Drs Brian Lacy and Monia Werlang on Eating Disorders

In this podcast, Dr Brian Lacy and Dr Monia Werlang discuss the misconceptions about eating disorders, gastrointestinal manifestations, and the importance of including mental health professionals in a multidisciplinary approach to treatment.

Brian Lacy, MD, is a professor of medicine and gastroenterologist at Mayo Clinic Jacksonville, and Section Editor for Stomach and Small Bowel Disorders for the Gastroenterology Learning Network. 

Monia Werlang, MD, is clinical assistant professor of medicine at the University of South Carolina School of Medicine in Greenville, South Carolina. 

TRANSCRIPT:

Dr. Brian Lacy:  Welcome to this Gastroenterology Learning Network podcast. My name is Brian Lacy. I'm a Professor of Medicine at the Mayo Clinic in Jacksonville, Florida. I am absolutely delighted to be speaking today to Dr. Monia Werlang who is Clinical Assistant Professor of Medicine at the University of South Carolina School of Medicine in Greenville, South Carolina.

Our topic today is one that affects every provider regardless of specialty, and that's of eating disorders. Dr. Werlang, thank you for joining this podcast today. Let's begin simply in order to set the stage for our listeners. How common are eating disorders?

Dr. Monia Werlang:  Dr. Lacy, thank you so much for having me. Eating disorders are more common than probably we all think unless you studied a topic, you don't think of these diseases as very common. It does affect about 10% of the general population if you consider the lifetime prevalence.

If you consider the GI practice, the prevalence is actually even higher, close to 24-25% of patients who visit GI practice will have some type of eating disorder.

For example, in irritable-bowel syndrome, the prevalence can be even higher than 40%. If you think in general population in America, that accounts for about 30 million Americans that will have an eating disorder. It's an important group of diseases that we should be more well versed on.

Dr. Lacy:  Those are impressive numbers. We think about thyroid disorders as 6% of the population, but you just mentioned 10% of the population, at least 30 million adult Americans. That's an awful lot of people.

Thinking about eating disorders, we've spoken of them as a broad category. Could you briefly discuss how we define these using the newer DSM-5 categories?

Dr. Werlang:  Absolutely. In general, eating disorders, we consider an eating disorder as a persistent disturbance of eating that impairs physical or mental health. That is in general. All the different eating disorders are going to fall in different categories.

We can go more in detail about each one. There are several changes in DSM-5 new classification, but we'll have some time to go over that in detail in a little bit.

Dr. Lacy:  Perfect. Thank you. You've mentioned this great, broad definition. When we start thinking about the multiple eating disorders that are now recognized, and we'll go through these more carefully in a second, do you think that these are new disorders or are we getting better at diagnosing them?

Dr. Werlang:  Well, that is a difficult question. As we learn more about the eating disorders, we are finessing our classification, improving our ability to diagnose the, and being able to recognize symptoms that maybe were blamed on something else, another disease or another pathology or potentially, even dismissed. There is a good component of us being better physicians, hopefully, and being able to diagnose these better.

Dr. Lacy:  We're constantly learning, which is what makes this field so exciting. You mentioned the prevalence, maybe 30 million adult Americans with an eating disorder. Can you comment briefly on the impact of eating disorders on society and how that affects individuals and their families?

Dr. Werlang:  It's probably needless to say that having an eating disorder will affect your quality of life as eating as a part of our daily life, we eat multiple times a day. It will affect the quality of life for patients, also adds a lot of stress to family members who are concerned about the patient who is affected.

It's also a very severe, or can be a very severe mental health issue. If you put in perspective, eating disorders are the second mental health disorder in mortality. It's only surpassed by opioid addiction.

If you think about mental health disorders causing death, then eating disorders are second place worldwide. They're not a group of benign conditions. They can be very severe and have high mortality rates.

Dr. Lacy:  That's an impressive number. We're all aware of the tragedies surrounding opioid abuse and death rates. Now, we've just learned that eating disorders are number two. That's puts it in perspective.

Monia, you had a nice article in the "American Journal of Gastroenterology," in January of this year, discussing eating disorders. You mentioned in that article, some misconceptions about eating disorders, and one of them was that eating disorders are not just the province of young, educated, affluent, Caucasian women. Is that true? Should we consider eating disorders an equal opportunity disease?

Dr. Werlang:  Absolutely. Unfortunately, the patients who don't fit our previous, I'll consider it a stereotype of what we thought were the patients who would have an eating disorder. The patients who don't fit that, they have potentially a delayed diagnosis and eating disorders as in other conditions, having a delayed diagnosis also causes poor outcomes.

I should mention that about a third of patients who have an eating disorder are actually men and not women. There are other factors that I should also mention here, that eating disorders can happen in patients who have normal body mass index or BMIs, or even higher BMIs than considered normal. Above 25, patients can still have an eating disorder.

There are several studies also showing that this can happen in older patients and also patients who are dealing with diseases that are managed by diet. For example, diabetes, hypertension, heart disease. It's not just a disease of the young Caucasian women. It is the disease that can happen in any social class, in any BMI class, and in any race and ethnicity.

Dr. Lacy:  Those are great teaching points and sign for all of us to think about while we're in clinic later today or next week. Monia, shifting gears a bit. Why do you think eating disorders develop? Is this simply a reaction to stress or do you think maybe there's a genetic basis?

Dr. Werlang:  Very interestingly [laughs] as in other diseases, also, the pathophysiology of eating disorders is very complex, and we do not understand everything about it yet. There is good evidence to suggest that even caloric restriction and weight loss from other situations, from other diseases may trigger an eating disorder.

Restrictive eating and the starvation can lead an individual to develop many behaviors in cognitions that are characteristic of patients with eating disorders including preoccupation with foods, irritability, anxiety, loss of appetite and a lack of motivation for eating.

There are some specific risk factors, such as high levels of anxiety, harm avoidance, perfectionism, deficits in emotion regulation and body dissatisfaction, those are risk factors. There is a genetic predisposition, yes. There are a couple of things that patients can experience such as weight stigma and weight-related teasing that can predispose a patient to develop restrictive eating.

Finally, there are a couple of other more neurologic issues that can occur like dysregulation of the hypothalamic pituitary and adrenal axis and some catecholamines disturbances that can also affect the pathways that lead to eating disorders. A lot words to say that there is a lot that we don't know.

Dr. Lacy:  A great clinical peril there is. If we think about some of these patients, where sometimes we recommend diets that we think will be helpful, be careful that they're not taken to the extreme and we almost induce an eating disorder, so thank you.

You've mentioned, Monia, the impact of eating disorders on our healthcare system and the fact that these can develop in patients regardless of age, race, gender, ethnicity, economic background. How do you screen for eating disorders in clinic? Clinic is so busy, time is so limited for our providers. How can we do this efficiently?

Dr. Werlang:  The most important thing I learned studying eating disorders, as a doctor, is that you should not be afraid of asking patients directly if they have an eating disorder. Decrease the stigma yourself that you are comfortable asking about these.

Oftentimes patients will answer your question with a yes or no, and they are more open than you would think they are about an eating disorder. Sometimes the difficulty is with us in asking because maybe we don't know what to do with the information once we get the information, but that is important to be open and ask.

If the patient says no, if you have a high suspicion, you can still use some screening tools. There are no validated screening tools for the gastroenterology practice per se, but we have several primary care tools. One of them is the SCOFF, or S-C-O-F-F.

That is five questions that you can ask. If you have a high suspicion, maybe that would be more useful. The first question is, do you make yourself sick because you feel uncomfortably full? Second question, do you worry you have lost control over how much you eat?

Third question. Have you recently lost more than one stone or 14 pounds or 6.35 kilograms in a three-month period? Fourth question is, do you believe yourself to be fat when others say you are too thin? Fifth question would be, would you say that food dominates your life? If patients respond yes to two or more of these questions, then it's considered a positive test.

Dr. Lacy:  Wonderful. Five easy questions that can be asked. Don't be afraid to ask these questions because otherwise you can't help your patients. Again, that questionnaire is called the SCOFF, S-C-O-F-F. You can look it up online.

Monia, let's take a few minutes now and discuss some of the most common eating disorders and we'll go through these briefly. Let's begin with anorexia. How common is it? How can we identify it? What are some of the common GI manifestations of anorexia nervosa?

Dr. Werlang:  Anorexia is probably the most well-known eating disorder. The prevalence is not very high. If you consider the lifetime prevalence about 0.6%, it can be very severe. Anorexia nervosa, we define as a persistent energy intake restriction that leads to weight loss or leads to a failure to make expected gains in weight. For these patients, they have an intense fear of gaining weight or becoming fat.

Many patients do not explicitly state this fear of becoming fat or gaining weight, this can also be under-diagnosed. Patients sometimes will not volunteer the behaviors that they are engaging in.

The DSM-5, the new classification no longer requires that the patient has to have a low weight threshold. Its more based on a weight loss or under-weight status determined based on the physical health consequences of low weight and the individual's own historic weight and growth history.

It's not just about the BMI being low, but based on the patient's history and what has happened with them in the recent times. GI symptoms in anorexia can vary from constipation to gastroparesis. In fact, they can have abnormal gastric emptying test and accommodation test.

The trick here is that, a lot of the symptoms that patients have in the GI world for anorexia, a lot of them improve with weight restoration. That is a good thing to volunteer to your patients that their GI symptoms can be addressed, once their weight is restored.

Dr. Lacy:  That's a great teaching point because that gives patients hope that if we can get this disorder under control, many if not all of your GI symptoms will likely improve or resolve. Let's focus on bulimia and similarly how common is it, how to identify it and what are some of the manifestations.

Dr. Werlang:  The lifetime prevalence of bulimia is about 1%. We can identify this by asking some good questions. The patients will describe recurrent episodes of binge eating, which is defined as eating an objectively large amount of food in a discreet period of time.

To qualify as binge, the individual would need to experience a marked feeling of loss of control during the eating episodes. It's not just going to a party and eating a lot. It's absolutely feeling that you cannot control the amount of food you eat, or that you lose control over a specific type of food. These behaviors need to occur at least once per week for about three months for it to be strictly by DSM-5 criteria.

Patients with bulimia nervosa, they evaluate themselves largely based on body shape or weight. They may be prone to under-reporting their symptoms, or behaviors, I should say. There could be also some diagnostic overlap between bulimia nervosa and anorexia nervosa as well.

Dr. Lacy:  You briefly touched on it because you brought up binge eating and binge-eating disorder. Is that something that's common and do you ever think we might, in clinic, confuse a patient with binge eating disorder from somebody with cyclic-vomiting syndrome or rumination syndrome?

Dr. Werlang:  Binge eating disorder is more common than anorexia or bulimia. It's about 3% of the population of America have binge eating disorder. This is different than bulimia in a sense that the episodes of binging occur in the binge eating disorder, but the patients do have the guilt or embarrassment related to eating and the sensational loss of control.

There is less so or no motivation regarding to weight. They don't necessarily engage in behaviors to restrict calories or purge after the binge eating, motivated by losing weight, trying to lose weight. They don't necessarily engage in that behavior.

Binge eating disorder can be confused because once a patient eats a large amount of food, they can experience lots of different symptoms. Maybe they will bring up the issue as a postprandial discomfort, or severe reflux, or rumination, or what we think is rumination.

In fact, they're eating such large amount of food that they can have a lot of symptoms just by the gastric distention. They are not a lot of studies in this, a very few, but I think it is a good topic to be studied in the future.

Dr. Lacy:  Wonderful. Many of our listeners may have heard the term ARFID. It's really not a term that's familiar for everybody. It stands, as you well know, for Avoidant/Restrictive Food Intake Disorder. How common is ARFID? Do you think that this is something that we've created by placing patients on restrictive diets?

Dr. Werlang:  How common ARFID is, is a very difficult question to answer. So far, we don't have good population studies to answer that question as far as prevalence goes. We do know more about in the pediatric population. We think that about 3% of children and adolescents will have ARFID. We do not have good data for adults.

This is a new classification under the DSM-5 and patients here have no motivation related to weight. They do restrict their dietary intake, because they are concerned about either symptoms they will have from the food or is related to the food texture or food color. It's not related to weight control at all.

It is distinct from picky eating, but the way some providers describe this is extreme picky eating. It does have to be classified as ARFID. It does have to affect their nutrition. Patients should not have insufficient energy or macro-nutrient intake.

For this diagnostic criteria to be met, the patient have to have weight loss or nutritional deficiencies that either lead to dependence of enteral feeding or nutritional supplements. It has to have some interference with psycho-social functioning.

Dr. Lacy:  Great teaching points about ARFID especially about not just the picky eater but somebody with less energy, nutrient deficiencies. Those are key things.

Monia, we haven't talked about too much about treatment so far. Could you briefly summarize treatment strategies for these disorders? Is this in a bailiwick of gastroenterologists or do we need assistance from our psychiatry colleagues?

Dr. Werlang:  Absolutely. These group of diseases should be approached in a multi-disciplinary approach. There are some things that will need to be dealt with sometimes in in-patient setting. For example, for patients who are very malnourished and they are unable to accept or tolerate PO intake.

Then there are some in-patient management that needs to be done for re-feeding and monitoring for re-feeding syndrome. Most patients can be treated in a out-patient setting and I would suggest that patients would have to have a follow-up with psychology, with psychiatry, some patients may benefit from psychiatric medications.

A dietitian will be very helpful in helping these patients maintain their nutritional status long-term and following with their primary-care providers because we are in the gastroenterology world, but eating disorders can cause other issues that will affect other sub-specialties.

Having the primary care as the quarterback and then using our help from the psychology and the psychiatric group will be key to help these patients.

Dr. Lacy:  Thank you. As gastroenterologists, we should be able to identify it but pull the rest of the team and you don't need to do this on your own.

Monia, as we wind down here. I want to come back to the topic of misconceptions because there are so many misconceptions out there about eating disorders. For great clinical pearls of teaching here today, would you dispel three or four of the biggest myths, once again. We can use those to help our patients in clinic.

Dr. Werlang:  Several things are important for us to understand. One of them, it does not just occur in women, a quarter or up to a third of the patients who have eating disorders are men. Other things is that it's not just a disease of the young. It does happen in older patients. It does happen in patients who have what we consider a normal BMI and also in high BMIs.

It can also occur in patients who are classified nowadays in obesity range. The most important thing is that these are treatable conditions. They are not diseases that patients are doomed and we should invest time.

We should send the referrals to the right people for our psychologists or psychiatrists or dietitians to work out and to treat these patients as early as possible because early intervention is key. Patients do respond better if we treat them early and soon.

Dr. Lacy:  Monia, that's a great message of hope for our patients out there with eating disorders, identify the problem, get them to the right person to help with treatment and things will likely improve. Again, this has been a wonderful discussion. I can't thank you enough on behalf of our listeners. Any last comments for our listeners?

Dr. Werlang:  I would say that if you have not read about it, if you haven't been familiar with it, I learned a lot about reading the Minnesota starvation study.

You don't have to read the whole thing, but learning about it just made me change how I understand that restriction of foods and malnutrition can affect the brain, our perception of foods, and can affect our GI tract.

It's a bidirectional relationship that we should consider. That patients who become malnourished for other reasons, for other diseases, for after surgery, after trauma, they may develop some issues eating afterwards, and they may have several GI issues that they will come to your office and think it's a primary GI issue and it may not be.

Patients and providers should be more aware about that. Hopefully this will help our gastroenterologists in the community to treat patients with eating disorders better.

Answering more about the question you asked me about placing patients on restrictive diets. I do think that there is a potential risk. We should be careful selecting the right patients when you decide to start restrictive diets, such as a low-FODMAP diet, for example.

Often time patients will look in the Internet of how to do that diet because maybe a dietician is not immediately accessible to them. Having a follow-up, if you recommend a restrictive diet it's very important to assess symptoms, to assess if patients responded to the diet and to help them reintroduce foods, especially if that restriction didn't help.

For patients who have Eosinophilic esophagitis for example, that we often recommend elimination diets or irritable bowel syndrome, that we often recommend elimination diets. It's so important that we have, hopefully help from a dietitian to guide the process.

If we don't have that immediately accessible, then we have patients follow up with us because patients should not be on an elimination diet or restrictive diet long term. That can cause malnutrition, that could cause nutrient deficiencies.

Maybe you're not even helping them in the first place, but they believed, since you recommend it in the first day that you should be on a restrictive diet that would help, and they would have to do that forever. Sometimes that's a miscommunication, or you didn't have the time to go over in detail. It's very important that we are careful with the patient selection and careful with follow-up.

Dr. Lacy:  Once again, thank you so much Dr Monia Werlang, assistant professor of medicine at the University of South Carolina School of Medicine, in Greenville, South Carolina. Thanks so much for your expertise here today.