Eating disorders in obese people

Introduction
The issue of obesity and eating disorders (PPD) has many interrelated aspects. Obesity (and even more so called dieting) can play a significant role in the etiology of eating disorders. Diets then, along with overeating, in the development of obesity. Obesity within the metabolic syndrome leads to increased cardiovascular mortality and morbidity, this risk is helped to reduce by bariatric operations that treat not only obesity, but also other components of the metabolic syndrome.

Eating disorders, especially anorexia nervosa and bulimia nervosa, have been of interest to psychiatrists for a long time. It is paradoxical that obesity, on the other hand, is treated almost exclusively by internists, unless it is accompanied by, for example, depression. Eating disorders in obese people have so far been completely ignored by internists, so patients were not even sent for psychiatric diagnosis.

Among the obese, the following eating disorders are most common : binge eating disorder, night eating syndrome and continuous eating (grazing). We specify the individual disorders in more detail.

None of the listed eating disorders is specified in ICD 10. In the 10th revision of the International Classification of Diseases, we find the categories Overeating associated with other mental disorders ( F50.4 ), Vomiting associated with other mental disorders ( F50.5 ), Other eating disorders ( F50.8 ) and Eating disorder, unspecified ( F50.9 ). Binge eating associated with other psychological disorders is described as binge eating that has led to obesity as a response to a stressful event. Loss of a loved one, accidents, surgical operations and emotionally stressful events can trigger "reactive obesity" especially in patients with a tendency to gain weight.

Description of individual faults
Binge Eating Disorder (BED)

The DSM IV (Diagnostic and Statistical Manual of Mental Disorders - Internationally Used 1994 American Psychiatric Association) lists the following criteria:

A. Binge eating is defined as eating more food than usual in a short period of time (less than 2 hours). During an attack, the patient loses control over his eating behavior.

B. Seizures are associated with 3 or more of the following:


 * the patient eats to an unpleasant fullness;
 * consumes large amounts of food without feeling hungry;
 * food is consumed more quickly than usual;
 * he eats alone because he is ashamed of the amount of food he eats;
 * overeating is followed by feelings of guilt, depression, self-disgust.

C. Present anxiety is associated with binge eating.

D. Binge eating episodes occur at a frequency of at least twice a week for the past 6 months.

E. Binge eating is not associated with subsequent compensatory behavior (as in other PPPs).

The results of research dealing with binge eating are inconsistent, as different criteria have been used to assess the severity of binge eating. Researches that strictly used the criteria for the diagnosis of BED according to DSM IV point to a frequency of occurrence of this disorder in obese patients of 4.2% or 7.5%. It was 10–27% for those waiting for a bariatric procedure.

Regardless of the stringency of the criteria used to diagnose BED, studies agree that patients with BED have higher depression scores,  earlier onset of obesity, and more general psychopathology. In individual research, we then find that patients with this disorder have more cravings, use more weight loss drugs, have a greater fear of being fat and are less satisfied with their own bodies than obese patients without this disorder [5. It is more often women under the age of 45 with a higher BMI (above 42).

Night eating syndrome (Night Eating Syndrome, NES)
NES criteria are not yet specified in the international classification of diseases. A. Stunkard is trying to include them in DSM V. In his opinion, it is a complex biobehavioral disorder with a disruption of the circadian rhythm.

Stunkard determines 2 basic diagnostic criteria:

A. evening meal (at least 25% of the daily caloric intake is consumed after dinner);

B. and/or awakening associated with food intake at least three times a week.

According to A. Stunkard the incidence of this disorder in the obese population is 6–16% and in patients suitable for bariatric surgery 8–42%. In Italy, they diagnosed NES in 10% of patients with obesity of the 2nd and 3rd degree (BMI is higher than 35), at the same time they found an increased incidence of depression in these patients. Our clinical experience best matches the results of Allison et al.'s research, which narrows the frequency of this syndrome in patients before bariatric surgery to 1.9-3.9%.

NES needs to be distinguished from the so-called Sleep related eating disorder (SRED). This disorder is specified by rapid consumption of food (mostly within ten minutes), but also inedible objects (cleaning agents, glue, etc.). Although these attacks also happen at night, it is not a shift in the circadian rhythm of eating. The patient usually has amnesia for nocturnal eating attacks.

Continuous eating (Grazing)
A newly described symptom has so far escaped the attention of researchers and clinicians. This is the continuous consumption of smaller amounts of food without free control. For the diagnosis of this symptom, the quantity of food consumed is not primarily important, but the quality of the experience, i.e. subjectively negative perception of loss of control over one's eating behavior and excessive food intake. This symptom is very important to monitor, especially in patients before a bariatric procedure, as it can fundamentally affect the success of the procedure. Binge eating occurring in a patient before a bariatric procedure can subsequently change to Grazing after the operation,.

Diagnostics
Patients often do not admit to eating disorders, and if they are aware of them, they are ashamed of them and hide them not only from the medical staff, but also from their immediate surroundings. The detection of PPP is facilitated by working with the menu, so it is often dieticians who are the first to raise suspicions of PPP. The patient also confides in the nurse about his problems more easily than the doctors, before whom he often tries to appear in a better light. However, an internist can diagnose PPP with several targeted questions such as: "Do you ever eat at night?", "Do you sometimes eat until you are uncomfortably full?", "If so, under what circumstances and how often does this happen to you?" ", "Do you snack during the day?", "Do you sometimes feel that you lose control over the way you eat (e.g. the speed of eating) and what you eat?". If the answers to these questions are positive (food during the night shift and exceptional overeating at parties are not pathological), it is advisable to send the patient to a psychologist or psychiatrist for further diagnosis. Loss of control over eating behavior and eating alone with subsequent feelings of shame are good clues for suspecting PPP.

The topic of eating disorders and bariatric surgery is beyond the scope of this article. Simply put, when PPP is suspected, we prefer a malabsorptive type of surgery (e.g. gastric bypass) to a restrictive one (e.g. gastric banding or gastric tubulation). However, one of the mandatory examinations before a bariatric procedure is a psychological examination, so the detection of eating disorders in bariatric candidates and the subsequent procedure for diagnosis is thereby ensured.

Therapy
Treatment of obese people with eating disorders requires a specific approach. It turns out to be advantageous to work in a multidisciplinary team - internist, dietician, clinical psychologist, consulting psychiatrist. Psychological treatment of eating disorders consists of psychotherapy. The type of psychotherapy depends on the psychotherapeutic equipment of a specific psychologist (or psychiatrist). Both individual and multi-member (couple, family and multi-family) therapy is used in the treatment of eating disorders. The direction of therapy is also not strictly given, we can use the spectrum from behavioral types of psychotherapy to psychoanalytic therapies to the directions of humanistic and existential psychotherapy.

Psychiatric medication is suitable for long-term untreated and more severe forms of PPP. Among the non-psychiatric drugs, sibutramine (temporarily suspended in Europe) has proven to be effective in the treatment of eating disorders in obese patients. It not only helped to reduce the weight of the patients, but also reduced the incidence of binge eating compared to a control group that took a placebo. The antiepileptic drug topiramate also has a similar effect with a beneficial anxiolytic effect inducing even a slight weight loss. In addition to topiramate, another anticonvulsant, lamotrigine, was also tested. On the same principle, i.e. primarily suppressing impulsivity, dual antidepressants can apparently also be effective, which specifically inhibit the reuptake of serotonin and noradrenaline (SNRI - e.g. duloxetine).

Conclusion
Eating disorders significantly affect the success of treatment in obese patients. Treatment by only one specialist - be it an obesitologist or a psychiatrist - is not very effective and exhausting for the said specialist. In practice, a multidisciplinary approach is proven, preferably in a team - an internist, a dietician, a clinical psychologist and a psychiatrist.

Related Articles

 * Psychological aspects of obesity
 * Eating disorders

Source

 * WEAK, Šárka. Psychological counseling in practice.

Reference
<ref group="KRCH, FD. Eating disorders. 2nd edition. Prague: Grada, 2005.  SOUČEK, M. Metabolic syndrome. Internal Medicine. 2009, year -, vol. 55, pp. 618-621,  SVAČINA, Š. Treatment of obesity in metabolic syndrome. Internal Medicine. 2009, year -, vol. 55, pp. 622-5,  ALLISON, KC, TA WADDEN, and DB SARWER, et al. Night Eating Syndrome and Binge Eating Disorder among Persons Seeking Bariatric Surgery: Prevalence and Related Features. Obesity. 2006, year -, vol. 14, pp. 77-82,  RICCA, V, E MANNUCCI and S MORETTI, et al. Screening for binge eating disorder in obese outpatients. Comprehensive Psychiatry. 2000, year -, vol. 41, pp. 111-115,  SARWER, DB, TA WADDEN, and AN FABRICATORE. AN. Psychosocial and Behavioral Aspects of Bariatric Surgery. Obesity Research. 2005, year -, vol. 13, pp. 639–648,  MUSSELL, MP, JE MITCHELL and M DE ZWAAN, et al. Clinical characteristics associated with binge eating in obese females: a descriptive study. International J Obes Relat Metab Disord. 1996, year -, vol. 20, pp. 324-31,  WHEELER, K., P. GREINER, and M. BOULTON. Exploring alexithymia, depression, and binge eating in self-reported eating disorders in women.. Perspect Psychiatry Care. 2005, year -, vol. 41, pp. 114-123,  GRISSET, NI and ML FITZGIBBON. The clinical significance of binge eating in an obese population: support for bed and questions regarding its criteria. Addict Behav. 1996, year -, vol. 21, pp. 57-66,  KOLOTKIN, RL, EC WESTMAN and T ØSTBYE, et al. Does Binge Eating Disorder Impact Weight-Related Quality of Life?. Obesity Research. 2004, year -, vol. 12, pp. 999–1005,  STUNKARD, AJ, K ALISSON and A GELIEBTER, et al. Development of criteria for a diagnosis: lessons from the night eating syndrome.. Compr Psychiatry.. 2009, vol. -, vol. 50, pp. 391-9.,  STUNKARD, AJ, K ALISSON, and J LUNDGREN. Issues for DSM-V: Night Eating Syndrome. Am J Psychiatry. 2008, year -, vol. 165, p. 424,  CALUGI, S, R GRAVE and G MARCHESINI. Night eating syndrome in class II-III obesity: metabolic and psychopathological features. Int J Obes (Lond). 2009, year -, vol. 33, pp. 899-904,  HOWELL, MJ and CH SCHENCK. Treatment of nocturnal eating disorders. Curr Treat Options Neurol. 2009, year -, vol. 11, pp. 333-9,  SAUNDERS, R. “Grazing”: a high risk behavior. Obesity Surgery. 2004, year -, vol. 14, pp. 98-102,  COLLES, SL, JB DIXON and PE O'BRIEN. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity (Silver Spring). 2008, year -, vol. 16, pp. 615-622,  FRIED, M. Bariatric surgery and the kidney. Internal Medicine. 2008, year -, vol. 54, pp. 468-71,  WILFLEY, DE, SJ CROW and JI HUDSON, et al. al. Efficacy of Sibutramine for the Treatment of Binge Eating Disorder: A Randomized Multicenter Placebo-Controlled Double-Blind Study. Am J Psychiatry. 2008, year -, vol. 165, pp. 51-58,  LEOMBRUNI, P., L. LAVAGNINO and S. FASSINO. Treatment of obese patients with binge eating disorder using topiramate: a review.. Neuropsychiatr Dis Treat. 2009, year -, vol. 5, pp. 385–392,  GUERDJIKOVA, A, SL MCELROY and JA WELGE, et al. Lamotrigine in the treatment of binge-eating disorder with obesity: a randomized, placebo-controlled monotherapy trial. Int Clin Psychopharmacol. 2009, year -, vol. 24, pp. 150-158,  LEOMBRUNI, P., L. LAVAGNINO and F. GASTALDI, et al. Duloxetine in obese binge eater outpatients: preliminary results from a 12-week open trial.. Human Psychopharmacology: Clinical and Experimental. 2009, year -, vol. 24, pp. 483-488, ">KRCH, FD. Poruchy příjmu potravy. 2. vydání. Praha : Grada, 2005.

SOUČEK, M. Metabolický syndrom. ''Vnitřní lékařství. ''2009, roč. -, vol. 55, s. 618-621,

SVAČINA, Š. Léčba obezity u metabolického syndromu. ''Vnitřní lékařství. ''2009, roč. -, vol. 55, s. 622-5,

ALLISON, KC, TA WADDEN a DB SARWER, et al. Night Eating Syndrome and Binge Eating Disorder among Persons Seeking Bariatric Surgery: Prevalence and Related Features. ''Obesity. ''2006, roč. -, vol. 14, s. 77-82,

RICCA, V, E MANNUCCI a S MORETTI, et al. Screening for binge eating disorder in obese outpatients. ''Comprehensive Psychiatry. ''2000, roč. -, vol. 41, s. 111-115,

SARWER, DB, TA WADDEN a AN FABRICATORE. AN. Psychosocial and Behavioral Aspects of Bariatric Surgery. ''Obesity Research. ''2005, roč. -, vol. 13, s. 639–648,

MUSSELL, MP, JE MITCHELL a M DE ZWAAN, et al. Clinical characteristics associated with binge eating in obese females: a descriptive study. ''Int. J. Obes Relat Metab Disord. ''1996, roč. -, vol. 20, s. 324-31,

WHEELER, K., P. GREINER a M. BOULTON. Exploring alexithymia, depression, and binge eating in self-reported eating disorders in women.. ''Perspect Psychiatr Care. ''2005, roč. -, vol. 41, s. 114-123,

GRISSET, NI a ML FITZGIBBON. The clinical significance of binge eating in an obese population: support for bed and questions regarding its criteria. ''Addict Behav. ''1996, roč. -, vol. 21, s. 57-66,

KOLOTKIN, RL, EC WESTMAN a T ØSTBYE, et al. Does Binge Eating Disorder Impact Weight-Related Quality of Life?. ''Obesity Research. ''2004, roč. -, vol. 12, s. 999–1005,

STUNKARD, AJ, K ALISSON a A GELIEBTER, et al. Development of criteria for a diagnosis: lessons from the night eating syndrome.. ''Compr Psychiatry.. ''2009, roč. -, vol. 50, s. 391-9.,

STUNKARD, AJ, K ALISSON a J LUNDGREN. Issues for DSM-V: Night Eating Syndrome. ''Am J Psychiatry. ''2008, roč. -, vol. 165, s. 424,

CALUGI, S, R GRAVE a G MARCHESINI. Night eating syndrome in class II-III obesity: metabolic and psychopathological features. ''Int J Obes (Lond). ''2009, roč. -, vol. 33, s. 899-904,

HOWELL, MJ a CH SCHENCK. Treatment of nocturnal eating disorders. ''Curr Treat Options Neurol. ''2009, roč. -, vol. 11, s. 333-9,

SAUNDERS, R. “Grazing”: a high risk behavior. ''Obesity Surgery. ''2004, roč. -, vol. 14, s. 98-102,

COLLES, SL, JB DIXON a PE O'BRIEN. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. ''Obesity (Silver Spring). ''2008, roč. -, vol. 16, s. 615-622,

FRIED, M. Bariatrická chirurgie a ledviny. ''Vnitř Lék. ''2008, roč. -, vol. 54, s. 468-71,

WILFLEY, DE, SJ CROW a JI HUDSON, et al. al. Efficacy of Sibutramine for the Treatment of Binge Eating Disorder: A Randomized Multicenter Placebo-Controlled Double-Blind Study. ''Am J Psychiatry. ''2008, roč. -, vol. 165, s. 51-58,

LEOMBRUNI, P., L. LAVAGNINO a S. FASSINO. Treatment of obese patients with binge eating disorder using topiramate: a review.. ''Neuropsychiatr Dis Treat. ''2009, roč. -, vol. 5, s. 385–392,

GUERDJIKOVA, A, SL MCELROY a JA WELGE, et al. Lamotrigine in the treatment of binge-eating disorder with obesity: a randomized, placebo-controlled monotherapy trial. ''Int Clin Psychopharmacol. ''2009, roč. -, vol. 24, s. 150-158,

LEOMBRUNI, P., L. LAVAGNINO a F. GASTALDI, et al. Duloxetine in obese binge eater outpatients: preliminary results from a 12-week open trial.. ''Human Psychopharmacology: Clinical and Experimental. ''2009, roč. -, vol. 24, s. 483-488,  <references group="KRCH, FD. Eating disorders. 2nd edition. Prague: Grada, 2005.  SOUČEK, M. Metabolic syndrome. Internal Medicine. 2009, year -, vol. 55, pp. 618-621,  SVAČINA, Š. Treatment of obesity in metabolic syndrome. Internal Medicine. 2009, year -, vol. 55, pp. 622-5,  ALLISON, KC, TA WADDEN, and DB SARWER, et al. Night Eating Syndrome and Binge Eating Disorder among Persons Seeking Bariatric Surgery: Prevalence and Related Features. Obesity. 2006, year -, vol. 14, pp. 77-82,  RICCA, V, E MANNUCCI and S MORETTI, et al. Screening for binge eating disorder in obese outpatients. Comprehensive Psychiatry. 2000, year -, vol. 41, pp. 111-115,  SARWER, DB, TA WADDEN, and AN FABRICATORE. AN. Psychosocial and Behavioral Aspects of Bariatric Surgery. Obesity Research. 2005, year -, vol. 13, pp. 639–648,  MUSSELL, MP, JE MITCHELL and M DE ZWAAN, et al. Clinical characteristics associated with binge eating in obese females: a descriptive study. International J Obes Relat Metab Disord. 1996, year -, vol. 20, pp. 324-31,  WHEELER, K., P. GREINER, and M. BOULTON. Exploring alexithymia, depression, and binge eating in self-reported eating disorders in women.. Perspect Psychiatry Care. 2005, year -, vol. 41, pp. 114-123,  GRISSET, NI and ML FITZGIBBON. The clinical significance of binge eating in an obese population: support for bed and questions regarding its criteria. Addict Behav. 1996, year -, vol. 21, pp. 57-66,  KOLOTKIN, RL, EC WESTMAN and T ØSTBYE, et al. Does Binge Eating Disorder Impact Weight-Related Quality of Life?. Obesity Research. 2004, year -, vol. 12, pp. 999–1005,  STUNKARD, AJ, K ALISSON and A GELIEBTER, et al. Development of criteria for a diagnosis: lessons from the night eating syndrome.. Compr Psychiatry.. 2009, vol. -, vol. 50, pp. 391-9.,  STUNKARD, AJ, K ALISSON, and J LUNDGREN. Issues for DSM-V: Night Eating Syndrome. Am J Psychiatry. 2008, year -, vol. 165, p. 424,  CALUGI, S, R GRAVE and G MARCHESINI. Night eating syndrome in class II-III obesity: metabolic and psychopathological features. Int J Obes (Lond). 2009, year -, vol. 33, pp. 899-904,  HOWELL, MJ and CH SCHENCK. Treatment of nocturnal eating disorders. Curr Treat Options Neurol. 2009, year -, vol. 11, pp. 333-9,  SAUNDERS, R. “Grazing”: a high risk behavior. Obesity Surgery. 2004, year -, vol. 14, pp. 98-102,  COLLES, SL, JB DIXON and PE O'BRIEN. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity (Silver Spring). 2008, year -, vol. 16, pp. 615-622,  FRIED, M. Bariatric surgery and the kidney. Internal Medicine. 2008, year -, vol. 54, pp. 468-71,  WILFLEY, DE, SJ CROW and JI HUDSON, et al. al. Efficacy of Sibutramine for the Treatment of Binge Eating Disorder: A Randomized Multicenter Placebo-Controlled Double-Blind Study. Am J Psychiatry. 2008, year -, vol. 165, pp. 51-58,  LEOMBRUNI, P., L. LAVAGNINO and S. FASSINO. Treatment of obese patients with binge eating disorder using topiramate: a review.. Neuropsychiatr Dis Treat. 2009, year -, vol. 5, pp. 385–392,  GUERDJIKOVA, A, SL MCELROY and JA WELGE, et al. Lamotrigine in the treatment of binge-eating disorder with obesity: a randomized, placebo-controlled monotherapy trial. Int Clin Psychopharmacol. 2009, year -, vol. 24, pp. 150-158,  LEOMBRUNI, P., L. LAVAGNINO and F. GASTALDI, et al. Duloxetine in obese binge eater outpatients: preliminary results from a 12-week open trial.. Human Psychopharmacology: Clinical and Experimental. 2009, year -, vol. 24, pp. 483-488,  " />