Bulimia and Binge Eating in Teens: What We Know and What To Do
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Bulimia and Binge Eating in Teens: What We Know and What To Do

August 15, 2019


So welcome everyone to our
Your Child’s Health University lecture this evening. My name is Felice Stonestrom and
I manage the community programs at Stanford Children’s Health. And just as a reminder, we
are videotaping our lecture this evening, so we ask that
you please silence your phones. And if you have questions,
if you would hold them to the end at which point
we will turn off the cameras and you can ask your
questions anonymously. So our lecture this evening is
titled Bulimia and Binge Eating in Teens What we
know and What to do. And we’re honored to have two
speakers tonight, Dr. Kara Fitzpatrick and
Dr. Shelly Agarwal. Dr. Kara Fitzpatrick is a
clinical assistant professor in the Division of Child
and Adolescent Psychiatry at Stanford. She attended Ohio State
College of Medicine in Ohio, completing
her internship at Nationwide Children’s
Hospital in Ohio, and then a fellowship
at Stanford University School of Medicine. Dr. Fitzpatrick’s
current research focuses on neuropsychology
and neuroimaging in eating disorders. She is particularly
interested in the role of weight suppression
and malnourishment on cognition, the evaluation
of neuropsychological deficits in adolescents and cognitive
features associated with obesity. Dr. Shelly Agarwal
is teaching faculty at Lucile Packard Children’s
Hospital at Stanford University, as well as
University of California at San Francisco Fresno
Division of Pediatrics. She’s a board
certified pediatrician and adolescent
medicine specialist. She has worked and
practiced in a variety of clinical
environments including various international
settings, and is actively involved in adolescent
programs related to nutrition, disordered eating,
under-served youth and general adolescent care. Her areas of interest
include wellness, mindfulness, preventative
health, and applying integrative principles
to assess and treat teens and young adults
within a holistic model. Thank you very much
both for coming. Good evening, I’m
Dr. Fitzpatrick. And I’m going to be starting
off our day, or our evening I guess, and really
covering what it is that makes up bulimia
and binge eating disorders, and what we think we
can do about them. I do have some disclosures. I am actually paid
to train people in the treatments– some
of the treatments that I’m going to be talking
about as empirically supported treatments for bulimia
and binge eating disorder. Over the last 10 years there’s
been significant advancements in the treatment of
eating disorders, especially for children
and adolescents. What we’ve seen is not
only changes in treatment, but also changes in
diagnostic categories. And so we’re going
to be talking tonight about what makes a diagnosis. How do you know someone has a
specific issue or challenge, and also what we
can do about that in terms of psychological
and psychiatric treatments. My next slides
are really boring, because they’re
actually going to cover the diagnostic criteria
for bulimia and binge eating in some depth. In fact, exactly the way they
are written for psychologists and psychiatrists. So bulimia nervosa
is characterized by recurrent episodes of binge
eating where binge really requires two things. The first is eating in a very
discrete or a short period of time, an amount of food that
is definitely larger than most individuals would eat. We sometimes refer to this
as a gross amount of food or a very large amount of food. And often it’s
not specific foods that someone is looking for. Someone may start
eating say a sandwich and begin eating a
variety of foods, and even sometimes non-food
items or condiments like ketchup or cocoa powder. For some people, they also
don’t eat quite as much but they feel, the
second part being the most important part of this
definition, a loss of control. They can’t stop themselves
from eating behaviors. And so it’s this loss
of control that’s actually critically important
in defining a binge eating episode. You’re not able to decide
how much or whether or not you can stop. And people often only stop
eating when they either reach a point of fullness that they
literally cannot eat anything more, or because they run out
of food or someone catches them, or they’re stopped
in another way. And it’s really
important to note this because that loss of control
is extremely distressing. All of us like to have a
certain amount of autonomy and independence in what we
do, and losing control really changes that game for people. The next thing that happens
with bulimia nervosa are what we call maladaptive
or inappropriate compensatory behaviors. In essence, what happens is
the individual is so afraid of weight gain from their
binge eating episode that they begin to engage in
behaviors that are thought to lead to weight loss. Or one might think
about it as negating the food that they
just ate, sort of erasing the eating episode. The most common type
of purging mechanism that people talk about
is self-induced vomiting. But it’s really
important to note that there can be other ways
in which people can purge, including the use of laxatives,
things that make you poop, diuretics, things
that make you pee, herbal supplements or
other types of medications, as well as fasting. So going on a juice fast or a
cleanse after a binge eating episode would also be
a maladaptive strategy for losing weight. And finally excessive exercise. And it’s really
important to note that what becomes excessive may
be categorized under two areas. One is compensatory exercise. I ate this amount of
calories, so now I’m going to exercise to burn
that amount of calories off. It can also be compulsive. I’m unable to stop myself
from engaging in exercise, and I engage in exercise
even under risk of injury or under less than
ideal circumstances. I had a patient tell me recently
about running in the hail. And she didn’t
want to be running, she knew it wasn’t appropriate,
but she couldn’t stop herself from doing that. In addition, because
these behaviors actually occur with a fair amount of
frequency in the population, you can’t just have
these behaviors, although personally as someone
who treats eating disorders, I would be worried about any
level of these behaviors. To meet criteria
you actually have to engage in these
behaviors on average about once a week
for three months. Again, like I said,
this is in order to meet criteria for this. The other aspects
of this disorder have to do with the way in
which we evaluate ourselves, and the ways in which these
symptoms interfere with us in our regular daily living. For self-evaluation needs
to be unduly influenced by weight and shape. And I want to take a moment
here and say body image dissatisfaction and people being
uncomfortable with their body or not liking
parts of their body is actually, unfortunately,
far more common than body care or
body enjoyment. Almost all of us
experience some level of body image dissatisfaction. What’s important here is that
the idea of how I look actually influences how I
feel about myself, what I feel I’m
capable of doing, the amount or
types of activities I’m willing to engage in. And so we find that fears
around weight, weight gain, and eating behaviors
actually stop the person from developing in a way
that we might think of as useful, healthy, and effective. Finally, these behaviors
can’t occur in the context of anorexia nervosa. And this is a
common misconception that people who engage in
inducing vomiting have bulimia, and that you have anorexia if
you don’t do those behaviors and you simply exercise. But actually the difference
between the two disorders has to do with how
much you weigh. So our patients who
have bulimia nervosa are at or above a
normal body weight. So you can’t look
at someone and tell that they have bulimia, because
their weight is in range. You can have these
exact same behaviors, but if your weight is
artificially suppressed or you’re below
weight, you’d meet criteria for anorexia nervosa. What you don’t get is
both at the same time. One of the things
that’s changed is we’ve started out in what
we call specifiers, or ways of understanding
where someone is in the trajectory
of their illness. And this is actually
really beneficial to people who are seeking treatment,
because this actually allows us to continue
billing for this disorder. And it’s a parity
diagnosis, so that makes it even more
fundable by insurance. And so you can be designated
as having partial remission. You’ve met full criteria for
bulimia nervosa in the past but currently you’re doing
better with symptoms, and you wouldn’t
meet full criteria, but you’d be in
partial remission. And then also in
full remission, which means that we’ve
begun to recognize that the absence of symptoms
may not mean that someone is completely well. And we may need to
continue treatment during a period of
symptom abstinence in order to help someone
get completely well. One of the other big
changes is that we’ve added measures of severity. And this is a terrible slide
and I really apologize, but severity is really
based on the number of episodes of your
inappropriate compensatory behavior. In other words, how often you
may be using vomiting, laxative use, diuretic use in order to
erase or negate a binge eating episode. And so you can see
from these numbers they range from mild to extreme. And what’s actually
fairly typical when people present
for treatment is that they’re
already following in the moderate to severe range. And so these behaviors
are much harder to identify than people
typically think that they are. What we see in
presentation also is the number of different
types of purgative methods that someone’s using is also
indicative of the course of treatment and the likelihood
of reaching full recovery. The more maladaptive
behaviors you’re using in order to lose
weight, the harder treatment is going to be. And that makes sense
to us, because we think about each of these
as separate treatment targets, things that
we need to identify. Now that’s bulimia nervosa. And bulimia nervosa’s
been codified in the literature
since the 1980s, and actually treatment
came about that quickly. So less than six
months after we created the diagnosis of bulimia
nervosa we had treatment for it. But binge eating disorder
is actually a new disorder. It became a
full-fledged disorder in the most recent iteration of
the Diagnostic and Statistical Manual. And it’s been the subject of
a fair amount of controversy, but also a fair
amount of research. So binge eating disorder is
the presence of recurrent binge eating episodes. The binges are described
exactly the way they are in bulimia nervosa,
but the difference is is that they’re associated with
three or more of the following. And I’m going to go
over these, but I will say that there was a very
interesting New York Times op-ed piece that was written
by a fairly famous psychiatrist right after we proposed these
criteria and he said, “Well, everybody does this.” And I think, at least myself
and several of my colleagues, we all sort of sat
back and went “Really?” And it tells you that there’s
this belief that binge eating is actually fairly common. Sometimes people refer
to Thanksgiving as binge eating day. But in fact, binge
eating by itself is very different
than typical eating. What most of us do when we
think that we might be binging is deliberate over-eating. I go out to eat and my
food is really good. And it’s I went to
Cheesecake Factory and it’s a portion
for like three people, but it tastes good and rice
doesn’t reheat really well, so I’m going to eat more
of it than I intended to. Sometimes we might
accidentally over-eat. There’s a lot of food in
front of us in a chip bag and we just keep eating, and
we meant to eat a serving size. Seven chips is a serving size. Does anybody ever just
eat one serving of chips? No, and so we
accidentally over-eat. A binge, however, in addition
to that loss of control, can’t stop yourself. People tend to eat much
more rapidly than normal. They might not even
fully chew their food, and as Americans we’re not
really great at chewing our food so well anyway. But they’re also eating until
they are uncomfortably full, so full that many people feel that
they have to vomit or otherwise get rid of the food
because they’re actually in pain from the amount of
food that they’re eating. Some people spontaneously
regurgitate because they simply can’t put any more food in. And then they’re also
eating large amounts of food in the absence of hunger cues. Anybody who’s gone
grocery shopping after a long day of work
where they’re really hungry will find that they actually
increase the amount of food that they’re putting
in their cart, or they might serve themselves
more at their next meal. But this is actually eating
even when you’re not hungry. It’s serving a different
purpose for this individual. And there’s also
eating alone often for fear of being
judged, humiliated, or embarrassed by the
amount that one is eating. And afterwards, people feel
very disappointed, or disgusted, depressed, or
guilty, or ashamed. Many people go to great lengths
to hide their eating behavior so that other people don’t
know how much they’re eating, where they’re eating,
or what they’re eating. So what we see in
binge eating disorder is there are these periods where
someone eats out of control. And one of the things that’s
really interesting about binge eating disorder is it
begins at a younger age, apparently, than it does–
than bulimia nervosa does. Bulimia nervosa tends to have
an onset between about 16 and 18 years of age, so
it’s a little bit later in adolescence, but can
onset at any point in time in the lifespan. We begin to see binge
eating episodes as early as late childhood
for some people. And again, it can onset
at any point in time across the lifespan. So there isn’t a
discrete period that we look at for this oncoming. But for some people, it
begins as an emotional eating. So when you guys have had a
bad day, what kinds of things do you say, oh,
I’ve had a bad day. I’m going to go home and
have some comfort foods. What kind of comfort foods do
you guys think about having? This is actually where
it’s participatory. Chocolate. Chocolate. Cake. Cake. How come nobody’s like– what? Pasta. Pasta. Nobody is like red
bell pepper slices. No? Crudites, a little
bit of broccoli. No? The reason why is a lot
of the times what we’re looking at for
emotional eating are foods that are high or rich
in carbohydrates, sweet, yummy rich foods. And we call those comfort
foods because, in fact, they produce serotonin. So when we eat
them they actually produce a neurohormone
or chemical that’s used in the brain
to stimulate feelings of wholeness, wellness,
well-being, and lack of depression. So the risk often
is that the kinds of foods that are binged upon,
both in bulimia and binge eating disorders, are
ones that actually have a high emotional
salience value. They feel good to us to eat. They’re very rewarding. They’re tasty. They’re yummy. And they impact
our neurobiology. Sometimes, and I find this
to be true more in girls than in boys, although
boys’ athletics sometimes has this aspect too,
is a very social aspect to binge eating episodes. I certainly know that when
I was younger and still had sleepovers with my
friends, and actually even now when I have sleepovers
with my friends, we tend to have a high
amount of junk food at home. And I remember when
I was in my teens we would bake brownies and
then eat the whole pan, and we didn’t think
anything of it. But in fact, often that
can be a starter episode for binge eating. In clinical populations,
people who are already being seen for treatment, we
find that binge eating disorder occurs in about 5% to 10%
of a clinical population. Compare that to bulimia where
it’s closer to 2% to 3%. However, when we look
at population studies, we actually find a much higher
rate of these behaviors. In other words, people who’ve
never sought treatment. And it’s expected
that binge eating in the general population
may be as high as 3% to 5% of the general population. But you notice I put
exclamation points and question marks behind it. The general
population for bulimia is likely to be as high
as 3% to 5% as well, but there are certain
times when people appear to be at very high
risk for engaging in binge eating and bulimic behaviors. And this is particularly
true for women in college. And one of the things we found
through different surveys that look at both eating
and drinking behaviors is that binge eating and binge
drinking appear to go together, and that binge eating
and purging behaviors exist in extraordinarily high
rates on college campuses among women. There are some
studies that suggest that the high rates
in college may be as high as 60% of females
actually engaging in at least one binge eating
and purging episode in their first
year at university. 60% isn’t a disorder. It’s not even below average. And so we need to know
that these behaviors exist, and that they are actually
in some places socially sanctioned or acceptable. And we need to begin
to think about what we’re going to do with this. Now one of the things that’s
really lovely is it used to be you either met criteria for
this disorder or you didn’t. Now the way the disorders
are structured and set up, we actually can diagnose
you with bulimia nervosa of a low frequency or duration,
or binge eating disorder of low frequency and duration. And I think this is
really a nod to the fact that these behaviors by
themselves are very concerning. And so if you don’t meet
the criteria to meet for full diagnosis,
we can diagnose you with a sub-threshold
level of disorder. We don’t have research
on binge eating disorder, but we know that sub-threshold
bulimia is associated with the same medical
risks and consequences as full blown bulimia nervosa
in children and adolescents. In other words, there
is not a safe level of engaging in maladaptive
compensatory behaviors. And if you think that these are
going on for someone that you care about, it’s very
important to intervene as quickly as we can. So if you think someone
has a difficulty, what do we do about it? We happen to be very
fortunate because there are several treatments
that are known to be effective for
bulimia nervosa, and to some extent for
binge eating disorder. And to the best
of my ability, I’m going to talk about for
children and adolescents. But some of this data is
actually pulled from adults, because what we
know is that there are three types
of treatment that appear to be effective for
people with binge eating and bulimia nervosa. I’m going to talk about
bulimia nervosa first. And I’m going to throw a whole
bunch of three letter acronyms at you. And I apologize,
because they all start to sound the same
after a little while. We know that both individual
and family approaches work for bulimia nervosa. The therapy approaches
that are individual are cognitive behavioral
therapy and dialectical behavior therapy. Cognitive behavioral therapy
has been studied in adolescents, young adults, and adults. Dialectical behavior
therapy has been studied in young adults and adults. And let me clarify my terms. Did you know that being a
teenager goes all the way up until you’re 24? So congratulations, some of you
might even still be teenagers. And if no matter what you’re
closer to it than you thought you would be, where
young adulthood is generally considered the
period from about 18 to 24, and now there are some efforts
to push it to about age 26, because quite frankly
nobody is really all that independent
before age 26 these days. And if you can still get covered
by your parents’ insurance, you’re probably
still a young adult. Family based therapy has only
been studied in adolescents. And it’s really not a
treatment that we generally do with young adults and
adults who are out of the home and away from their
families, but it can be utilized with some
modifications for young adults. It just simply
hasn’t been studied. So even though I presented
them with individual and then family, I’m actually
going to talk about them the other way around. What is family based therapy? Family based therapy
for bulimia nervosa is a very pragmatic treatment. Our goal is actually to
intervene with symptoms, and so the initial focus of the
treatment is all on symptoms. And it assumes that
the adolescent is not in control of their eating. In fact, by definition, with
bulimia nervosa and binge eating you’re experiencing a
loss of control and therefore not able to manage your
own eating behaviors. And the treatment actually
aims to put parents in charge of those
behaviors, to move it so that parents are taking
control over the adolescent’s eating. And I want to be
very specific here, over the adolescent’s eating. Nobody really wants to be in
control of their adolescent’s social life. You might think you do, but
for sure you really don’t. You don’t really want to be
in control of their homework, either. So it’s a very narrow
focused therapy. And the goal on symptoms
is to first focus on meal normalization. One of the gravest
mistakes that we make when people are
binging and purging is to assume that
if they’re binging and they’re not throwing
it up, or even if they are, to wait a long time
until they’re no longer hungry in order to eat again. But in fact, one of the
best things for treatment is meal normalization,
eating three meals and two to three snacks a
day at regular intervals, regardless of whether or not you
have breakthrough binge eating or purging behaviors. Normalizing your
eating in some studies can attenuate symptoms of
bulimia by as much as 60%, so just having regular food. The other thing
that we do is we put parents in charge of interfering
with purging behaviors or other types of
maladaptive behaviors. We might ask parents to monitor
their teenagers after meals for an hour or more in
order to prevent them from going to the bathroom,
prevent excessive exercise. We may ask parents or loved
ones to go through their room and remove diet
pills, laxatives, or herbal supplements. We may identify–
have parents help identify some of
the behaviors that are interfering
in regular eating, and help right that system. The other thing parents
can do, or loved ones if they’re involved, is
actually make it harder to engage in binges. And someone just
told me the other day that they use this
as a sales technique for selling Girl Scout
cookies, because one of the things that
I talk about a lot is we almost all have foods
that if we start eating them we can’t stop. And one of mine is Thin
Mint Girl Scout cookies that are in the freezer. If they’re room
temperature, they could sit there for four years
and and I wouldn’t touch them. But there’s something about
them being in the freezer where they’re crisp, and
cold, and minty, and uh. This is why I don’t
buy Girl Scout cookies. If I eat them, I will keep
going back and getting them over, and over, and over again. And if someone brings
them into my house, which they better not
do, I will eat them even if they belong to them. So one of the
strategies is actually to take away foods
that trigger a binge. Another strategy
is actually once we start binging we’re
likely to binge on high carbohydrate,
sweet, rich foods that are readily available. The one that always comes
to my mind is cereal. Cereal comes in
really big boxes. It’s really easy to eat. I wish I could tell you
how many of my patients binge on– Honey Bunches of
Oats seems to be really quite popular binge food. If you can just take
one box and continue to eat it without stopping,
or without any cues that you’ve reached a
place of limitation, then it’s very easy in a
loss of control episode to keep going through it. So we start to create artificial
barriers, such as putting your cereal in serving
size containers so that each time you’re
going to have one you have to stop– oops, sorry. And open a container again. You have to actually interfere
or stop your eating behavior to engage in another
opening, or it creates a little cognitive stop period. So you can see that families can
be quite effective in this way. And we know that families can
and must really help patients, because the family actually
has skills to bring. Parents, siblings, they
know the patient better than anybody else. They’re there and
they’re observing, and they’re experts in that. So the therapist
in an FBT is really leveraging parental
skills and relationships to bring about change. And everyone is working
together to combat this illness. It’s really lovely because
parents and children, when bulimia nervosa
is in the picture, often are more collaborative
than say with anorexia nervosa. Patients can often identify
what they have trouble with. So in the first phase
what we’re doing is we’re raising parental
anxiety to act. We’re disrupting
maladaptive eating patterns. We’re identifying things that
put you at risk for engaging in these maladaptive behaviors. FYI, being really tired
or being really hungry, those are both huge triggers
for binge eating behaviors. And we really do parent
directed replacement with healthy behaviors. Bulimia nervosa is a very
collaborative treatment. But of course parents shouldn’t
be in charge of everything for a very long time. So in the second
phase of treatment, we’re really working
for parents to hand back that control to the adolescent. And there’s a slow process
of emphasizing a maintenance of secured skills. In other words,
you’re doing breakfast and you never
binge at breakfast, and you seem to be doing really
well with that, so you’re going to get to do breakfast
kind of on your own and unmonitored. We’ll drop you off at school. And I wrote continued
weight gain, but actually that should be
continued weight maintenance. I apologize for that. I don’t know why I
didn’t catch that. What we are not trying
to do is lose weight. This is not a
weight loss therapy, nor are the treatments
for binge eating disorder. We do not want people dieting,
because dieting holds in place all of the things that set you
up to develop these disorders. And there’s an emphasis
throughout the second phase of therapy on finding
other behaviors of eating in normalized settings. So people eat out, and
learning how to eat and control your portions when they may be
higher than or larger than you might typically
serve yourself or you don’t know what’s in them. The other thing we do
is supplement behaviors that may cause binge eating
and create rewards for things that are not food-based. And that continues
throughout phase three. The third phase of this
treatment the patient is either weight restored
or weight maintained, and they’re having
more typical thoughts. They’re thinking about
their body image, weight, and shape are more in
line with the rest of us. In other words, I’m overweight,
but it doesn’t actually stop me from doing anything. I wear the clothes
that I want to wear. I wear bathing suits. I go swimming. I do all sorts of things. I’m not waiting until my
body looks a certain way or feels a certain way to
engage in these activities. I may learn to like certain
things about my body. And then we also focus
on relapse prevention, because we know
these disorders have a very high risk of relapse, and
the reason why is very clear. You will never in your life
be able to go without eating. And so securing these
skills in a variety of different situations,
eating at home, eating out with friends,
eating in a cafeteria, eating when you’re
at work, we recognize that there are
lots of areas where there may be risks for relapse. And then we also restore
typical family functioning. We’ve scared parents to
death about the risks of these disorders,
and I’m going to let Dr. Aggarwal
do that for you. And so once we’ve
scared you to death, it’s really hard to lower
your anxiety about the types of risks of these behaviors. And we also want to restore
typical adolescent functioning. Now what does cognitive
behavioral therapy look like? Interestingly, it’s the
same as– I’m sorry. Let me finish with
family based therapy. The outcomes are
the same as they are for cognitive
behavioral therapy, which I’ll talk about in a second,
but it’s more efficient. Change happens faster. We get faster cessation of
binge eating and purging behaviors in family
based therapy than we do in cognitive
behavioral therapy. But before we get
too excited, we’re talking about
three studies ever. Bulimia nervosa in
children and adolescents, and is probably one of the
worst studied disorders. There have been very few
comprehensive treatment studies that have been done
of outpatient therapy, and of them, Stanford
and University of Chicago
collaborative group have published three of the
five total studies that are out there. So what do we do for
individual treatment? All of those things
that I just said happen in family based therapy
where parents might be managing it happen in cognitive
behavioral therapy, but it involves the
individual, the patient him or herself being the one who’s
monitoring diet, feelings, conflicts, and the things that
lead up to binge purge cycles. So the targets are the same. We want to normalize eating. We want to undo thoughts
around the body image, shape, and weight, and
ideas around food. But rather than having
family step in and do this, we increase monitoring
for the individual. We get them to pay
attention to their thinking. And just like in
family based therapy, there are three
phases of treatment. And the phases actually
map very well on to FBT. Where in the first phase we’re
educating and normalizing eating. We’re really emphasizing the
importance of paying attention to what you’re eating, when
you’re eating, how you’re eating, who you’re eating with. And this is going to
sound a little odd but the emotional and social
circumstances under which you’re eating, and how
your urges to engage in maladaptive behaviors are. In phase two when we’ve had
some normalization and reduction in symptoms, we start to
pay attention to both food and emotion triggers. We want to actually
stop you from engaging in these behaviors
before they even begin. It’s sort of what you might
think of as risk management. But associated with
that, we’re also exposing you to feared food. So if I was going
through this therapy, someone would
actually make me eat Thin Mints that had
been in the freezer and not let me over-eat on them. I’d like to see who can
manage me doing that. But actually I’m pretty
sure people could do it. So we want to make sure
that people aren’t living their lives with
feared foods, that they don’t look at foods
as good or bad, because actually food is food. But you might have
foods that you might be more selective
with when you eat them or how much you eat of them. And finally in the third
phase, just like family based therapy, its development
of interpersonal skills, resilience skills,
management skills for going out into the world
and actually having a life worth living and the things that
supplement or overcome the risk for binge eating. And so because I know that
I’m running a little bit over, I’m going to sort of
quickly push past. These are the things
that I was just saying, but it was faster
for me to say them. Now DBT is something different. How many of you have heard of
dialectical behavior therapy before? OK, a couple of people. Dialectical behavior
therapy really looks at treatment a
little bit differently. It says that at the
core of it, most of us are experiencing
what we’re going to call maladaptive
emotion regulation skills. In other words, how do
I control my emotions in a way that makes me
effective, useful, motivated, and more constant? And so what we’re doing in DBT
for binge eating and bulimia is really looking at these
emotion regulation skills. We’re trying to figure out what
thing– how your emotions may drive certain
behaviors, and where we might use food
logging, write down what you’re actually eating. DBT uses something called
a chain analysis, which starts with your emotions. I was giving a talk and I
was feeling kind of nervous, and I was thinking, oh,
I need to reward myself. And what kind of reward
could I come up with and it was chocolate. And then I went home and
there was a lot of chocolate, and I was feeling
really stressed out so– and you’re tying emotions
and emotion regulation back into this. DBT was originally
created for use with people who engage in
self-injurious and suicidal behaviors. And because those self-injurious
behaviors co-occur with bulimia nervosa
fairly frequently, they’re relatively
highly co-morbid. DBT was really thought
of as a treatment that could address both sets
of behaviors at the same time. And it views that
binge purge cycle as part of
dysregulated emotions. It’s important to
note that the longer that we engage in binge
eating and purging behaviors, the more purging
behaviors become uncoupled from food and eating. In fact, where you
might start off purging because
you were binging, over time what we
often see is people start purging for it’s an
emotion regulation capacity. This is hard to believe
because very few of us engage in self-induced vomiting. And most of the time
when we do vomit it’s because we
feel badly, but even you might notice that if
you’ve been feeling ill and you throw up you feel
better for about 20 minutes. If your mood is stable
and you induce vomiting, it will actually
improve your mood. It will heighten your mood. It will make you feel good. It’s like hitting an
emotional reset button. And that lasts for
about 20 to 30 minutes. And so we know that one
of the things that we have to target in treatment is
the ways in which our biology can become addicted to
hitting the reset button that is purging behaviors. And DBT takes that track as
primary, where CBT and family based take that as secondary. So this is beneficial even
without a focus on food for some people who may have
more dysregulated emotions. Fortunately, we can
also use medications, although we rarely if ever
used medications alone. So we’ve studied the use
of Prozac or fluoxetine, and we find that in
high doses, these are quite high– an
average dose for something such as depression would
be about 20 milligrams. In very high doses
SSRIs may be useful, and they are FDA approved
or several of them are, for use in bulimia
nervosa, so they’re labeled for this use. And its efficacy or its action
is independent of depression or anxiety. So even if you’re not
experiencing depression or anxiety symptoms,
high doses of SSRIs may actually attenuate
binge eating episodes. And these studies have been done
in adults and older adolescents or young adults, not in
teenagers under the age of 18, although it has been
used for that use. The thing is that we don’t
use these medications alone. The first step is
always psychotherapy, and generally psychotherapy
for six months or more in order to get
control of symptoms. We really use the
SSRIs when we’re having a hard time getting all
of the symptoms under control, because they present
their very own risks. Binge eating disorder
treatment is fairly limited. We know very little
about effective binge eating disorder treatment
in children and adolescents. Even though it was only
added as a disorder recently, there are actually
more therapy studies for binge eating disorder
in adults and young adults than there are for
bulimia and anorexia, actually more than bulimia
and anorexia combined. And the studies that we have
have focused almost solely on adults and young adults. So what I’m going
to talk about here are not specific to
children and adolescents, although there are
very good reasons to believe that these
treatments would be effective. And so that the two individual
approaches that we talk about are CBT and DBT, exactly
as I have described them for bulimia nervosa,
only instead of focusing on purging
behaviors we simply are focusing on the
things that lead up to binge eating behaviors. Again, CBT would probably be
considered the gold standard, but not well studied in
children and adolescents at all, and there really aren’t
randomized clinical trials. So I can say that we’ve
used these treatments and they’ve been effective,
but I can’t really point you toward the science
to say that this is empirically supported. We know that there is some
future research for these. There are some
ongoing studies now looking at DBT, both in
group and individual practice for patients with
bulimia nervosa, as well as IPT, which stands
for interpersonal psychotherapy. There is one study that was
done looking at group cognitive behavioral versus group
interpersonal psychotherapy for adolescents,
and they actually were equally effective. And interpersonal
psychotherapy, learning how to relate and interact
with other people, managing interpersonal skills,
managing interpersonal emotions actually gave better
relapse prevention than cognitive
behavioral therapy. So it’s been started to be
moved into these treatments and something that’s sometimes
called CBT enhanced, which is really just
saying we stole parts of the other treatment
that worked really well and put them into ours. But that’s OK, because
that’s actually good science. We do know that there are
other adjunctive treatments that sometimes people use
like art therapy, emotion therapy, and movement
therapy, but these have never been studied, especially not
in children and adolescents. And there are programs
that use hospital inpatient partial hospitalization
programs, but also these are
not as well studied. Pharmacologically, there
are ongoing studies looking at SSRIs, as well as the
atypical anti-psychotics for some people with
bulimia and binge eating. But the atypical anti-psychotics
have the side effect of causing weight gain in some
groups, certainly not all. And so, and they can also
lower your seizure threshold, as does purging behavior,
so sometimes there’s some risk for that. What’s on tap for for
binge eating disorder? We need to study all of it. There are studies
being done looking at all of these treatments right
now, because it’s increasingly being identified as a
problem and a challenge that has major medical and
psychological risk factors. So this is me if anyone
needs to reach me, and I will happily hand
this over to Dr. Aggarwal. I am Dr. Aggarwal. I’m one of the
adolescent faculty here, so I’m in the Division of
Adolescent and Young Adult Medicine. And I am the medical
piece of what we’re going to be talking
about this evening. So just a brief sort of outline
in reference to the things that we’ll go over,
adolescent development I think it’s really key to look
at the foundation of development when you think about
adolescents and young adults. How does that influence what
happens next in reference to something like bulimia
or binge eating disorder? How does it influence
illness, essentially, in an adolescent
and a young adult? We’ll talk a little bit,
obviously, about bulimia and binge eating disorder. What happens to the
body, and what does this mean in terms of
caring for your teen. So adolescence is a
very dynamic time. We’re talking– we
have all been there, and we all know that it’s
a complex time of change. It’s a complex time
of biological change. You’re going through puberty. You’re starting puberty. You’re progressing
through puberty. You’re completing puberty. You’re learning how
to think about things in more complex ways. If you think about
your own child or when you were
a child yourself, the way you thought about things
when you were 8, as compared to 12, as compared to
17, as compared to 21, these were very different
ways in which you thought about the same information. And this is very much
related to the biology of your body, the
growth and development of your body and your brain. So this is very much embedded
in the science of your body, if you will. Now psychosocially
what that means is in terms of how did you
interact with your peers? How did you engage
with your environment? How did you engage with
your parents and the adults around you? This is also a moving
target, if you will, during your adolescent years. This changes as your body
grows, as your thoughts change, as your mind changes over time. So when we think
about adolescence, we want to think about
this dynamic model of progressive change. The next few slides
are looking at how we split up the concept
of adolescent development. We think about it a
couple of different ways. We think about early,
middle, and late. And this is probably
just pay more attention to the pictures than anything. In reference to thinking
about a group of individuals in this age, when you’re a
young adolescent potentially in these ages, you’re a
more concrete thinker, you’re a more black
and white thinker. Things can be either
very good or very bad. And sometimes having
a gray zone can be a little bit more
challenging to conceptualize, to really wrap your mind around
during this particular time. So it’s very normal to
think about who you are. Am I normal? Am I not normal? Is this good? Is this bad? So that’s more typical
for early adolescence. If you think about your
middle adolescent years, more in the ages
of like 14 to 17, this is kind of an
evolving time period. You’re progressing
through puberty, potentially completing a
lot of pubertal development, thinking about once again
who am I as a person. What are my beliefs? We think of this as
a time with increased risk-taking behaviors. And we’re going to talk a
little bit more about that as we explore what does
it mean to be a teenager and what does it
mean to be a teenager to have– who has bulimia
or binge eating disorder in the medical
context of things, oftentimes identifying
with peers in reference to what is normal,
fashion, hair. The way I think about
this is everybody’s trying to be different
by looking the same. So that is a very common thing
for adolescent development. We think about late
adolescence, so you’re thinking about more of
your young adult years. And as Dr.
Fitzpatrick mentioned, where as we’re understanding
more and more about what is development look like for
a teenager and young adult. We’re finding that really
your adolescent years stay until your mid-20s,
and that really is related to the concept of
brain development, which we’ll also talk about and how
that informs certain ideas about decision-making. So this is progressing
in terms of who am I going to be in the world. What are my beliefs? Potentially realigning
with parental norms. We think of adolescence
as a very conflicted time, in terms of having a lot
of conflict with parents, and that’s the most common
thing people think of. But in general, most teens
tend to get along with parents. But these are some
common ideas that we have about being a teenager. I wanted to introduce some ideas
about the brain in progress and highlight some of
what Dr. Fitzpatrick said in reference to how
does this influence adolescent decision-making. The adolescent
brain is changing. During your teen years, we have
this progressive development from being a more concrete
to a more abstract thinker. That is very much embedded
in the science of your body. The brain is going through
a fine-tuning process, if you will, in reference
to more complex thought. Some of the areas that
are more linked to, let’s say more emotional thinking,
potentially develop a little sooner than the
areas that are linked more to more executive
functioning, or what we think of as rational thinking. Now does that mean that
teenagers are irrational, that they’re just
naturally impulsive? We associate these
ideas with them, but in reality that
isn’t always the case. We know through various
pieces of science, through research that
teenagers in many ways can assess risk very
similarly to adults. When you give them
certain tasks they’re able to evaluate
it in a way that is very similar to
their adult peer, who might be given the same task. But what we’re finding
is that their value of the reward of the task
could potentially be skewed. And this is very much
embedded in the reward system, the neuroscience of the body. So there is some
thought then when we get a positive stimulus,
we as adults react to it. Teens may have a
more significant neurochemical reaction
through the reward system, through the dopamine
system, than the adult. So going to that
party where Tim is going to be that mom and
dad really don’t like him, and it’s probably
not a good idea. You know, I really shouldn’t
go but it’ll be so much fun. The value on the
reward is skewed, even though the risk
assessment of what you’re doing may potentially be there. So this is on the heels of what
Dr. Fitzpatrick was saying. When someone purges,
it could feel good for about the next
20 minutes or so. So it’s not that
a teen may not be able to wrap their
mind around the fact that I shouldn’t purge. I know that this is harmful. I know my doctor
told me I shouldn’t. I know my therapist said that,
hey, this is potentially really harmful and these behaviors
build on themselves, and they become more
difficult to break over time. They’ve heard that information. But I’m going to feel better
once I purge could outweigh the I shouldn’t do it,
or I know I shouldn’t. Now you wrap that around the
subsequent feelings of guilt, I just did something
I shouldn’t, and it becomes a vicious cycle. But some of that,
that need to purge could very much be embedded
in the science of the body. That’s one of the ways in
which I think about it. So it’s really important
to understand that it’s not that teens are making
reckless decisions, but their ability to kind of
weigh the risk benefit of it, or the fact that
I will feel better may be skewed in one direction. So eating disorders and
medical complications. This is one of the–
this is a broad concept that I want to highlight. And the gist of this, the way
in which I think about this is, as in nature, the body
will try and find balance. So that is what the
body is seeking. And when we have
dysregulated behaviors, the body will try
and compensate for those dysregulated behaviors. Now the compensation,
depending on how dysregulated the behaviors,
may not be enough. And this is when
we start getting into a slippery slope
and dangerous territory in reference to how does your
body manage that dysregulation. And we’re going to go into some
of the details around that. So the body will
conserve energy. I use a lot of
analogies, so this is one of the analogies I
use, of the car and gasoline. If you think about
the fact that when the system is
dysregulated, it’s going to go into a survival response. That’s essentially the way
to think about it in terms of the science of your body. What do you need
to make a car run? Gasoline. We’re not talking about
electrics or hybrids. You need gasoline. What happens if you don’t
give the car gasoline? It uses what it had, slows
down, slows down, slows down, eventually will stop. What if you give
the car gasoline, take it away, give the car
gasoline, take it away? What if you– what does that do
to the efficiency of that car? It’s not going to be
as efficient a car. The body is very
similar in that way. Your metabolism is essentially
the engine of your body. Food is really the fuel. It is the energy with
which your engine runs. When a well-fed
engine works fast. When you have an engine that
is not being properly fed, when you have a body that is
not being properly fed, when you have food that’s being
put in and taken out, that affects the metabolism
and actually slows the metabolism of the body. So one of the consequences over
time of particularly bulimia, despite the fact that the
adolescent or young adult may be motivated to
lose weight, they might have a drive for thinness,
they might want a lean body type, is in fact weight gain. Because the
metabolism of the body is in fact more likely to slow
than become more efficient. And this is something that is
very hard for an adolescent to understand, because
once again it’s an immediate sort of approach. I’ve eaten too much. I feel really badly about this. I need to do something to
feel better and potentially to achieve my goal
of being thin, and therefore there can
be purging behaviors. So we explain that
principle in terms of the metabolism and
the potential slowing, and the fact that
you’re actually being counterproductive
to the goal that you want. But it sometimes needs to
be explained multiple times in reference to somebody
really being able to wrap their mind around that. That slowing response of the
body, what does that mean? Anytime something slows
it’s going to quiet down. That’s the way I think about it. So how do we see
that in the system? We see it through
lower heart rates. We see it through
lower blood pressures. We see it through
lower temperatures. These are all mechanisms
by which the body tries to conserve energy. You don’t have consistent
energy in in a way that is sustainable for the system. The system is going to try and
survive the best that it can. It will try and conserve energy. So in that survival mode, it
will also try and prioritize certain organ systems,
the brain, the heart. Adolescents will often
tell you, depending on how much energy
they’re taking in, depending on their
degree of malnutrition, malnutrition is the umbrella
term that we’re using here. They feel cold. Their hands and
feet can feel cold. That is the body
prioritizing certain organs as opposed to getting
as much blood out to the hands and the feet. That’s one way in which
it shows up in reference to the science of your body. If your body is not
consistently getting nutrition, it’s not going to prioritize
growth and development. So if we think about an
adolescent who is a 12-year-old and you think about a 19,
20-year-old adolescent, there’s a significant
amount of growth that’s happened during
that time period. And one of the analogies
I use for that is you’re building the house
you’re going to live in. So you’re building a lot of your
bone density during that time. You’re building your organs. You’re building the
body that you’re going to carry with
you into adult life. So this is a really
key growth time, in reference to getting
the nutrition that you need so you build a strong
foundation that you then carry with you into adult life. And if you’re not building
that strong foundation, you’re more likely to have
complications, not just as a teenager but then
also in adulthood. I won’t go over this, because
Dr. Fitzpatrick already reviewed some of that. So we’ll talk about
complications with bulimia. I put this slide up
front, because for teens and young adults more
immediate consequences, more visual consequences
may be more impactful, talking about things
such as your skin and having unhealthy
skin, if you will. You can have dry skin and hair. Skin is our largest organ. A healthy body is going to
demonstrate healthy skin. So people can oftentimes,
when once again, one of the first things
we’ll see is dry hair, dry skin, hair loss over time. You need a well-nourished
body in order to grow hair. People can appear tired. They can appear pale. I mentioned this last thing
called Russell’s sign. That’s a medical term,
and what that is is sometimes adolescents use their
hands to help them to purge. And by purging I mean vomiting,
although Dr. Fitzpatrick also mentioned different
methods of purging, which include the
use of laxatives, or diuretics, or even exercise. But in this context what I mean
when I say purging is vomiting. And what sometimes can happen
is if you’re repeatedly using your hand to
induce vomiting, you can get scars and
abrasions on your fingers and your knuckles. And so this is one
of the signs that we might see with the teenager
or young adult who’s struggling with this illness,
that they have these abrasions and scars or thickened skin,
and we call that Russell’s sign. So I’ve got some pictures. Obviously as you can see
some of them are cartoons and some of them are
just regular pictures in an effort to explain some of
the things that we worry about. We’re going to talk about the
gastrointestinal tract, the GI tract. We’ll just call it the
GI tract in reference to why do we worry about
certain medical complications in the context of bulimia. So our GI tract
extends from our mouth all the way down to our rectum. And we’re going to
think about and talk about what are the complications
that we worry about when we have someone who is
vomiting and bringing up the stomach acids that should
be housed in our stomach. Let me just go back to this
picture for just one second. So if you think about the mouth,
the esophagus, the tube that carries the food
into our stomach. And then this
essentially communicates with our intestines and we
have our small intestine, our large intestine,
and eventually where we stool
through our rectum, just to give you a sense of
what are we talking about here. In the mouth, if you
are vomiting repeatedly it’s not uncommon
that people will have inflammation at the back
of their throat and potentially a sore throat. Sometimes they can have red dots
from the pressure of vomiting repeatedly. So this is something
that we can see. Swollen glands is often
something else that we see. If you’ve ever eaten
something really tart you’ve probably
had that reaction where you have the release
of some saliva in your mouth. We’ve all had that experience. That is your salivary glands
and your parotid glands. That’s those glands
working to help you digest the food that
you’ve put in your mouth, and those glands kick
in any time we eat. These glands when they’re
repeatedly stimulated, potentially through
the action of purging, can enlarge over time. So this diagram
right here basically shows the parotid
gland in particular that we see sometimes
gets larger and can feel occasionally painful and
tender for the adolescent. It gets swollen, essentially. How does that show
up in reference to if you’re concerned
that there’s behaviors that you’re potentially
seeing that you want to see whether or not is this
worsening, is there potentially purging. You might notice that
there are changes in the facial structure of
the young person that you’re working with. You might notice that they’re
getting a little bit more swollen around their jaw line. That could suggest that these
glands are potentially getting a little bit more swollen. Tooth decay is something
that we commonly see. If you think about once again
the stomach acids being brought up into the mouth
repeatedly, it can wear on the enamel of the teeth. You can get yellowing and
tooth sensitivity over time, because you’re wearing off of
the enamel, the enamel layer. Interestingly enough in binge
eating disorder as well, you can have an increased
risk for tooth decay also, because if you’re binging
on some of the foods that Dr. Fitzpatrick
described, particularly sugary foods, high
carbohydrate foods, that increases your
propensity for tooth decay. So this is something
that we can see in terms of increased risk for
cavities, caries, gingivitis, all those sorts of
things with someone who is struggling with
binge eating disorder, and then with bulimia in
reference to enamel erosion. Excuse me. Bad breath is also
something else that is commonly–
that can be something that is commonly seen. This might be more
impressive for an adolescent to hear something
like this is something that could cause bad breath. This is something that could
make your teeth a little bit more sensitive. Potentially those longer term
consequences, such as this could have an impact
on your development, this could have an impact on
future consequences for you. Those things might not
register as much with a teen, but whereas you’re
talking about something like, hey, your skin
might not look as healthy, or your teeth might turn
yellow, or your breath might not smell good, these potentially
are things that could be more impactful for your teen. So this is just highlighting
some more of the GI tract issues. This is a little snippet of that
connection between the stomach and the esophagus. The skin in our mouth is
very similar to the skin in our esophagus, which
is different than the skin in our stomach. The skin in our
stomach is thicker. It’s used to having the
stomach acids, which are going to be– which
are basically a more complex fluid, if you will. The skin in our mouth
and our esophagus is not designed to be
exposed to that stomach acid for an extended period
of time or repeatedly. So when we do have the
gentle skin of our mouth and our esophagus
repeatedly exposed, it can lead to damage
to that skin over time. And the force with which
sometimes adolescents or young adults can–
they purge or vomit, making themselves throw up, can
lead to tissue damage as well. It might lead to tears, and
we worry about them bleeding as a result of these tears. Sometimes the
tears can be small. Sometimes the
tears can be large, and we are concerned that
that might lead to bleeding, depending on the degree
of that tearing that happens with that
gentle skin that is being repeatedly exposed. Acid reflux, the
discomfort that’s associated with that, GI
pain, potentially chest discomfort or pain. These are things that
people can complain of. So these are some of
the things that we think about in reference
to the GI complications. In reference to how do these
things influence the heart, dehydration is a concept that
influences general well-being, but then also potentially could
influence the heart as well. You could lose fluids
when you’re purging. You can vomit an excess
amount of fluids. If you’re using something
like a diuretic or a laxative, you can pee out or stool
out a large amount of fluid. This can lead to dehydration. That is going to lead
to weakness, potentially for an adolescent. That can also lead to
changes in their heart rate and their blood pressure. And these are things
that we consider when we check their heart
rates and blood pressures when they come into our clinic. If you think about how your
heart works when you’re lying down, it
doesn’t have to work as hard to get blood to
your head, to your feet, and back to your heart. Now if you think about how your
heart works when you sit up, it works a little bit harder to
get blood up, down, and back. Now you stand up, it’s
working even harder at getting blood to your feet,
getting blood to your brain, getting it back,
and circulating it in different parts of your body. If you’re otherwise
healthy, the heart, the body should be able to make
an adjustment in your heart rate and blood pressure within
a reasonable range to where you don’t feel dizzy, where
you don’t feel wobbly. You’re able to get up
from a seated position. You’re able to get up out of bed
and not really feel badly, not feel once again dizzy or so. When your system is weakened,
let’s say potentially you’re dehydrated,
you’re not eating in an appropriate manner. Your body is going
to be weakened and your heart isn’t able
to make those adjustments in that reasonable range. So your blood flow
changes, blood flow changes to your brain. That is going to be
felt by the individual. That could be felt as dizziness. We worry about somebody passing
out as a result of that. So this is an important
marker in reference to the well-being of the body. Can the body, can the heart
make an adjustment in reference to the heart rate and blood
pressure in a safe way when you’re doing
different activities? So one of the other
things we talk about is loss of electrolytes,
especially potassium. So electrolytes, the
word I use word is salts. We have certain important
salts in our body that essentially help
our body to work well. When we have a dysfunction,
what happens with that is that we can have a
shifting in these salts. When we have somebody who is
purging, or using a diuretic, or using a laxative, it changes
the balance of these salts. These salts are very important
for our heart to beat well. They’re very important for even
for ourselves to work well. So we worry about how having
low levels of certain salts can lead to dysfunction
in reference to how your heart is beating. A broad concept to think
about is once again that quieting response and
how does the body adjust to increased energy demands. So I included something
here in reference to cardiac output,
exercise capacity. Oftentimes young
people can be very motivated to be very active. If they are not feeding
the engine of their body to support that
level of activity, their body is going to get
more and more depleted. So that’s a really
important thing to keep in mind in
reference to, first of all, not having enough nutrition
to support basic function. And then secondly, overexerting
the body and the impact that that could
have in reference to collapsing, or in
reference to feeling fatigued, in
reference to the heart not being able to
tolerate stress or intensity in reference
to excess activity. This is also once
again broad concepts, and on the heels of what
Dr. Fitzpatrick was talking about in cognitive
changes, how are you thinking when you’re depleted. I’m sure everybody has had the
experience of being tired, not getting enough sleep, maybe
having a day where you weren’t able to eat as well as you
would have otherwise liked to. By the end of that
day, you probably were not able to do much more,
because you hadn’t nourished and taken care of your system. So if you think about this
happening on a regular basis, people aren’t necessarily going
to feel well and think well, and you could have
slowed thinking. We talk about stuck thinking. One of the things
that we frequently see is when adolescents when
they’re not eating well, when they’re not taking
care of their system they tend to ruminate more on
certain thoughts and behaviors related to their
dysfunctional eating. They tend to be more stuck in
it when they’re not consistently nourishing their body. And what we’ve
oftentimes seen is you have to have a
certain threshold of consistent nutrition,
maybe even consistent weight before adolescents
are able to move beyond that stuck
sort of thinking. So that’s an important
thing to keep in mind. We mentioned the
distortions in reference to self-assessment
of weight and shape. Once again, if your
body’s more depleted, are you even going
to have the energy to challenge some of
these thoughts that could be coming up for you. So this is embedded in
the science of your body, if you will. So there’s a lot
of systemic effects that can happen with the body. And I just included
this because I thought it was an easy, sort
of diagrammatic approach in reference to
some of the things that we’ve already talked
about and in looking at the various impacts that
could happen with the body. One of the other things
that I didn’t mention is something that’s
present in the corner here, which is hormones. This is if you think
about it most intuitively, does it make sense for
the body to lose blood if it doesn’t have the nutrition
in order to replace and replete those cells. It really doesn’t. The body goes into
protective or survival mode. How does it do that? It does that by trying to quiet
that system down and shut it off, essentially. We do that by quieting
down the hormones that help us to get periods,
so the hormones that help with pubertal development. Those same hormones that help
with pubertal development in periods are the
hormones that also help us to build strong bones. So irregular cycles,
irregular periods, irregularity in this
sense, once again, are a marker for
imbalance in the body. This of course has the
short term consequences of suggesting the
imbalance and the impact. And then, of course, the
long term consequences the longer malnutrition goes
on, the more of an impact it’s likely to
have on the system. And there are some studies
to suggest that bulimia, in particular in reference
to reproductive health in the future, that
it impacts that. And it could be related to
hormone irregularity, but then also just the chronic
effects of malnutrition. So this is just an important
concept to be aware of. So in terms of binge
eating disorder, we’ve brought in some
concepts in reference to that as we’ve been
talking about bulimia. Binge eating disorder, the
medical complications of this are really very similar
to the disorders related with clinical obesity, although
not all individuals who have binge eating
disorder are overweight. But if you think about what are
the complications with this, oftentimes we see
limpid abnormalities which are high cholesterol
or are high triglycerides. This could be related from
maladaptive eating habits. We see risks of high blood
pressure, risks for diabetes, obstructive sleep apnea. Essentially, this
is something that’s more related to weight
for some, for individuals. And once again, very
similar to the complications related to clinical obesity. Potential vitamin deficiencies. Despite the fact
that someone may be binging on large
volumes of food, it doesn’t necessarily
mean that they’re getting the nutrients that they
need in order for their body to work well. So people can have
vitamin deficiencies, despite the fact that
they may feel like they’re eating excessively. Based on weight related
to binge eating disorder, people could have
stress on their joints. We talked about problems
with menses and infertility in reference to
irregularity of the bodies– I mean irregularity in
terms of the body function. And people who suffer
with binge eating disorder can also have increased symptoms
of irritable bowel syndrome, fibromyalgia, insomnia. One of the concepts that
I talk about frequently is we all think about how we
need nutrition in order to run, in order to be
physically active. But in reality, you also
need nutrition in order for your brain to work well
and for you to sleep well. So sleep dysregulation
is something that we commonly see in
disordered eating and eating disorders because
your brain is not getting the nutrition in order
to be able to sleep well. So this is something
that I frequently tell parents and tell teens,
because a lot of time people complain of the fact
that they’re not able to fall asleep,
that they’re waking up, or that they just don’t
have restful sleep. And there’s a lot of
complex nuances in reference to sleep in terms of how
stress affects the system, but nutrition is a key
piece of your, once again, your body staying in
balance and working well, and also regulating your sleep. So these are some of the
concepts in reference to bulimia and binge
eating disorder, in terms of the
medical complications. And we can certainly
talk more about it as we talk about the
Questions section. Thank you.

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  1. Personally, I suffer from BN. Identifying and becoming aware of the problem is the first step to overcoming it so here I come…

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