Integrative Medicine Approaches to Eating DisordersCarolyn Ross, MD, MPHEating Disorder and Integrative Medicine Consultant1855 S. Pearl St.Denver, CO 80210520-440-0079Crossmd@mac.comwww.carolynrossmd.com

ObjectivesParticipants will be able to list two common characteristics between all eating disorder diagnosesParticipants will be able to name one medication studied in the treatment of eating disordersParticipants will be able to understand American Psychiatric Association recommendations for Anorexia or Bulimia*

Eating Disorders7 million females .5-3.7% of females have AN 1.1-4.2 % have BN2-5% - B.E.D.

1 million males with AN

10-25% of those with AN will die as a direct result of the disease

19% of college-aged females are bulimic

35% of US population is obese

Eating DisordersHave one of the highest mortality rates of all psychiatric diagnosesSMR = 11.6 for anorexia; 1.3 for bulimiaSMR for suicide in anorexia = 56.9Severity of alcohol use was associated with increased risk for mortalityHospitalization for an affective disorder was protective from mortalityKeel PK, et al. Arch of Gen Psych. 2/2003;60(2)

DSM-IV Criteria for Anorexia NervosaRefusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight reduction less than 85% of expected or failure to gain weight during growth to less than 85% of expected)Unrealistic fear of gaining weight or becoming fatUnrealistic appraisal of body weight or shape or denial of seriousness of current low body weight.In postmenarcheal females, amenorrhea (i.e. absence of at least 3 consecutive menstrual cycles.)May be binge-purge type of restricting type

DSM-IV Criteria for Bulimia NervosaNote: may be purging type (self-induced vomiting or using laxatives) or nonpurging type (exercise or fasting)Inappropriate behavior to compensate for overeating (e.g. self-induced vomiting, laxatives, diuretics, fastingEating and compensation at least twice a week for 3 monthsSelf-evaluation is unduly influenced by body shape and weightRecurrent episodes of binge eatingEating, in a discrete period of time (e.g. up to two hours) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.A sense of lack of control during the episode

DSM-IV Criteria for B.E.D. or C.E.Recurrent episodes of binge eating. An episode is characterized by: Eating a larger amount of food than normal during a short period of time (within any two hour period) Lack of control over eating during the binge episode (i.e. the feeling that one cannot stop eating).Binge eating episodes are associated with three or more of the following:.Eating until feeling uncomfortably full Eating large amounts of food when not physically hungryEating much more rapidly than normal Eating alone because you are embarrassed by how much you're eatingFeeling disgusted, depressed, or guilty after overeating Marked distress regarding binge eating is present Binge eating occurs, on average, at least 2 days a week for six monthsThe binge eating is not associated with the regular use of inappropriate compensatory behavior (i.e. purging, excessive exercise, etc.) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa

Definitions of Eating DisordersWeight preoccupation and excessive self-evaluation of weight and shape50-64% of anorexics develop bulimic behaviors / bulimics often begin to restrict

Common Co-MorbiditiesMajor Depressive DisorderLifetime risk in Anorexics = 80%Anxiety Disorders, ADHD, OCD, PanicOCD prevalence= 30% in patients with eating disordersPersonality Disorders - 21-97%Cluster B most common with bulimia (dramatic/erratic)Cluster C most common with anorexia (avoidant/anxious)Social PhobiasSubstance Use DisordersPrevalence in anorexia = 12-18%Prevalence in bulimia = 30-70%PTSD

Integrative Approach to ED

Screening for Eating Disorders SCOFF Questions*

Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?Do you worry that you have lost Control over how much you eat?Have you recently lost more than One stone (14 lb [6.4 kg]) in a three-month period?Do you think you are too Fat, even though others say you are too thin?Would you say that Food dominates your life?One point for every yes answer; a score >= 2 indicates a likely case of anorexia nervosa or bulimia nervosa (sensitivity: 100 percent; specificity: 87.5 percent).

Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999; 319:1467.

*12.5% False positive rate*

Screening for Eating Disorders

TABLE 4 Suggested Screening Questions for Anorexia Nervosa and Bulimia Nervosa

How many diets have you been on in the past year?Do you think you should be dieting?Are you dissatisfied with your body size?Does your weight affect the way you think about yourself?A positive response to any of these questions warrants further evaluation.

Information from Anstine D, Grinenko D. Rapid screening for disordered eating in college-aged females in the primary care setting. J Adolesc Health 2000;26:338-42.*

Newer Pieces to the PuzzleSPECT scans in anorexics show decreased cerebral blood flow in multiple areas of the brain associated withEmotional stability, social function, Learning and memory (temporal)Impulsivity and Attentiveness (prefrontal cortex)Worry and Obsessiveness (cingulate system)Scans showed improvement with weight restoration

This is your brain on STRESS: HPA Axis, ED, SUD and TraumaHypothalamus ----------------- Pituitary ------------ Target organ Hormone production

Thyroid: TRH TSH T3 and T4

CRH/CRF ACTH & Beta endorphinsCortisol

Sex Hormones: GnRH FSH and LH Estrogen/Testoster

Serotonin decreased self-mutilation, impulsiveness, cravingsNo consistent serotonin findings in ED/CD/SUD

Obesity and StressAcute stress associated with severe, yet reversible, form of insulin resistanceBrandi LS, et al. Clin Sci 1993;85:525-35Psychosocial stress associated with insulin resistanceRaikkonen K, et al. Metabolism 1996; 45:1533-38Nilsson PM, et al. J Intern Med 1995; 237:479-86

ED and Stress Bulimics may have a complex and poorly understood dysregulation of the HPA axis associated with the disease.[1]A study in patients with night eating syndrome also demonstrated dysregulation of the HPA axis with blunting of the CRH-induced ACTH and cortisol response.[2]1] Birketvedt GS, Drivenes E, Agledahl I, et al. Bulimia nervosa a primary defect in the hypothalamic-pituitary-adrenal axis? Appetite. 2006 Mar;46(2):164-7. Epub 2006 Feb 24.[2] Krupa D. www.the-aps.org/press/journal/release2-7-02-4.htm. [

GeneticsTwin studies show:a substantial contribution to AN and BN and traits associated with bothUnique environmental influences (trauma, sports that emphasize thinness) > shared environmental influences (SES, religion, parenting style)Those with a mother or sister with AN are:12 X more likely to develop AN4 X more likely to develop BN*

GeneticsBinge Eating DisorderBinge-eating disorder is a familial disorder caused in part by factors distinct from other familial factors for obesityHereditability estimated at 57% (Javaras KN, et al. 2007)Obesity / Compulsive OvereatingHereditability estimated at between 40-70%

Causes of Eating Disorders

Causes of eating disordersFamily history of eating disorder or chemical dependencyEarly onset pubertyIncreased BMI prior to onsetMood disorder historyHighly competitive academic/social environmentsEnmeshed or disengaged family system*

Precipitating factorsInternal or external sense of loss of controlPuberty and attendant weight gainMajor life transitions: separation/individuation/identityTraumatic events: abuse / rejection / failureFamily issues: divorceInnocent weight lossOnset of co-morbid illness*

Eating Disorders Influence of the culture

Ana Carolina RestonBrazilian ModelDied at age 21 after prolonged hospitalization forAnorexiaBulimiaKidney FailureSepticemiaBMI 13.5Weight 88 lbs.

There were times I felt fat. I had a distorted image of myself Ana Carolina Reston (1985-2006)

Eating DisordersHavent you had enough calories?Parents divorced at age 9, no longer Daddys little girl or gifted student

Julie and Morticia

One-quarter of what you eat keeps you alive. The other three-quarters keeps your doctor alive. (Hieroglyph found in an ancient Egyptian tomb)

The doctor of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition. Thomas Edison

Nutrition and Eating Disorders: Its not just about foodKeys 1950s study Signs of under/malnutritionmood disordersobsession with foodbizarre food rituals*

Let they food be thy medicine, and let thy medicine be food.

ProteinNutrient DensitySugar

Dietary Supplements

Dietary SupplementsDepressionLonger remission with Omega-3 FA supplementationCott J, 2004Populations with high depression have low EFAs

Eating DisordersLevels of EFAs decreased in ANEFAs effect zinc absorptionZinc necessary for EFA metabolism

Omega 3 FASuicide RiskLow DHA% and Low Omega-3:6 ratio predicted risk in depressed patients over 2 year periodAm J Psychiatry, Sublette M, et al. 2006Borderline personality disorderOmega 3 FA decrease anger and aggressionBMJ 3/05

Dietary SupplementsCalcium, Magnesium, Vitamin DFood sources of zinc:OystersFortified breakfast cerealLean meatsYogurtBeansNuts and seeds

SupplementsDigestion & Absorption:Enzymes: Thorne or Tyler Probiotics: Lactobacillus GGDeficient in patients with chronic constipationHongisto, 2005With fiber decreased constipation and bloatingKhalif, 2005IBSKajander, 2005

Supplements for Depression5-HTP: Serotonin precursorTreatment for refractory depressionInsomniaCowan 1996Cangiano C, 1992Cochrane Database

Supplements for AnxietyL-TheanineValerian RootBenzodiazepine withdrawalSleepMorin CM, 2005Shinomiya K, 2005AnxietyKohnen R, 1988Andreatini R, 2003Kava-Kava

Yager, et al. (1999) patient on Prozac (20 mg/day) for alcohol-induced mood disorder. Hx ETOH hepatitis. Pt. took 2 gelcaps of Valerian root and felt like Im on acid.Mc Gregor, et al. (1989) reported 4 cases of hepatotoxicity with combined preparations containing valerian root.Chan (1995) Cases of ingestion of 15-20 grams of valerian root caused headache, excitability, uneasiness, cardiac disturbances but no signs of hepatitis

St. Johns Wort

Dosage: 300 mg three times a daySAD, ADHD, OCD, Anxiety, DepressionStudy done on (Perika-Natures Way):Extract WS5572: 3% hyperforin300 mg three times dailySIDE EFFECTSReduces effect of digitalisMay increase effects and side effects of products that increase serotonin (5-HTP, SAMe, SSRIs)May increase the effect of Xanax, Coumadin, Immunosuppresive agentsRobitussin DM increase serotoninMay decrease effectiveness of OCPsMay increase metabolism of DilantinMay reduce levels of Zocor(not Pravacol or Lescol) / ?Lipitor/MevacorOther: may induce mania in bipolar patientsOther: high doses may cause sunburn-like reaction

St. Johns Wort Case ReportYager, et al. Patient with long-standing GAD with panic attacks. Patient began taking St. Johns wort and reported reduction in panic attacks from 3-4/day to 3-4/week. Patient also taking passionflower and wild oat and in CBT.

Patient comments about supplementsThe nutritional supplements made it easier for me to begin eating again. I didnt have the bloating and stomach pain I had when I went through this process in my last treatment.

I never thought I could sleep without my sleep medications. I feel much more well rested and not as groggy as when I took the sleep medicines.*

Anorexia Nervosa/Bulimia Nervosa/ Binge Eating Disorder

History and SxAmenorrhea, Constipation, headaches, fainting, cold intoleranceBloating, fullness, lethargy, GERD, abdominal pain, sore throat, abn mensesConstipation, GERD, fatigue, abnormal menses, PCOSPhysical findingsCachexia, acrocyanosis, dry skin, hair loss, bradycardia, orthostatic hypotension, hypothermia, loss of muscle mass and sq fat, lanugoKnuckle calluses, dental enamel erosion, salivary gland enlargement, cardiomegaly (ipecac toxicity). Can be normal or sl overwt.Overweight or obeseLaboratory findingsHypoglycemia, leukopenia, elevated liver enzymes, euthyroid sick syndrome (low TSH, normal T3, T4), OSTEOPENIAHypochloremic, hypokalemic or metabolic acidosis (from vomiting), hypokalemia (from laxatives / diuretics, inc. amylase Hyperlipidemia, hyperglycemia, Insulin resistanceElevated androgensECG findingsLow voltage, prolonged QT interval, bradycardiaLow voltage, prolonged QT interval, bradycardiaVariable

Medications used in the Treatment of Eating DisordersTopamax - decreased binge eating behavior, BMI and weight in Binge eating disorder (BED) Mc Elroy, et al. Biol Psych 2007 May 1;61(9)In one study, the use of Clozapine/olanzapine may worsen symptoms of binge eating Gebhart, et al. J Neural Transm 2007 Aug; 114(8)Sertraline - decrease in Night Eating Syndrome behaviors: nighttime hyperphagia, awakenings, nocturnal ingestions and Beck Depression scores Stunkard AJ, et al. J Clin Psych 2006 Oct; 67(10)

*

Medications for EDMedications tried for AN have been disappointing and / or studies hampered by small sizeNone have a significant impact on weight gainTricyclics show improvement in mood onlyHigh drop-out rates limit ability to draw conclusions

*

Medications for EDBulimiaTrials with Prozac (60 mg/day) for up to 18 weeksReduce binging and purgingReduce psychological symptomsTrials with Luvox and Trazadone - small studies show some efficacyPreliminary study on Zofran (Ondansetron) - an antiemetic and 5HT3 Antagonist decreased binging and purging when patients self-administered prn cravingsMedication only trials show abstinence in only a minority of patients.

Medications for Binge Eating DisorderTrial of Prozac vs. placeboDecrease in binging, depressionAbstinence rates, high drop-out rates and long-term follow-up not reported - conclusions ?Overall, in short term studies, SSRIs lead to reduction in binging, decrease in weight and severity of illness and decrease in psychological symptomsLong-term follow up is lackingNo data on abstinence from bingingTopamax and Sibutramine - decrease in binging. No long term data High placebo response in all trials is noteworthy

Mind-Body Therapies

Mind-Body Treatments of Mental IllnessRestoring the mind-body connectionStress reductionResearch shows efficacy for:ADD and ADHDInsomniaMemory improvements after head traumaPanic disorderChronic PainEating Disorders

Mind-Body TherapiesGuided ImagerySelf-hypnosisRelaxation TherapiesBreath work, Meditation, PMRMindful Practices forEatingExercisingSelf-soothing

Research on YogaBerger (1992): Yoga & Swimming decreased anger, confusion, tension and depression more than aerobic trainingShannahoff-Khalsa (1996): Yogic techniques used to treat OCDY-BOCS group mean improvement was +54%; improvement on Perceived Stress Scale; 3/5 stopped fluoxetine, 2/5 decreased doseWoolery, et al (2004): Iyengar yoga effective in decreasing symptoms in subjects with mild depression.Yoga in ED patients produced increased body contentment, self-confidence and general emotional maturationYoga has been effective in treatment of drug addiction in India and USHatha yoga found equal to group therapy for reducing drug use and criminal activities in patients on methadone maintenanceSKY yoga breathing in patients with HAM-D >17 (n=45): remission rates were equal for yoga and imipramine but lower than remission rates for ECT.

CASESJulias depressionThom - from Obesity to Anorexia*

Thom no reason to live40 y.o. WM Hx of morbid obesity now severely anorexicS/P Gastric bypass surgeryNeuromuscular scoliosisDiet consisted of grilled cheese sandwich/day + 10-15 Reeses PB cupsWheelchairDay in the Life

History of ThomI dont know how I got here..Adult child of alcoholic silent eater since age 9 / Mother locked up the cabinetsYoungest of 5 children I could do whatever I wanted and not get punishedThe loss of his sons

ThomMedical:Difficulties with solid food EGDOsteoporosis- Why?SpectracellEDI-3CAMAcupuncture: pulse very deficient wiry pulseSomatics: collapse of his coreChiropractic increase height/ pain decreasedMassageReiki low energy along left sideZero Balancing felt body soaking up energy

Upper endoscopy showing marked stenosis at site of anastomosis of gastric bypass surgery.

Thom K 3/06Weight 183 lbs.Height 58 Loves dogsMoved to board and care homeRelapsed with ETOH within 3 months

Resources

Healing D.H. LawrenceI am not a mechanism, an assembly of various sections.And it is not because the mechanism is working wrongly that I am ill.I am ill because of wounds to the soul, to the deep emotional self and wounds to the soul take a long, long time, only time can help and patience, and a certain difficult repentance, long, difficult repentance, realization of lifes mistake, and the freeing oneselfFrom the endless repetition of the mistake which mankind at large has chosen to sanctify.

ReferencesKaye Wh, et al. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. AM J Psychiatry, 2004 Dec; 161(12):2215-21.Latner JD, Wilson GT. Binge eating and satiety in bulimia nervosa and binge eating disorder: effects of macronutrient intake. Int J Eat Disord. 2004 Dec;36(4):402-15.Dalvit-McPhillips S. A dietary approach to bulimia treatment. Physiol Behav 33(5):769-75, 1984.Blouin AG, et al. A double-blind placebo-controlled glucose challenge in bulimia nervosa: psychological effects. Biol Psychiatry 33(3):160-8, 1993.Ward NI. Assessment of zinc status & oral supplementation in anorexia nervosa. J Nutr Med 1:171-7, 1990.Yamaguchi H, et al. Anorexia nervosa responding to zinc supplementation: a case report. Gastroenterol Jpn. 1992 Aug;27(4):554-8.Cowan PJ, et al. Moderate dieting causes 5HT2Cr eceptor supersensitivity. Psychol Med 26(6):1155-9, 1996.

References8.Misra M, et al. Alternations in cortisol secretory dynamics in adolescent girls with anorexia nervosa and effects on bone metabolism. J Clin Endocrinol Metab. 2004 Oct; 89(10):4972-80.9.Guinn B, et al. J Sch Health 1997 Mar; 67(3):112-5.10.Ferron C. Adolescence 1997 Fall; 32(127):735-4511.Laessle RG, et al. A comparison of nutritional management with stress management in the treatment of bulimia nervosa. Br J Psychiatry. 1991 Aug;159:250-61.12.Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Pediatr Int. 2000 Feb;42(1):76-81.13.Cangiano C, et al. Am J Clin Nutr. 1992 Nov;56(5):863-7.14.Bressa GM, S-adenosyl-l-methionine (SAMe) as antidepressant: meta-analysis of clinical studies. Acta Neurol Scand Suppl. 1994;154:7-14.15.Friedel HA, et al. SAMe. A review of its pharmacological properties and therapeutic potential in liver dysfunction and affective disorders in relation to its physiological role in cell metabolism. Drugs. 1989 Sep;38(3):39-416.SAMe for treatment of depression, osteoarthritis and liver disease. www.ahrq.gov/clinic/epcsums/samesum.htm17.The Rhodiola Revolution. Richard Brown, MD & Pat Garberger, MD

In young women, the risk of developing anorexia is 0.5 to 1 percent, and mortality is estimated at 4 to 10 percent.4,5 In the same population, the risk of developing bulimia is 2 to 5 percent,1,6 and the incidence of disordered eating that does not meet strict criteria for eating disorders may be twice that of the above conditions.2 Frequent dieting and desire for weight loss occur much more commonly than overt eating disorders. In 1999, the Youth Risk Behavior Surveillance Survey7 reported that 58 percent of students in the United States had exercised to lose weight, and 40 percent of students had restricted caloric intake in an attempt to lose weight.Risk factors for developing an eating disorder include participation in activities that promote thinness, such as ballet dancing, modeling, and athletics,4 and certain personality traits, such as low self-esteem, difficulty expressing negative emotions, difficulty resolving conflict, and being a perfectionist.1 Eating disorders are particularly common in young women with type 1 diabetes mellitus. Up to one third of women with type 1 diabetes may have eating disorders, and these women are at especially high risk of microvascular and metabolic complications.8Study of 246 women: 136 with AN, 110 with BN for FIVE years.11 of the women died, 10 with AN, 1 with BN; 4 of AN deaths = from suicideHistory of alcohol use was not always picked up by providers

STANDARDIZED MORTALITY RATIO= NUMBER OF DEATHS IN THE POPULATION / NUMBER OF EXPECTED DEATHS IF EACH AGE GROUP HAD THE SAME AGE-SPECIFIC DEATH RATE AS THE REFERENCE POPULATION (RATIO OF OBSERVED DEATHS TO EXPECTED)Personality disorders (Axis II diagnoses) also are common, with comorbidity rates reported at 21 to 97 percent.15 The wide range is related to the complexity of evaluating these diagnoses. Patients with bulimia are more likely to have a cluster B diagnosis (dramatic/ erratic), whereas patients with anorexia are more likely to have a cluster C diagnosis (avoidant/anxious).15

Major depression is the most common comorbid condition among patients with anorexia, with a lifetime risk as high as 80 percent.5 Anxiety disorders, especially social phobia, also are common.5 Obsessive-compulsive disorder has a prevalence of 30 percent among patients with eating disorders.13 Substance abuse prevalence is estimated at 12 to 18 percent in patients with anorexia and 30 to 70 percent in patients with bulimia.14NOTE HOW ALL OF THESE SYSTEMS ARE AFFECTED IN EDGlucocorticoids such as cortisol can contributeto insulin resistance because of its opposing actions of insulin. How this works is unclear.Catecholamines and cortisol can also increase blood sugar. Chronic elevaitons of cortisol resulted in increase plasma insulin levels (Goldstein et al. Am J Physiol 1993 Individual differences in reacting to stress also include personality differences that affect coping styles avoidant people differ radically in their responses to stress than those who emotionally detach in times of stress. Social support is a major determinant of successful coping. It comes as no surprise that the loss of a loved one ranks as one of the most stressful events in life. The degree to which we need to control a situation impacts our perception about stressful life events. The most stressful events according to research are the ones in which we feel helpless. [1] The more we feel empowered in our ability to deal with stressful situations, the more successful we can be. This does not apply to pathological desires to control often seen in our eating disorder patients, for whom any loss of control is actually extremely stressful and can trigger an increase in the eating disorder behaviors. [1] Hoffman, DL. Therapeutic Herbalism p. 2-95

More recently, attention has also been directed to examination of an additional reaction to the fight / flight response to stress the immobility or freeze response. Peter Levine describes this frozen state as on in which the rage, terror and helplessness have built up to a level of activation that overwhelms the nervous system. At this point, immobility will take over and the individual will either freeze or collapse. What happens then is that the intense, frozen energy, instead of discharging, gets bound up with the overwhelming, highly activated, emotional states of terror, rage and helplessness.[1] [1] Levine, Peter. Walking the Tiger: Healing Trauma. North Atlantic Books, Berkeley, CA. 1997: p. 100 Brumberg reported that books, magazines touting calorie counting, fashion industry promoting slimness, TV and movies message that thin is sexy and successful, emphasis on physical fitness and athleticismCONTRIBUTES TO INCIDENCE OF ED

ED ALSO RELATED TO CHANGES IN CULTURAL NORMS. LOOK AT PREVIOUS GENERATIONS NORMS FOR BEAUTY VS. CURRENT DAY. MAY EXPLAIN THE INCREASING INCIDENCE OF ED SINCE THE 1960SAnorexia can be described as the extension of determined dieting. All of ED have in common the desire to control weight and appearance.

Anorectic families described as enmeshed,, vacillating between overprotectiveness and abandonment. Minuchin noted that the maintenance of the symptomatic child often defused parental conflicts thereby keeping the family in balance

CBT: AN is a conceptualized as a learned behavior maintained by positive reinforcement. The indiv diets to lose weight and is reinforced by peers and society. Reinforcement for wt loss is so powerful that the individual maintains the anorexic behavior despite threats to health and well being

Brumberg reported that books, magazines touting calorie counting, fashion industry promoting slimness, TV and movies message that thin is sexy and successful, emphasis on physical fitness and athleticism

ED as a spectrum from anorexia to compulsive overeatingAN is an attempt of the self to refuse itself and there is a dissolution of the link between the self and the body. When negative expectations theyre not able to meet occur, they rise above the need to meet these expectations to a place of not needing. FROZENFamily theories view ED as a cry for help for a conflicted and dysfunctional family. Cognitive-behavioral theoryMedia influenceProtein Study done on 18 women with BN or BED showed that consumption of extra protein 3 hr before a meal reduced binging eating. Pts. Consumed less food at meals after protein than after carbohydrate supplementation, had less hunger.

Nutrient dense diets promote weight gain and decreased binging

Sugar may affect opiate-mediated feeding behavior. Carbohydrates often play a role in binging and often sweet snacking occurs during stress. Administration of an opiate antagonist, naloxone, suppressed binge eating behavior in one study

ITS NOT ABOUT THE FOOD ITS ABOUT WHY THE PATIENTS ARE EATING THE FOODS THEY DO AND IN THE WAY THEY DOZINC: supplementation for 60 days has been shown to help with weight gain in anorexics. Zinc deficiency causes decrease in smell and taste. Observational studies have shown that zinc supplementation increases rate of weight gain. Zinc is also lower in patients with depression. Zinc supplementation may improve appetite and mental state.

FOLIC ACID: may be deficient in AN. Study of all female anorexics being admitted to a hospital were studied and there was significant deficiency in over 80% of patients. In another study, there were no significant deficiencies found.In bulimics one study found FA to be deficient in BN

NIACIN: the first Sx of niacin deficiency in Anorexia. AN may be a subclinical form of pellagra edema is part of this. A study of the diet of anorexics showed low niacin intake. Niacin supplementation has been shown in several case reports to improve appetite and mental state

THIAMINE several case reports of AN with deficiency Wernicke-Korsakoff syndrome / one with recurrent hypothermia

B6 levels were low in a small observational study of 13 low weight patients with AN or BN

B12: AN may have higher levels of B12 or deficiency

Other deficiencies: studies have shown that some AN have low Vit D, low intake of Vit C, Vit E

One observational study dhowed low levels of serum copper with corresponding depression in ceruloplasmin

AN Levels of EFAs decreased in observational studies. EFAs are important in zinc absorption. Zinc is necessary for two stages of EFA metabolism.

DIETING MAY ALTER BRAIN SEROTONIN FUNCTION IN WOMEN (NOT MEN) relates to depression and frequency of binges

SAMe - contributes to the synthesis, activation and/or metabolism of such compounds as hormones, neurotransmitters, nucleic acids, proteins, phospholipids and certain drugs SAMe is superior to placebo and possibly as effective as tricyclic antidepressants in trials lasting up to 42 days Compared to treatment with conventional antidepressant pharmacology, treatment with SAMe was not associated with a statistically significant difference in outcomes (risk ratios for a 25 and for a 50 percent decrease in the Hamilton Rating score for depression were 0.99 and 0.93, respectively; effect size for the Hamilton Rating score for depression measured continuously was 0.08 (95 percent CI [-0.17, -0.32])).

meta-analysis showed a greater response rate with SAMe when compared with placebo, with a global effect size ranging from 17% to 38% depending on the definition of response, and an antidepressant effect comparable with that of standard tricyclic antidepressants. Essential fatty acids: EPA & DHA -1-9 grams/dayAN Levels of EFAs decreased in observational studies. EFAs are important in zinc absorption. Zinc is necessary for two stages of EFA metabolismOmega-3 and omega-6 fatty acids are essential fatty acids because it cannot be synthesized by the body and must be obtained through diet or supplementation. Omega-3 f.a. are known to be anti-inflammatory, heart protective, blood vessel dilation and blood clot prevention benefits. Omega-6 f.a. tend to promote inflammation and blood clot formation. The omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are found in fish and fish oils such as salmon, mackerel, tuna and sardines. Alpha-linoleic acid (ALA) is an omega-3 f.a. that is found in seeds and oils, green leafy vegetables, walnuts and soybeans. The diet of early humans supplied a ratio of 1:1 of omega-3 to omega-6 f.a. The modern American diet is approximately 10:1.Omega-3 fatty acids offer several benefits in the treatment of eating disorders:1. Omega-3 f.a. have been shown to lower serum triglyceride levels common in diabetics and to improve the levels of the good cholesterol, HDL. . 2. High consumption of omega-3 FAs has a beneficial effect on metabolic syndrome, insulin sensitivity and glucose tolerance, a useful benefit for compulsive overeaters with obesity many of whom also have the metabolic syndrome.3. Sudden death syndrome caused by abnormal rhythms of the heart (ventricular arrhythmia) in patients with coronary heart disease (CHD) and those with NO evidence of CHD was decreased by 45-50%. Anorexics are at higher risk of sudden death and while this has not been studied in anorexics, specifically, it may provide a significant benefit. (AFP, 2004)4. Many studies have shown a benefit of omega-3 f.a. to treat depression and bipolar disorder. Some epidemiological studies demonstrated that countries in which there is high consumption of fish have a lower incidence of depression and bipolar disorder. Several studies have also shown a decrease of omega-3 f.a. in patients with depression. Omega-3 fatty acid supplements can be given along with prescriptions medications for depression and bipolar disorder.5. EPA was shown in one study to decrease aggressiveness and depression in borderline personality disorder. (see ePA on nat. med database)Bipolar patients treated with omega-3 FAs stayed in remission longer than those on placebo and had less depression, but no change in mania.Because metabolism of omega-3 f.a. can cause oxidative stress, they should be taken with a Vitamin E supplement in doses between 400-800 IU daily. Omega-6 f.a.(gamma-linoleic acid and linoleic acid) are readily available in the diet in the form of meat, dairy and vegetable oils, and supplementation is generally not necessary. However, in anorexics with very restrictive diets, omega-6 f.a. supplementation may be useful. Omega-6 supplements include evening primrose oil, pumpkin oil, borage oil or hemp oil. Some symptoms of deficiency include hair and nail problems. Interactions and adverse effects for omega-3 FAs include an increase in bleeding time; however, there are no known cases of abnormal bleeding as a result of omega-3 supplementation even at high doses or in combination with anti-coagulant medications. Fish oil in high doses can increase LDL cholesterol levels, but the clinical significance of this finding is unclear. Side effects include fishy burp or aftertaste and stomach upset. Dosages range from 1-3 gms for treatment of depression or for prevention of heart disease up to 9 grams for treatment of bipolar disorder.Severely depressed patients have lower levels of the serotonin metabolite 5HIAA in CSF. Both cholesterol lowering therapies and low cholesterol levels have been associated with an increased risk of suicide;8-10 the prevailing theory holds that low cholesterol levels lower serotonin turnover. However, drug and diet therapies to lower cholesterol also alter essential fatty acid levels. Since essential fatty acid levels predict CSF 5-HIAA levels, and cholesterol does not,11,12 cholesterol levels may be a surrogate marker for changes in essential fatty acids.

A recent study by Andrew Stoll et al found that dietary supplementation with DHA and EPA showed marked mood-stabilizing activity in bipolar disorder.32 A four-month, double-blind, placebo-controlled study compared 15 one-gram capsules of fish oil daily (containing 9.6 g/d omega-3 fatty acids) to an olive oil placebo, as an adjunct to usual treatment in 30 patients with bipolar disorder. Participating subjects were men and women, 18 to 65 years old, who met DSM-IV criteria for bipolar disorder (types I or II), and were free of other medical and psychiatric illnesses. Patients were required to have had at least one manic or hypomanic episode within the past year, in order to enhance the power of the study to detect a difference between the two treatment groups within the study period. The omega-3 fatty acid-treated group had a significantly longer period of remission than the placebo group (P = 0.002). During the four-month trial, two of 14 patients relapsed in the fish oil group while nine of 16 relapsed in the placebo-treated group.

AJP - Low Omega-3 levels and suicide risk Sublette M, Hibbeln J, Galfalvy H, et al. Omega-3 Polyunsaturated Essential Fatty Acid Status as a Predictor of Future Suicide Risk. Am J Psychiatry, 2006;163:1100-1102.OBJECTIVE: Low levels of docosahexaenoic acid, a polyunsaturated fatty acid, and elevated ratios of omega-6/omega-3 fatty acids are associated with major depression and, possibly, suicidal behavior. Predicting risk of future suicidal behaviors by essential fatty acid status merits examination. METHOD: Plasma polyunsaturated fatty acid levels in phospholipids were measured in 33 medication-free depressed subjects monitored for suicide attempt over a 2-year period. Survival analysis examined the association of plasma polyunsaturated fatty acid status and pathological outcome. RESULTS: Seven subjects attempted suicide on follow-up. A lower docosahexaenoic acid percentage of total plasma polyunsaturated fatty acids and a higher omega-6/omega-3 ratio predicted suicide attempt. CONCLUSIONS: A low docosahexaenoic acid percentage and low omega-3 proportions of lipid profile predicted risk of suicidal behavior among depressed patients over the 2-year period. If confirmed, this finding would have implications for the neurobiology of suicide and reduction of suicide risk. 2

Other issues: calcium and vitamin DOne study showed that AN have significantly higher serum cortisol concentrations = a direct consequence of undernutrition and assoc with dec in bone formation contributin to low BMD.Placebo controlled double blind crossover study in IBS entericd coated peppermint oil was better than placebo in relieving abdominal sx Khalif IL, 2005 Nov;37(11):838-49Hongisto SM, et al. Eur J Clin Nutr.2005 Oct 26.Kajander K, et al. Aliment Pharmacol Ther, 2005 Sep 1;22(5):387-94

Hongisto: fibre rich bread and lactobacillus GG on intestinal transit time and bowel function increased fibre improves constipation and lactobacillus gg reduces adverse GI effects associated with increased fibre.

Khalif: demonstrated that constipation causes striking changes in faecal flora, ikntestinal permeability and the stemic immune response and showed decreased concentrations of Bifidobacterium and Lactobacillus in constipation patients

Kajander: probiotic mixture was effective in alleviating irritable bowel shyndrome symptoms

Valerian is a sedative-hypnotic for insomnia and an anxiolytic for restlessness and sleep disorders assoc with anxiety. Also reported to decrease social anxiety. Valerian reduces time to onset sleep and improves quality of sleep. Can be given TID but warn patients to look for drowsiness. Reports of hepatotoxicity with use of multiingredient prepartions probably idiosyncratic. Caution

Kohnen: double blind trial of 48 adults : valerian reduced sensations of anxiety without measurable sedation. Compared to valium, valerian showed similar reduction in Hamilton Anxiety Scale after four weeks (Andreatini)

Valerian hops combination was equivalent to benadryl but better than placebo for sleep. Valerian produced slightly greater, though nonsignif, reductions of sleep latency after 14 days of tx. QOL was > in the valerian group vs. placebo. No adverse SE found

SHINOMIYA: Valerian extract had sleep inducing effects and sleep quality enhancement effects in sleep-disturbed rats5HTP is related to both L-tryptophan and serotonin. L-tryptophan is converted in the body to 5HTP, which can then be converted to serotonin which readily crosses the blood brain barier and increases CNS synthesis of serotonin.

5HTP: Cangiano et al showd that supplementation with 5 HTP (900 mg) vs. placebo in a double blinded study with and w/o diet prescrioption produced weight loss in obese patients and reduction in CHO intake, increase in early satiety.Taking 5 HTP orally helps to improve sx of depression incljuding patients with treatment resistant depression.Also helpful to treat insomnia: MAIN SIDE EFFECT = GI

Cochrane review of randomized trials in pts with unipolar depression or dysthymia comparing tryptophan or 5HTP vs. placebo: few studies met criteria for sufficient quality to be included, trend did show 5 HTP better than placebo

Theanine is the major amino acid found in green tea. Green tea contains 1% to 3% theanine (7685,7690). Theanine is also found in some mushrooms (12188). Theanine has historically been used for it's relaxing and anti-anxiety effects. It's thought that theanine might work for anxiety by increasing levels of GABA and serotonin (12188

5HTP is related to both L-tryptophan and serotonin. L-tryptophan is converted in the body to 5HTP, which can then be converted to serotonin which readily crosses the blood brain barier and increases CNS synthesis of serotonin.

5HTP: Cangiano et al showd that supplementation with 5 HTP (900 mg) vs. placebo in a double blinded study with and w/o diet prescrioption produced weight loss in obese patients and reduction in CHO intake, increase in early satiety.Taking 5 HTP orally helps to improve sx of depression incljuding patients with treatment resistant depression.Also helpful to treat insomnia: MAIN SIDE EFFECT = GI

Cochrane review of randomized trials in pts with unipolar depression or dysthymia comparing tryptophan or 5HTP vs. placebo: few studies met criteria for sufficient quality to be included, trend did show 5 HTP better than placebo

Anxiety. Kava extracts standardized to 70% kava-lactones are superior to placebo (2093,2094,2095,7325,11372), and possibly comparable to low-dose benzodiazepines (2092). Treatment for 1-8 weeks may be necessary for significant improvement (2094,2095). Most clinical studies on the effectiveness of kava for anxiety disorders have used the standardized extract WS 1490 (W. Schwabe). This extract is standardized to contain 70% kava-lactones (also known as kavapyrones). This extract is more than twice as concentrated as most products that are commercially available. POSSIBLY EFFECTIVE Benzodiazepine withdrawal. There is some evidence that upwardly titrating kava over one week while tapering the benzodiazepine over two weeks can prevent withdrawal symptoms in some people with non-psychotic anxiety (7325).

Valerian root officinalis: used to treat nerves in women and anxiety in 10th c. and shell shock in WWI.Valerians postulated mechanism is through GABA agonist activity 9affinity for GABA (A) receptors, inhibition of GABA reuptake, Serotonin, 5-HT(A) agonism and inhibition of MAO uptake

Case could be explained by combined use of valerian with ETOH, hepatitis may have decreased breakdown of valerian constituents. May have been a combination of MAO-like effects of valerian and serotonergic effects of prozacObese patients: nsulin resistance also increases circulating levels of insulin, which elevate androgen production. A number of mechanisms for this have been found, including the lowering of sex-hormonebinding globulin, increased androgen production by direct stimulation or indirectly by the production of insulin-like growth factor I. The relationship between insulin and androgens is thought to be the underlying trigger of polycystic ovary syndrome (PCOS), which is also known as functional ovarian hyperandrogenism.32 PCOS is a frequent cause of menstrual dysfunction in the adolescent.PCOS is defined by elevated androgen associated with anovulation, which manifests clinically as oligomenorrhea and/or dysfunctional uterine bleeding. While it usually occurs in obese patients, it also may occur in patients with a normal weight. Hyperandrogenism can also lead to other undesirable effects such as hirsutism, acne, acanthosis nigricans and, less commonly, clitoromegaly. Because of the anovulation and the lack of progesterone production, a state of unopposed estrogen is induced. As mentioned earlier, this state increases the risk of endometrial cancer. Lowered fertility is also characteristic.When evaluating the patient with suspected PCOS, it also is necessary to rule out other potential hormonal abnormalities such as thyroid disease, hyperprolactinemia or adrenal abnormalities. It is important to note, however, that ultrasonographic evidence of polycystic ovaries is not necessary for diagnosis and, in fact, polycystic ovaries may occur in normally menstruating patients.For example, a few recent, small studies have demonstrated that metformin (Glucophage) improves menstrual function and hyperandrogenism in patients with PCOSIn a single-center, placebo contrlled study, topiramate dec. binge eating and weight in patients with BED and obesity. Total of 407 patients with BMI between 30-50 kg/m2 (195 on med/ 199 on placebo). Topamax reduced binge eating days/week, episodes/wk, weight (5kg vs. .2-3.2kg wt loss) and BMI. 58% had binge eating remission. SE: paresthesia, URIs, somnolence and nausea.Clozapine = ClozarilOlanzapine = ZYPREXASertraline = ZOLOFTThe 5-HT3 receptor antagonists are selective serotonin inhibitors, competitively inhibit the binding of serotonin to 5-HT3 receptors. Their antiemetic effects are postulated to stem from blockade of 5-HT3 receptors located on the nerve terminals of the vagus in the periphery and centrally in the chemoreceptor trigger zone of the area postrema. These drugs have little or no affinity for other serotonin receptors; for alpha or beta-adrenergic; for dopaminergic; or for histamine receptors

SHORT TERM EFFICACY FOR ALL MEDS ONLY.

What is Mind-body medicine? The techniques in mind body medicine are the same tech that drove the development of psychoanalysis and all forms of psychotherapy (hypnosis and guided imagery)AN is an attempt of the self to refuse itself and there is a dissolution of th elink between the self and the body. Comes negative expectations theyre not able to meet so they rise above the need to meet these expectations to a place of not needing.

Biofeedback may be helpful in regulating some of the Sx of ADHD, difficulty with methodological designs of studies; research lags behind anecdotal evidence

Insomnia: JAMA review on insomnia related to chronic pain was helped by biofeedback More research is needed

Panic patients studied at Stanford reported biofeedback can assist patients withInsomnia randomized trial of hypnosis found it helped pts. Get to sleep more quickly than placebo

hypothesis that makes sense is that folks with bulimia feel intense emotions and then binge or purge. Self-soothing may break that cycle. Esplen and colleagues found that one effective treatment is guided imagery. Fifty women with diagnosed bulimia were randomized to compare 6 weeks of guided imagery with no treatment. Women in the guided imagery cohort showed a 74% reduction in bingeing and 75% reduction in vomiting! They also showed improvements in attitudes regarding eating, dieting, and body weight as well as loneliness and self-comforting (Esplen et al, 1998).

hypothesis that makes sense is that folks with bulimia feel intense emotions and then binge or purge. Self-soothing may break that cycle. Esplen and colleagues found that one effective treatment is guided imagery. Fifty women with diagnosed bulimia were randomized to compare 6 weeks of guided imagery with no treatment. Women in the guided imagery cohort showed a 74% reduction in bingeing and 75% reduction in vomiting! They also showed improvements in attitudes regarding eating, dieting, and body weight as well as loneliness and self-comforting (Esplen et al, 1998).In every ancient tradition, there are ceremonies and rituals around food. In all of these traditions, the guides to health and wholeness have a sacred place for food/nutrition. In Aryuveda, there are the four Doshas which prescribe food by body type. In TCM, it is known that different foods are used to nourish the kidneys or spleen qi.

Important to restore the sacredness of FOOD which is lost in our fast food, busy culture.

Mindfulness:

Prayer to start the meal: With appreciation I am going to eat; not to frolic and not to indulge, not to increase conceitedness, and only in order to maintain my body, and prolong life and to benefit myself and to quench hunger so that I can commit wholesome deeds to benefit myself and to benefit othersI will benefit by this food in prolonging my life, in leading a wholesome and peaceful life. From the Book of Discipline