sure what she wants
to be when she grows up
E: Sheepishly admitted to binging and purging when
asked directly at least once a week. She became
tearful at this time.
D: Has tried “everything under the sun at least once”
S: 6 lifetime partners, male and female, inconsistent
condom use. LSIC was one month ago. History of
sexual abuse by paternal uncle in early childhood.
S:History of cutting in 8th grade. No current suicidal or
homicidal ideation, but did think about it in 9th grade.
What do you want to do?
Labs
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Think about it
If mostly vomiting, expect a hypocholoremic
metabolic alkalosis
If mostly using laxatives (inducing diarrhea),
expect acidosis
If mostly using diuretics, may be hypokalemic
If using a combination….who knows?
Often, labs are normal, if they are not, that is a
very concerning sign.
Rushing, et al. Prim Care Companion J Clin Psychiatry. 2003; 5(5): 217–224.
Levels of Care
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Outpatient
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Intensive Outpatient Program
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Day treatment program with focus on mental health
Residential Treatment Facility
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Add group therapy, family therapy, meal support
Partial Hospitalization Program
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Medical, mental health, nutrition
Full-time live-in program with focus on mental
health
Inpatient Hospitalization
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Focus on medical stabilization
When to Hospitalize?
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Bradycardia or orthostatic pulse change
greater than 30 when going from sitting to
standing
Hypothermia < 96F
Altered mental status
Fainting
Electrolyte imbalance
Rapid weight loss
Severe malnutrition
Acute food refusal
Inability to break cycle of disordered eating
Psychiatric emergency: suicidal, psychotic etc.
Refeeding Syndrome
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Potentially fatal shifts in fluids and electrolytes
that may occur in malnourished patients
receiving increased nutrition either enterally or
parenterally.
Result of hormonal and metabolic changes as
patient moves from catabolic to anabolic
metabolism
Hypophosphatemia is the hallmark feature.
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Abnormal sodium and fluid balance
Changes in glucose, protein, and fat metabolism
Thiamine deficiency
Hypokalemia
Hypomagnesaemia
Mehana, et. Al. BMJ. 2008 June 28; 336(7659): 1495–1498.
Flashback!
Refeeding
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• Second level
• Third level
Recovery?
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Among adolescents with Anorexia Nervosa
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50%-70% fully recover
20% improve but have residual symptoms
10-20% develop chronic AN
Among adolescents with Bulimia Nervosa
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With early treatment 50% fully recover in 2 years
20%-50% will have chronic symptoms
AAP: Textbook of Adolescent Health Care
Food for thought
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Anne is 5’6” and weighs 170 lbs at her well
child check. You give her nutritional advice.
When you see her 3 months later for her flu
vaccine, she weighs 140 lbs. You praise her
for her good job getting to a healthy weight.
Ana is 5’6” and weighs 130 lbs at her well child
check. When you see her three months later
for her flu vaccine she weighs 100 lbs. You
refer her to adolescent medicine for an eating
disorder.
Resources:NEDA
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• Second level
• Third level
Resources: AED
Click to edit Master text styles
• Second level
• Third level
Reference: E.D. Medical
Management
Diagnosis, Treatment
and resources
Translating into
different languages
http://www.aedweb.org/
Resources_for_Profes
sionals/3997.htm
Thank you!
Meera Beharry
254-935-4844
254-935-4867 (confidential voicemail)
[email protected]