The Positive Effects of Early Treatment Response

Vol. 28 / No. 2 — Eating Disorders Review

For many patients, early response can predict remission.

Early response to treatment for an eating disorder is often linked to a positive outcome, and to remission. Changes in behavior in the first weeks of treatment, such as a reduction in binge- eating and purging behaviors, or early weight gain in anorexic patients, can predict remission after a variety of treatments, regardless of the type or duration (Appetite. 2009. 52:805). This factor also enables clinicians to personalize treatment to improve outcome.

A group from King’s College, the University of Palermo, Italy, and the Federal University of Rio de Janeiro, Brazil, conducted a systematic review and meta-analysis of the literature to see how predictive early response actually is for patients with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) or eating disorders not otherwise specified (Eur Eat Disord Rev. 2017. 25:67).

Early responses were keyed to the disorder

One of the initial findings reported by Dr. Bruno Palazzo Nazar and his colleagues was how the definition of “early response” varied according to the individual eating disorder. For patients with AN, the main outcome was attaining 95% of ideal body weight (IBW). In contrast, for patients with BN, it was a percentage reduction in binge eating and/or purging over a variable time period. For AN patients, early weight gains by outpatient adolescents with AN were predictive of remission in studies that used family-based therapy (Psychothotherapy, Chicago IL. 2016. 53:251) and cognitive behavioral therapy. This pattern was the same for inpatient AN treatment, where early weight gains at different time points during the first 6 weeks of therapy could predict remission (Psychother Res. 2007. 17:218; J Eat Disord Assoc. 2016. 10:1002/erv.2443). In contrast, for BN patients, the predictive pattern was far weaker, and early response was only moderately linked to better outcome. In BED studies, early response had only a fair capacity to predict good outcome.

Clinical implications of the findings

The study results indicated that failure to respond to outpatient psychological treatment during the early phase of treatment is linked to persistent symptoms in patients with AN at one year. The authors also reported there is a 77% chance that a patient who responds early will have a remission of symptoms at the end of treatment.

Among patients with BED, early response to treatment showed a high specificity and low sensitivity in predicting remission—there was an approximately 30% increase in the chances of remission in a patient with BED with an early response, and these individuals were 5 times more likely to achieve remission than were patients with slower responses (Clin Psychol Rev. 2012. 32:292).

In contrast to the positive effects of early response among patients with AN and BED, early response among BN patients did not strongly predict remission. In fact, an early response to treatment by patients with BN increased their chances of remission only by 15%.

These results should spur interest in identifying modifications to existing treatments to increase the likelihood of early response.

An Option for Those with Severe Anorexia Nervosa: Deep Brain Stimulation

Vol. 28 / No. 2 — Eating Disorders Review

After 1 year, AN patients had weight gains and improved mood.

Deep brain stimulation, or DBS, has been helpful for a number of neurological disorders, including Parkinson’s disease, and has been studied for the treatment of refractory psychiatric disorders, including major depression and obsessive-compulsive disease (OCD). Similar to a cardiac pacemaker, DBS uses implanted electrodes to send low-level electrical currents to specific structures deep within the brain. Implantation of the electrodes into the brain requires precise surgery and careful brain mapping for each individual.

Nir Lipsman, MD, and a team at the University of Toronto recently reported that DBS of the subcallosal cingulate, deep in the brain’s white matter, can significantly improve anxiety and depression, along with affective regulation, and can help increase body weight for patients with extreme treatment-resistant AN. This is the largest study thus far of DBS used for patients with long-term treatment-resistant AN (Lancet Psychiatry 2017; Feb 23, published online before print). All the 16 women in the pilot study were markedly underweight at the beginning of the study and had AN for a mean of 18 years. Most (88%) of the women also had comorbid mood and anxiety disorders.

Analyzing the effects one year after surgery

The Canadian researchers reported that DBS can affect the brain circuitry that might maintain anorexia, making the disorder so resistant to treatment. In their pilot trial of 16 women with severe, highly treatment-refractive and chronic AN (mean age: 34 years), one year after the surgery, DBS of the subcallosal cingulate was found to be safe. The procedure also improved mood and, over time, BMI as well. The implants provided continuous stimulation of the subcallosal cingulate for 12 months.

Even though most of the women tolerated the procedure and implants well, nearly half had adverse effects. Two women asked that the devices be removed or deactivated. The most common adverse effect was pain related to the surgical implantation itself or to positioning of the electrodes. Seven, or 44%, of the subjects had serious adverse effects, including electrolyte disturbances, but most appear to have been related to AN itself (all patients had severe and unrelenting symptoms). One woman had an unexplained seizure several months after her electrodes were implanted.  Importantly, the overall tolerability of the procedure seemed similar to what has been previously observed in depression and OCD, despite the precarious physical state of people with severe AN.

Eleven of the 14 women who completed the study had an increase of at least 1 BMI unit after 12 months of DBS, and the average BMI after 12 months was 17.34 kg/m2, vs 13.83 kg/m2 at the beginning of the study. DBS also improved depression and anxiety and emotional dysfunction scores. The mean Hamilton Depression Rating Scale score was 8.79 at the end of the 12 months, vs 19.4 at baseline. The mean Beck Anxiety Inventory score was 38.0, compared to 27.14 at baseline, and mean dysfunction in emotional regulation score was 131.8 vs 104.4 at baseline.

At the end of the 12 months, positron emission tomographic images showed significant changes in cerebral glucose metabolism in key brain structures, suggesting that DBS can directly affect AN-related brain circuitry. The authors noted that a longer-term study will help determine how long the positive effects of DBS last in AN patients with such severe disease.

Challenges for Autistic Individuals Who Also Binge-Eat

Vol. 28 / No. 2 — Eating Disorders Review

Even though binge eating is widespread among those with autism spectrum disease (ASD), current diagnostic criteria make it nearly impossible to assess binge eating among autistic patients, according to Janice Goldschmidt, MS, RD, LDN, Director of Nutrition Services at Community Support Services, Gaithersburg, MD. Goldschmidt discussed her current research and findings on binge eating and ASD during a poster session at the 2017 iaedp Symposium in Las Vegas. She also noted that although cognitive behavioral therapy (CBT) has strong support in the treatment of BED, it may not be effective for many ASD patients. And, DSM-5 criteria stipulate that if an ED co-occurs with ASD or another mental disorder, then the condition is secondary and a stand-alone diagnosis isn’t warranted. Goldschmidt also noted that the current practice of denying a stand-alone diagnosis of BED or any eating disorder for those with ASD and other mental disorders needs to be addressed. Without a stand-alone diagnosis, binge eating on the autism spectrum is much less likely to draw the interest of ED specialists.

Obesity Stigma

by Jenny Ellison, Ph.D.

Obesity has been considered problematic for a long time. Medical, philosophical, and religious scholars, in texts dating back over two thousand years, suggest that fatness is a sign of physical or moral imbalance. Over time body fat has retained this negative cultural baggage. While the problems understood to result from having a larger body have shifted from religious, to moral, to health concerns, what remains is a deeply ingrained cultural belief that being fat is bad. Research shows that in the historical and contemporary context, obesity represents danger, an excess of desire, lack of control, laziness, and ignorance of nutrition (Farrell 2011). Health practitioners need to understand the depth of historical and contemporary bias against fat people. People experience their health, fat or thin, not with discreet dividing lines between medical and social settings, but immersed in a culture that is fascinated with controlling body weight.

What is obesity stigma?

Obesity stigma is the idea that a person’s weight is a reflection of their character (Farrell 2011). It can be experienced individually, through negative comments about weight, unsolicited advice about dieting, and assumptions about a person’s physical fitness or food consumption. But obesity stigma is also a social problem. Obesity stigma shapes not only how people think and talk about weight, but also how larger people are treated. Studies indicate that obese people face discrimination in employment (Kirkland 2003; Rothblum 1992; Solovay 2000). In the United States, people have been denied health insurance based on weight alone (Kirkland 2008; Wann 2009). In Canada, obesity stigma has resulted in discrimination in the healthcare system (Ellison, McPhail, Mitchinson 2016). The “obesity epidemic” identified in the 1990s may have increased instances of stigma in Canada and the United States. Some evidence suggests an uptick in eating disorders among children in the wake of the anti-obesity public health messaging of the 2000s (CTV News 2013). Messaging aimed at eliciting shame from fat people has been described as a “pedagogy of disgust” by Deborah Lupton, because of their stigmatizing representations of larger bodies (2013).

Obesity stigma is experienced by people who are fat, but it impacts all people (Wooley 1970). Negative attitudes toward obesity targets women, racialized people, the working class, rural people, and children in different ways (Beauboeuf-Lafontant 2003; Ellison, McPhail and Mitchinson 2016). Obesity sigma overlaps with racial discrimination, class privilege, sexism, and ableism (Farrell 2011). Starting in the 1800s, American popular culture began to reflect the idea that there is a connection between civilization and slenderness. At sights like the Chicago World’s Fair, exhibits and newspapers suggest that “primitive people” have a preference for large bodies, whereas civilized people control their appetites (Farrell 2011). These ideas, embedded in western culture, shape contemporary approaches to obesity reduction and food systems (McPhail 2016). For example, health research about Canadian Indigenous peoples has repeated the false idea that they are genetically predisposed to storing body fat (Poudrier 2016). Assumptions about class, ethnicity, and knowledge of nutrition also spill over into the way health professionals treat patients, and students are treated by teachers (Rothblum 1992; Petherick 2016).

Responding to Obesity Stigma

People have reacted to obesity stigma in different ways, often informally. This includes internalizing negative messaging, dieting, feeling angry, and lashing out at family or peers (Joannise 1999). Since the 1960s fat activist groups have formed in response to negative social messaging about obesity. Fat activism was not just about obesity stigma but about transforming the way that weight is understood in western societies. Fat activism has taken on many different forms – some of it looks like other types of advocacy for civil and human “rights” of the 1960s. More commonly, however, activists see fatness in terms of social and cultural “rights”: the right to participate, the right to social inclusion, and the right to clothing that fits (Ellison 2016). Thousands of people have participated in fat activist groups, online communities, and social events. While the majority of obese people are not fat activists, the movement offers insight into how it feels to be fat, and how fat people themselves would like to deal with stigma. Activists ask that health professionals:

• Foster a culture of empathy and not shame. Don’t talk about weight if it isn’t the presenting issue.

• Promote exercise for physical fitness and happiness, not weight loss.

• See food as nourishment and not “good/bad.”

Fat activism shows us the potential for carving out safe spaces for people that acknowledge their specific physical and gendered needs (Ellison 2013).

Experts increasingly recognize that stigma itself can cause health problems. In Canada, the Canadian Obesity Network, dedicated to reducing obesity, has also recognized stigma is a major barrier to health promotion. Health at Every Size researchers suggest promoting exercise, a balanced diet, and intuitive eating has better health outcomes than anti-obesity messaging (Farrell 2011). Focusing on environmental changes, rather than targeting particular populations, is also an important facet of health promotion (Abel, Leslie and Yancey 2000). Shifting the way people think about weight is not easy. It can begin by recognizing that obesity stigma is a social problem, rooted in culture, and not in a person’s character.

Ramadan: The Battle of Fasting for God or Eating Disorders?

By Malak Saddy, RDN, LD

As an apprehensive and self-conscious youth, Ramadan posed a bit of an inconvenience for me as I tried to manage my daily life, as well as a platform to advertise my variance to the community in which I lived. I knew I was different and unique, my name, Malak, stuck out like a wrong note in a serenade of Lisas and Megans. My frizzy, curly, unruly, brown hair and garlicky packed lunch of hummus and pita all screamed I was different.  Add to that, once a year for a month, I would go sit and hide myself in the school library during lunch, patiently waiting for the bell to ring to join my friends again. I would sit quietly away from the cafeteria aromas and constant questions of why I wasn’t eating. It was a part of my life that I practiced and celebrated with all my being. As I grew older and continued practicing Ramadan I became more confident and vulnerable. I didn’t shield myself in the school library. I began to embrace the holy month and with that I was bombarded with questions and statements of, “How much weight do you lose?” “You can’t have water?!” “That’s a great diet, I bet you get so skinny at the end of the month.” I would cringe at these comments and respond that Ramadan wasn’t about weight loss or dieting, it was about being grateful for all the blessings that one has in life like health, food, water, and shelter, as well as friends and family that cared for you.

That special time for Muslims around the world is soon approaching. For those who have an eating disorder, Ramadan can pose a whole set of difficulties and internal battles such as fasting for my eating disorder or for God? It is during this month that so many eating disorders go under the radar.

Since the Muslim calendar is lunar, the times and dates of Ramadan change and this year it begins at the end of May. It is a month of fasting and spirituality, for all able bodied, and sound minded Muslims. According to tradition, it is the month of mercy and forgiveness. During this holy month, Muslims must fast daily from predawn to sunset. Depending on the moons sighting the number of days Muslims fast varies from 29 to 30 days. This time of year, while we are fasting between 18 to 19 hours in various parts of the Northern hemisphere, Muslims in the Southern hemisphere are fulfilling their religious duties during short winter days which last about 10 to11 hours.

Fasting does not only entail abstaining from all food and drink, but also from any bad behaviors and habits, and sexual intimacy during the fast. It is a month of divine and physical cleansing, with extra special prayers and supplications. A time of hiatus from our daily material lives. A month of reflection and contemplation. A practice of willpower, empathy, humanitarian servitude, and patience. A month of training for the body and soul, to seek redemption and to continue the journey of righteousness throughout the year.

The barrier we may face as clinicians when treating a Muslim client is that culturally many refer to “illness” as physical diseases like cancer or diabetes and disregard eating disorders, depression, and anxiety. These beliefs encourage the feelings of continued shame, guilt, and comparison. These are some of the hurdles that our clients must overcome empowering them into recovery.

As a clinician when the subject of not fasting has been discussed, I have been met with both acceptance and rejection by both clients and families. There are multiple aspects and guidelines that you can reflect to those who come into your practice debating that necessity. When counseling clients, I have found the following to be helpful in reflecting back to them:

1. Contacting a local mosque and involve an Imam who is well versed in mental health and social issues and who can explain to the client that fasting is only for those healthy individuals.
2. He/she can participate in the of holy month without fasting, but rather through other acts of worship as well. Perhaps they can connect with their faith and God through abstaining from using social media, serving the community, restraining from anger, doing good deeds, or preforming charities to those in need.
3. In the Quran, the Book of Islam, God (Allah in Arabic) revealed, “Fast the prescribed number of days; except if any of you is ill or on a journey, let him fast a similar number of days later. For those who cannot endure it for medical reasons, there is a ransom: the feeding of the one poor person for each missed day” [chapter 2 verse 183].
4. It also states in the Quran that one can pay Fidyah, in which a donation of food or money is used to help those in need. When one is not able to fast, paying this compensation still deems one practicing Islam and participating in Ramadan.

In my years of practice, I have learned in general that when approaching the topic of religion and culture with a client, to always treat this with sensitivity, respect, and compassion, for culture and religion are integral parts of the human frame work. Begin to have the conversation with your client before Ramadan starts and gain a better understanding of what the holiday means to them. By approaching the topic with knowledge and alternatives it can lead to a more supportive and recovery minded discussion.

Malak, in her own words, has offered, “should anyone have a Muslim client and would like to speak to me further to contact me via email. I would love to help out in anyway that I can.” Malak can be reached by emailing malak.saddy@centerfordiscovery.com

Making Your Body an Ally in the Treatment and Recovery of Binge Eating Disorder

By Kari Anderson, DBH, LCMHC, CEDS with Shiri Macri, MA, LCMHC

Like other eating disorders, body shame is at the root of binge eating disorder. This shame can spring from many places: an internalization of society’s “thin ideal,” trauma, or simply from a long history of dieting. But unlike the restricting or purging involved in other eating disorders, the act of bingeing is an egodystonic behavior, meaning it leads one away from his or her value of thinness. That only compounds the shame. Add to that the trauma of living in a plus size body in our culture and many come to feel that they are unworthy—and, worse, that it’s their own fault.

Being present in a body that harbors so much shame is intolerable. As a protective measure, many sufferers binge eat to disconnect from painful thoughts and feelings. The mind of someone with binge eating disorder includes a borage of judgment and shame—judgment about the food, the body, the person themselves. People can get so caught up in these narratives that escape through binge eating seems to be the only possibility. But shame and self-loathing peak in the aftermath of a binge, further perpetuating the cycle. As a counter measure, many with binge eating try and restrict, but in an attempt to regulate the arousal system, the body “takes over” and this eating behavior becomes compulsive and reactive, leaving people feeling out of control.

Reconnection to the body is part of the healing process, which is why mindfulness—bringing awareness to the present moment without judgment—is an ideal intervention for binge eating disorder. Our western diet culture teaches us not to trust our decision making around food and to hate our bodies, forcing us to turn to outside “experts” for the answers. A mindful practice helps to reverse this, allowing us to notice what truly feels good—instead of a focusing on being good or looking good. In the practice of mindful meditation, we gain the ability to simply observe our thoughts and feelings. That, in turn, empowers us to take charge of our responses and disengage from automatic reactivity.

Third-wave cognitive behavioral interventions that are infused with mindfulness, such as dialectical behavior therapy, help shift someone from dichotomous, all-or-nothing thinking to a more flexible perspective, and encourage a more self-compassionate inner dialogue.

Mindful movement also plays an important role for those recovering from binge eating, helping them to gently and gradually reconnect with their physical bodies. In a preliminary study, Dr. Shane McIver, at Deakin University in Melbourne, Australia found a 12-week yoga program decreased binge eating and improved other health measures. Numerous studies by D. Vancampfort have found that combining physical activity and cognitive behavioral therapy improves outcomes for those with mental disorders including those with binge eating disorder. Body-based interventions can be very effective in healing underlying trauma, extensive work by Dr. Bessel Van Der Kolk has found. When the arousal system is overactivated as a result of trauma, the body enters a fight-flight mode and a person can become hypervigilant to “threats,” real or imagined. Body-based treatments such as yoga allow a person to literally move through the hyper-aroused state and into healing.

Intentional focus on merging the mind and body, healing one’s relationship with body through acceptance and forgiveness techniques, and ongoing self-care can help shift someone suffering from binge eating disorder from body shame to a functional focus on his or her body, therefore, neutralizing the shame that has so far kept them locked in the disordered behavior.

About the authors:

Dr. Kari Anderson has been treating eating disorders for 25 years, with particular emphasis on Binge Eating Disorder. She has served in several clinical and administrative roles for inpatient treatment centers, The Rader Institute and Remuda Ranch Programs. She currently is Executive Director for Green Mountain at Fox Run and President of their Women’s Center for Binge and Emotional Eating in Ludlow, Vermont.

She earned her Doctorate in Behavioral Health at Arizona State University in 2012. Kari is faculty for the Eating Disorder Institute at Plymouth State University in New Hampshire. She also serves on the Eating Disorder Specialist Certification Committee for the International Association of Eating Disorder Professionals.

Co-creator of the Am I Hungry?® Mindful Eating for Binge Eating Program, Kari also co-authored the award-winning book, Eat What You Love, Love What You Eat for Binge Eating: A Mindful Eating Program for Healing Your Relationship with Food and Your Body.

Shedding New Light on Eating Disorders at Midlife

Courtesy of Eating Disorders Review

Shedding New Light on Eating Disorders at Midlife

Even the researchers were surprised when their study of 5,655 women in their 40s and 50s revealed that more than 15% of the women met criteria for a lifetime eating disorder. Another surprise: 3.6% of the women reported their eating disorders had been diagnosed only within the past year.  The participants were drawn from the UK Avon Longitudinal Study of Parents and Children, a prospective study of pregnant women who expected to deliver their babies between April 1, 1991, and December 31, 1992.This was the first study of the prevalence, risk factors and healthcare use by middle-aged women with eating disorders. It is also the first study to investigate childhood and personality risk factors for full threshold and sub-threshold eating disorders. Nadia Micali, MD, PhD, and her colleagues at the Eating and Weight Disorders Program at Mt Sinai Hospital, New York City, reported that the number of women who had an eating disorder in the past was slightly higher than anticipated, and some women had first been diagnosed with an eating disorder at midlife. Childhood sexual abuse was prospectively associated with all binge/purge type disorders and an external locus of control was associated with binge eating disorder. Better maternal care was protective for bulimia nervosa. Childhood life events and interpersonal sensitivity were associated with all eating disorders.The study was first published online January 17, 2017, in BMC Medicine, an open-access journal.