ANOREXIA NERVOSA  PET scan study: caudate nucleus metabolism was higher in

 Greek: loss of appetite the anorectic state than after realimentation

 Latin: nervous origin  dysfunction neurotransmitters involved in regulating eating
behavior in the paraventricular nucleus of the hypothalamus
 syndrome - 3 criteria  serotonin
 self-induced starvation to a significant degree (behavior)  dopamine
 relentless drive for thinness or a morbid fear of fatness  norepinephrine
(psychopatholgy)  corticotropin-releasing factor (CRF)
 presence of medical signs and symptoms resulting from  neuropeptide Y
starvation (physiological symptomatology)  gonadotropin-releasing hormone
 thyroid-stimulating hormone
 +/- disturbances of body image – perception that one is Social Factors
distressingly large despite obvious thinness  find support for their practices in society's emphasis on
thinness and exercise
 50%- reduce total food intake  No family constellations are specific to anorexia
 50%- diet + binge eating followed by purging behaviors nervosa
 close, but troubled, relationships with their parents
 F > M (10-20X)  high levels of hostility, chaos, and isolation and low levels
 in adolescence of nurturance and empathy
 underlying psychological disturbance:  strict ballet schools: sevenfold increase
 conflicts: girlhood  womanhood  wrestling - 17 &
 helplessness and difficulty establishing autonomy  gay orientation in men
 from spontaneous recovery to a waxing and waning course to
death
Psychological and Psychodynamic Factors
 reaction to the demand that adolescents behave more
EPIDEMIOLOGY
independently and increase their social and sexual
 onset
functioning
 5 % - early 20s
 most common: midteens (14 -18 years)  typically lack a sense of autonomy and selfhood
 developed countries  they experience their bodies as somehow under the control
of their parents, so that self-starvation may be an effort to
 young women in modeling and ballet (require thinness)
gain validation as a unique and special person
 these young patients have been unable to separate
COMORBIDITY
psychologically from their mothers
 depression 65%
 the body may be perceived as though it were inhabited by
 social phobia 35 %
the introject of an intrusive and unempathic mother
 OCD 25%
 starvation may unconsciously mean arresting the growth of
this intrusive internal object and thereby destroying it
(projective identification)
ETIOLOGY  feel that oral desires are greedy and unacceptable;
 Biological, social, and psychological factors are implicated in therefore, these desires are projectively disavowed
the causes of anorexia nervosa
 monozygotic twins > dizygotic twins Neuroendocrine Changes in Anorexia Nervosa and
 Sisters of patients with anorexia nervosa are likely to be Experimental Starvation
afflicted (social influences)
Hormone Anorexia Nervosa Weight Loss
 Major mood disorders: family members > general population
 diminished NE turnover and activity are suggested by Corticotropin-releasing Increased Increased
reduced 3-methoxy-4-hydroxyphenylglycol (MHPG) levels in hormone (CRH)
the urine and the cerebrospinal fluid (CSF) Plasma cortisol levels Mildly increased Mildly
 inverse relation between MHPG and depression increased
Diurnal cortisol Blunted Blunted
Biological Factors difference
 Endogenous opioids  denial of hunger Luteinizing hormone Decreased, prepubertal Decreased
 Starvation  hypercortisolemia not suppression by (LH) pattern
dexamethasone Follicle-stimulating Decreased, prepubertal Decreased
 ↓ Thyroid function hormone (FSH) pattern
 CT: enlarged CSF spaces (enlarged sulci and ventricles)

1
Growth hormone (GH) Impaired regulation Same
Increased basal levels Norepinephrine Reduced turnover Reduced
and limited response to turnover
pharmacological probes Dopamine Blunted response to –
Somatomedin C Decreased Decreased pharmacological probes

Thyroxine (T4) Normal or slightly Normal or

decreased slightly DSM-5 Diagnostic Criteria for Anorexiazzzz
decreased
Triiodothyronine (T3) Mildly decreased Mildly
decreased
Reverse T3 Mildly increased Mildly
increased
Hormone Anorexia Nervosa Weight Loss
Thyrotropin- Normal Normal
stimulating hormone
(TSH) Diagnosis and Clinical Features
TSH response to Delayed or blunted Delayed or  present when
thyrotropin-releasing blunted 1. an individual voluntarily reduces and maintains an
hormone (TRH) unhealthy degree of weight loss or fails to gain
Insulin Delayed release - weight proportional to growth;
2. an individual experiences an intense fear of
C-peptide Decreased - becoming fat, has a relentless drive for thinness
despite obvious medical starvation, or both;
Vasopressin Secretion uncoupled - 3. an individual experiences significant starvation-
from osmotic challenge related medical symptomatology, often, but not
Serotonin Increased function with exclusively, abnormal reproductive hormone
weight restoration functioning, but also hypothermia, bradycardia,
orthostasis, and severely reduced body fat stores;
and
4. the behaviors and psychopathology are present for
at least 3 months.
 An intense fear of gaining weight and becoming
obese is present in all patients
 loss of appetite is usually rare until late in the
disorder.
 abuse laxatives and even diuretics to lose weight, and
ritualistic exercising, extensive cycling, walking,
jogging, and running
 exhibit peculiar behavior about food
• hide food all over the house and frequently carry
large quantities of candies in their pockets and
purses
• they try to dispose of food in their napkins or
hide it in their pockets
• cut their meat into very small pieces and spend a
great deal of time rearranging the pieces on their
plates
 Obsessive-compulsive behavior, depression, and
anxiety are other psychiatric symptoms of anorexia
nervosa most frequently noted in the literature
 Poor sexual adjustment is frequently described
 delayed psychosocial sexual development
 unusual minority of anorectic patients have a premorbid
history of promiscuity, substance abuse, or both and
during the disorder do not show a decreased interest in
sex

2
  usually come to medical attention when their weight loss
becomes apparent
• hypothermia (as low as 35°C), dependent
edema, bradycardia, hypotension, and lanugo
(the appearance of neonatal-like hair) appear
• ECG changes: T wave flattening or inversion,
ST segment depression, and lengthening of the
QT interval
• Gastric dilation is a rare complication of anorexia
nervosa
• shown a superior mesenteric artery syndrome
Subtypes
 two subtypes:
1. Food-restricting category
- 50 % of cases
- food intake is highly restricted (usually with
attempts to consume fewer than 300 to 500
calories per day and no fat grams
- the patient may be relentlessly and compulsively
overactive, with overuse athletic injuries
- often have obsessive-compulsive traits with
respect to food and other matters
2. Purging category
- alternate attempts at rigorous dieting with
intermittent binge or purge episodes
- purging represents a secondary compensation for
the unwanted calories
• sometimes, repetitive purging occurs
without prior binge eating, after ingesting
only relatively few calories both may be
socially isolated and have depressive
disorder symptoms and diminished
sexual interest
• overexercising and perfectionistic traits are
common in both types
 Those who practice binge eating and purging share
many features with persons who have bulimia
nervosa without anorexia nervos
 Those who binge eat and purge tend to have families
in which some members are obese, and they
themselves have histories of heavier body weights
before the disorder than do persons with the restricting
type
 Binge eating-purging persons are likely to be
associated with substance abuse, impulse control
disorders, and personality disorders.
 Persons with restricting anorexia nervosa often have
obsessive-compulsive traits with respect to food and
other matters.
 Some persons with anorexia nervosa may purge but
not binge
 have high rates of comorbid major depressive
disorders; MDD or dysthymic disorder in up to 50%
of patients
 often secretive, deny their symptoms, and resist
treatment
3
 MSE usually shows a patient who is alert and
knowledgeable on the subject of nutrition and who is
preoccupied with food and weight
 must have a thorough general PE and NE
 (+) vomiting - a hypokalemic alkalosis may be
present
 serum electrolyte levels must be determined initially
and periodically during hospitalization
Pathology and Laboratory Examination
 CBC : leukopenia with a relative lymphocytosis in
emaciated patients
 serum electrolyte determination: hypokalemic
alkalosis
 Fasting serum glucose concentrations: low
 serum salivary amylase concentrations: elevated if
vomiting
 ECG: ST segment and T-wave changes
 hypotension and bradycardia
 high serum cholesterol level
 amenorrhea, mild hypothyroidism, and hypersecretion
of corticotrophin-releasing hormone
DIFFERENTIAL DIAGNOSIS
 medical illness- tumor or cancer
 Depressive disorders
 somatization disorder
 Schizophrenia
 bulimia nervosa
 hyperactivity of the vagus nerve - bradycardia,
hypotension and other parasympathomimetic signs and
symptoms are present
COURSE AND PROGNOSIS
 varies greatly: spontaneous recovery without
treatment, recovery after a variety of treatments, a
fluctuating course of weight gains followed by
relapses, and a gradually deteriorating course
resulting in death
 restricting-type anorectic patients seemed less likely to
recover than those of the binge eating-purging type
 In general, the prognosis is not good
 Indicators of a favorable outcome are
1. admission of hunger
2. lessening of denial and immaturity
3. improved self-esteem
 factors related to poor outcome:
1. childhood neuroticism
2. parental conflict
3. bulimia nervosa
4. vomiting
5. laxative abuse
6. various behavioral manifestations (e.g., OC,
hysterical, depressive, psychosomatic, neurotic, and
denial symptoms)
 25% - recover completely
 50% - improved and functioning fairly well
  25% - functioning poorly with a chronic underweight
condition
 About half of patients with anorexia nervosa eventually
will have the symptoms of bulimia, usually within the first
year after the onset of anorexia nervosa.
TREATMENT
 a comprehensive treatment plan, including
hospitalization when necessary and both individual and
family therapy, is recommended
 behavioral, interpersonal, and cognitive approaches
and, in some cases, medication should be considered
A. Hospitalization
 first consideration: to restore patients' nutritional
state; dehydration, starvation, and electrolyte
imbalances
 combination of a behavioral management
approach, individual psychotherapy, family
education and therapy, and, in some cases,
psychotropic medications
 Compulsory admission or commitment should be
obtained only when the risk of death from the
complications of malnutrition is likely.
 Patients should be weighed daily, early in the
morning after emptying the bladder.
 The daily fluid intake and urine output should be
recorded.
 If vomiting is occurring, hospital staff members must
monitor serum electrolyte levels regularly .
 Because food is often regurgitated after meals, the
staff may be able to control vomiting by making the
bathroom inaccessible
 Stool softeners may occasionally be given, but never
laxatives.
 Should give patients about 500 calories over the
amount required to maintain their present weight
(usually 1,500 to 2,000 calories a day; in six equal
feedings throughout the day
 a liquid food supplement may be advisable
 continue outpatient supervision of the problems
identified in the patients and their families
B. Psychotherapy
1. Cognitive-Behavioral Therapy
- can be applied in both inpatient and outpatient
settings
- for inducing weight gain
- Monitoring is an essential component
- to monitor their food intake, their feelings and
emotions, their binging and purging behaviors, and
their problems in interpersonal relationships
- taught cognitive restructuring to identify automatic
thoughts and to challenge their core beliefs
2. Family Therapy
- should be done for all patients with anorexia
nervosa who are living with their families
- brief counseling sessions with immediate family
C. Pharmacotherapy
4
- studies have not yet identified any medication
that yields definitive improvement of the core
symptoms of anorexia nervosa
- cyproheptadine (Periactin) - a drug with
antihistaminic and antiserotonergic properties, for
patients with the restricting type of anorexia
nervosa
- Amitriptyline (Elavil)
- clomipramine, pimozide (Orap), and
chlorpromazine (Thorazine)
Bulimia Nervosa
 episodes of binge eating + inappropriate ways of stopping
weight gain
 Physical discomfort (abdominal pain or nausea) terminates the
binge eating  followed by feelings of guilt, depression, or self-
disgust.
 maintain a normal body weight
 "oxhunger" in Greek
 "nervous involvement" in Latin.
 may represent a failed attempt at anorexia nervosa, sharing
the goal of becoming very thin, but occurring in an individual
less able to sustain prolonged semistarvation or severe hunger
as consistently as classic restricting anorexia nervosa patients.
 reasons
 "breakthrough eating" episodes of giving in to hunger pangs
generated by efforts to restrict eating so as to maintain a
socially desirable level of thinness.
 means to self- medicate during times of emotional distress.
 eating binges provoke panic as individuals feel that their eating
has been out of control.
 The unwanted binges lead to secondary attempts to avoid the
feared weight gain by a variety of compensatory behaviors,
such as purging or excessive exercise
EPIDEMIOLOGY
 more prevalent than anorexia nervosa
 1 to 4 % of young women
 onset is often later in adolescence than that of
anorexia nervosa
 Approximately 20 % of college women experience
transient bulimic symptoms at some point during
their college years
ETIOLOGY
Biological Factors
 serotonin and norepinephrine have been implicated
 plasma endorphin levels are raised in some patients who
vomit
 increased frequency of bulimia nervosa is found in first-
degree relatives of persons with the disorder
Social Factors
 tend to be high achievers and to respond to societal
pressures to be slender
 many patients with bulimia nervosa are depressed and
have increased familial depression
 the families of patients with bulimia nervosa are
generally less close and more conflictual
 their parents as neglectful and rejecting
Psychological Factors
 have difficulties with adolescent demands, but
patients with bulimia nervosa are more outgoing,
angry, and impulsive than those with anorexia
nervosa
 alcohol dependence, shoplifting, and emotional
lability (including suicide attempts) are associated
with bulimia nervosa
 generally, experience their uncontrolled eating as
more ego-dystonic than do patients with anorexia
nervosa and so seek help more readily
 lack superego control and the ego strength of their
counterparts with anorexia nervosa
 the difficulties controlling their impulses are often
manifested by substance dependence and self-
destructive sexual relationships in addition to the
binge eating and
 have histories of difficulties separating from
caretakers, as manifested by the absence of
transitional objects during their early childhood
years
 struggle for separation from a maternal figure is
played out in the ambivalence toward food; eating
may represent a wish to fuse with the caretaker, and
regurgitating may unconsciously express a wish for
separation
DIAGNOSIS AND CLINICAL FEATURES
5
 bulimia nervosa is present when
1. episodes of binge eating occur relatively
frequently (twice a week or more) for at least 3
months;
2. compensatory behaviors are practiced after binge
eating to prevent weight gain, primarily self-
induced vomiting, laxative abuse, diuretics, or
abuse of emetics (80 % of cases), and, less
commonly, severe dieting and strenuous exercise
(20 % of cases);
3. weight is not severely lowered as in anorexia
nervosa; and
4. the patient has a morbid fear of fatness, a
relentless drive for thinness, or both and a
disproportionate amount of self-evaluation
depends on body weight and shape
 clinicians should explore the possibility that the
patient has experienced a brief or prolonged prior
bout of anorexia nervosa, present in approximately
half of those with bulimia nervosa
 Binging usually precedes vomiting by about 1 year.
 Vomiting is common and is usually induced by
sticking a finger down the throat
 Depression, sometimes called postbinge anguish,
often follows the episode
 During binges, patients eat food that is sweet, high in
calories, and generally soft or smooth textured
 Most patients are within their normal weight range, but
some may be underweight or overweight.
 Bulimia nervosa occurs in persons with high rates of
mood disorders and impulse control disorders.
 Patients with bulimia nervosa also have increased rates
of anxiety disorders, bipolar I disorder, and dissociative
disorders, and histories of sexual abuse.
-
DSM-5 Diagnostic Criteria for Bulimia Nervosa
Subtypes
1. Bulimic persons who purge
- regularly engage in self-induced vomiting or the use of
laxatives or diuretics
- at risk for hypokalemia from vomiting or laxative
abuse and hypochloremic alkalosis
- gastric and esophageal tears
2. Binge eaters who do not purge
- less body-image disturbance and less anxiety
concerning eating
- tend to be obese
- use strict dieting, fasting, or vigorous exercise but
do not regularly engage in purging
Pathology
and Laboratory Examinations
electrolyte abnormalities
thyroid function remains intact
nonsuppression on the dexamethasone-suppression
test
 hypomagnesemia and hyperamylasemia
 menstrual disturbance
  Hypotension and bradycardia
Differential Diagnosis
anorexia nervosa, binge eating-purging type
 neurological disease, such as epileptic-equivalent
seizures, central nervous system tumors, Kluver-Bucy
syndrome, or Kleine-Levin syndrome
• Kluver-Bucy syndrome are visual agnosia,
compulsive licking and biting, examination of
objects by the mouth, inability to ignore any
stimulus, placidity, altered sexual behavior
(hypersexuality), and altered dietary habits,
especially hyperphagia.
• Kleine-Levin syndrome consists of periodic
hypersomnia lasting for 2 to 3 weeks and
hyperphagia
 concurrent seasonal affective disorder and patterns
of atypical depression (with overeating and
oversleeping in low-light months)
 comorbid impulsive behaviors, including substance
abuse, and lack of ability to control themselves in such
diverse areas as money management (resulting in
impulse buying and compulsive shopping) and sexual
relationships (often resulting in brief, passionate
attachments and promiscuity)
 borderline personality disorder and other mixed
personality disorders
 bipolar II disorder
COURSE AND PROGNOSIS
 higher rates of partial and full recovery compared
with anorexia nervosa
 Approximately 30 % continued to engage in
recurrent binge-eating or purging behaviors.
 A history of substance use problems and a longer
duration of the disorder at presentation predicted
worse outcome.
TREATMENT
 Most patients with uncomplicated bulimia nervosa
do not require hospitalization.
 outpatient treatment is usually not difficult, but
psychotherapy is frequently stormy and may be
prolonged
 In some cases, when eating binges are out of
control, outpatient treatment does not work, or a
patient exhibits such additional psychiatric
symptoms as suicidality and substance abuse,
hospitalization may become necessary.
 In addition, electrolyte and metabolic disturbances
resulting from severe purging may necessitate
hospitalization.
A. Psychotherapy
1. Cognitive-Behavioral Therapy
- Cognitive-behavioral therapy (CBT) should be
considered the benchmark, first-line treatment for
bulimia nervosa.
6
- based on strict adherence to rigorously implemented,
highly detailed, manual-guided treatments that include
about 18 to 20 sessions over 5 to 6 months
- CBT implements a number of cognitive and
behavioral procedures to (1) interrupt the self-
maintaining behavioral cycle of bingeing and dieting
and (2) alter the individual's dysfunctional cognitions;
beliefs about food, weight, body image; and overall
self-concept.
2. Dynamic Psychotherapy
- a tendency to concretize introjective and
projective defense mechanisms.
- In a manner analogous to splitting, patients divide
food into two categories: items that are nutritious
and those that are unhealthy.
B. Pharmacotherapy
 Antidepressant medications
 Carbamazepine (Tegretol) and lithium (Eskalith) have not
shown impressive results as treatments for binge eating,
but they have been used in the treatment of patients with
bulimia nervosa with comorbid mood disorders, such as
bipolar I disorder
 studies show that CBT and medications are the most
effective combination
Eating Disorder not Otherwise Specified
 a residual category used for eating disorders that do not
meet the criteria for a specific eating disorder
 Binge-eating disorder, that is, recurrent episodes of
binge eating in the absence of the inappropriate
compensatory behaviors characteristic of bulimia
nervosa falls into this category.
 Such patients are not fixated on body shape and
weight.
DSM-5 Diagnostic Criteria for Eating Disorder Not
Otherwise Specified
 The eating disorder not otherwise specified category is
for disorders of eating that do not meet the criteria for any
specific eating disorder. Examples include:
1. For females, all of the criteria for anorexia nervosa
are met except that the individual has regular
menses.
2. All of the criteria for anorexia nervosa are met except
that, despite significant weight loss, the individual's
current weight is in the normal range.
3. All of the criteria for bulimia nervosa are met except that
the binge eating and inappropriate compensatory
mechanisms occur at a frequency of less than twice a
week or for a duration of less than 3 months.
4. The regular use of inappropriate compensatory
behavior by an individual of normal body weight after
eating small amounts of food (e.g., self- induced
vomiting after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but not
swallowing, large amounts of food.
6. Binge-eating disorder: recurrent episodes of binge
eating in the absence of the regular use of
 inappropriate compensatory behaviors characteristic
of bulimia nervosa.

BINGE EATING DISORDER

 they eat an abnormally large amount of food over a
short time.
 do not compensate in any way after a binge episode
(e.g., laxative use).
 Binge episodes often occur in private, include foods
of dense caloric content, and, during the binge, the
person cannot control his or her eating.

EPIDEMIOLOGY
 most common eating disorder.
 25 % of patients who seek medical care for obesity
 50 to 75 % of severely obese (BMI > 40).
 females (4 %) > males (2 %).

ETIOLOGY
 cause is unknown
 Impulsive and extroverted personality styles
 occur during periods of stress
 used to reduce anxiety or alleviate depressive moods.

DIAGNOSIS AND CLINICAL FEATURES

 the binges must be characterized by four features:
DIFFERENTIAL DIAGNOSIS
• eating more rapidly than normal and to the
 Binge eating disorder vs bulimia nervosa
point of being uncomfortably full
• S: recurrent binge eating.
• eating large amounts of food even when not
• binge eating disorder patients have no recurrent
hungry
compensatory behavior such as vomiting, laxative
• eating alone
abuse, or excessive dieting.
• eeling guilty or otherwise upset about the
 Binge eating disorder vs anorexia nervosa
episode
• no excessive drive for thinness
 occur at least once a week for at least 3 months
• normal weight or obese.
 Approximately half of individuals with binge eating
 The prevalence of binge eating disorder is higher in
disorder are obese, have an earlier onset of obesity
overweight populations (3 %) than in the general
than those without the disorder
population (approximately 2 %).
 Binge eating disorder is also more prevalent
COURSE AND PROGNOSIS. in families than obesity
 long-term effect : Severe obesity
TREATMENT
DSM-5 Diagnostic Criteria for Binge Eating Disorder  Psychotherapy- Cognitive-behavioral therapy (CBT)
is the most effective
 Self-Help Groups- Self-help groups such as
Overeaters Anonymous (OA) have proven to be
helpful in patients with binge eating disorder. For
the treatment of moderate obesity, organizations
such as Weight Watchers can be extremelyhelpful
and do not involve common fads or quick fixes.
 Psychopharmacotherapy- SSRIs

OTHER SPECIFIED FEEDING OR EATING DISORDER

Night Eating Syndrome
 consumption of large amounts of food after the
evening meal
 little appetite during the day and suffer from insomnia

7
 o stomach
Purging Disorder o produces satiety
 recurrent purging behavior after consuming a small o potential used as a weight loss agent in humans
amount of food in persons of normal weight who have a  olfactory system - satiety.
distorted view of their weight or body image.
 strong stimulation of the olfactory bulbs in the nose with
 Purging behavior: self-induced vomiting, laxative
food odors by use of an inhaler saturated with a particular
abuse, enemas, and diuretics.
smell produces satiety for that food
 behavior must not be associated with anorexia
nervosa.
 Cannabinoid receptors
 occur at least once a week for 3-months
 related to appetite and are stimulated with cannabis
OBESITY AND THE METABOLIC SYNDROME (marijuana).
 Appetite
OBESITY  desire for food
 genetic susceptibility  increased by psychological factors :thoughts or feelings
 increased availability of high- energy foods
 decreased physical activity
Genetic Factors
 leading cause of preventable death in the US  80% - family history
 identical twins raised apart can both be obese
 excess of body fat in healthy individuals
 body fat: 25% BW in women; 18% in men Genetic Factors Affecting Body Weight
 Overweight - weight above some reference norm, Genetic Factor Description
typically standards derived from actuarial or Leptin hypothalamus that control feeding behavior,
epidemiological data. hunger, body temperature, and energy
expenditure.
 increasing weight reflects increasing obesity, but not suppresses feeding and exerts its effects on
always metabolism
suppress feeding by inhibiting neuropeptide Y.
 body mass index (BMI) - most common
 weight kg / height m2 Neuropeptide Y Brain
• 20 to 25 - healthy weight stimulator of feeding.
• 25 to 27 – somewhat elevated risk Suppressed by Leptin
• > 27 – clearly increased risk
• > 30 – greatly increased risk Ghrelin An acylated, 28-amino acid peptide secreted
by stomach.
ETIOLOGY activates neuropeptide Y neurons in the
 accumulate fat by eating more calories than are expended hypothalamic arcuate nucleus
as energy; thus intake of energy exceeds its dissipation stimulate food intake
 An error of no more than 10 % in either intake or output
would lead to a 30-pound change in body weight in 1 year. Melanocortins Acts on certain hypothalamic neurons that
inhibit feeding
Satiety
 when hunger is satisfied disruptions of the melanocortin-4 receptor.
 mechanism controlling food intake Carboxypeptidase E process proinsulin and neuropeptide Y.
obesity, hyperglycemia suppressed by
 a metabolic signal, derived from food that has been
insulin.
absorbed, is carried by the blood to the brain, where the
signal activates receptor cells, in the hypothalamus, to
produce satiety. Mitochondrial brown fat, white fat and muscle cells
 dysfunction in regulating eating behavior through the uncoupling proteins energy expenditure and body weight
hypothalamus. regulation.
 serotonin, dopamine, and norepinephrine Tubby protein paraventricular nucleus of the hypothalamus
mutations show adult onset of obesity
 CRF, neuropeptide Y, GnRH, and TSH
 obestatin

8
Developmental Factors  excessively after they have had their evening meal,
 begins early in life - adipose tissue with an seems to be precipitated by stressful life
increased number of adipocytes of increased size. circumstances and coping with psychological problems
 begins in adult life, - increase in the size of the
adipocytes. Differential Diagnosis
 leptin, made by fat cells, acts as a fat thermostat. Other Syndromes
 low leptin, more fat consumed  night-eating syndrome- using sedatives( Zolpidem) to
sleep
Physical Activity Factors  binge-eating syndrome (bulimia)
 the marked decrease in physical activity in affluent  Pickwickian syndrome - 100 % over desirable weight
societies seems to be the major factor in the rise of and has associated respiratory and cardiovascular
obesity as a public health problem pathology
 physical inactivity restricts energy expenditure and
 Body Dysmorphic Disorder (Dysmorphophobia)
may contribute to increased food intake
Brain-Damage Factors
METABOLIC SYNDROME
 destruction of the ventromedial hypothalamus  metabolic abnormalities + obesity, cardiovascular
Health Factors disease, type II diabetes
 consequence of identifiable illness
• genetic disorders: Prader-Willi syndrome,  diagnosed when >/= 3 of the following five risk
neuroendocrine abnormalities factors:
 seasonal affective disorder 1. abdominal obesity,
Other Clinical Factors 2. high triglyceride level,
 Cushing's disease,myxedema, other neuroendocrine 3. low HDL cholesterol level,
disorders include adiposogenital dystrophy (Frohlich's 4. hypertension
syndrome), which is characterized by obesity and sexual 5. an elevated fasting blood glucose level
and skeletal abnormalities
 obesity, insulin resistance and a genetic vulnerability
Illnesses That Can Explain Some Cases of Obesity are involved
1. Genetic (dysmorphic) obesities  Second generation (atypical) antipsychotic
Autosomal recessive medication has been implicated as a
X-linked cause (Clozapine and Olanzapine)
Chromosomal (e.g., Prader-Willi syndrome)  Tx: weight loss, exercise and the use of statins and
2. Neuroendocrine obesities antihypertensives
Hypothalamic syndromes
Cushing's syndrome WHO Clinical Criteria for Metabolic Syndrome
Hypothyroidism  Insulin resistance, identified by 1 of the following:
Polycystic ovarian syndrome (Stein-Leventhal 1. Type II diabetes
syndrome) 2. Impaired fasting glucose
Pseudohypoparathyroidism 3. Impaired glucose tolerance
Hypogonadism 4. Or for those with normal fasting glucose levels
Growth hormone deficiency (<110 mg/dL), glucose uptake below the lowest
Insulinoma and hyperinsulinism quartile for background population under
3. Iatrogenic obesities investigation under hyperinsulinemic, euglycemic
Drugs (psychiatric) conditions
Hypothalamic surgery (neuroendocrine)
 Plus any 2 of the following:
Psychotropic Drugs 1. Antihypertensive medication and/or high blood
 long-term use of steroid medications pressure (>140 / >90 mm Hg)
 patients treated for major depression, psychotic 2. Plasma triglycerides >150 mg/dL (>1.7 mmol/L)
disturbances, and bipolar disorder typically gain 3 to 10
kg; can produce the so-called metabolic syndrome 3. BMI >30 kg/m2
waist:hip ratio >0.9 in men, >0.85 in women
4. Urinary albumin excretion rate >20 µg/min or
Psychological Factors
albumin:creatinine ratio >30 mg/g
 many obese patients are emotionally disturbed
persons who, because of the availability of the
overeating mechanism in their environments, have Screen Patients Before Prescribing Antipsychotics
learned to use hyperphagia as a means of  Personal history of obesity

9
  Family history of obesity
 Diabetes Exercise
 Dyslipidemias
 Hypertension Pharmacotherapy
 Cardiovascular disease  suppresses appetite, but tolerance to this effect may
 body mass index develop after several weeks of use
 Waist circumference at level of umbilicus  initial trial period of 4 weeks with a specific drug can be
 Blood pressure used; then, if the patient responds with weight loss, the
 Fasting plasma glucose drug can be continued to see whether tolerance
 Fasting lipid profile develops
 approved by the FDA for long-term use is orlistat
Course and Prognosis (Xenical), which is a selective gastric and pancreatic
 obese men, regardless of smoking habits, have a higher lipase inhibitor that reduces the absorption of dietary fat
mortality from colon, rectal, and prostate cancer (which is then excreted in stool
 obese women have a higher mortality from cancer of the  Sibutramine alpha2-phenylethylamine that inhibits the
gallbladder, biliary passages, breast (postmenopause), reuptake of serotonin and norepinephrine (and
uterus (including cervix and endometrium), and ovaries dopamine to a limited extent); for weight loss and the
 prognosis for weight reduction is poor, and the course of maintenance of weight loss (i.e., long-term use)
obesity tends toward inexorable progression Drugs for the Treatment of Obesity
 prognosis is particularly poor for those who become Rimonabant
obese in childhood  DRAs, or sympathomimetics, are among the most
widely used appetite suppressants
 an alternative to psychostimulants
Usual Dosage Range  MOA: selective cannabinoid-1 receptor (CB1)
Generic Name Trade Name(s) (mg/day) blocker.
 reduce body weight and improve cardiovascular risk
Amphetamine and Biphetamine 12.5-20
factors
dextroamphetamine
 20 mg causes significant weight loss, reduction in
Methamphetamine Desoxyn 10-15 waist circumference, increase in HDL cholesterol,
Benzphetamine Didrex 75-150 reduction in triglycerides and increases in plasma
adiponectin
Phendimetrazine Bontril, Plegine, 105  Adiponectin
Prelu-2, X-Trozine • glucose regulation and fatty acid
Phentermine catabolism
• secreted from adipose tissue
Hydrochloride Adipex-P, Fastin, 18.75-37.5 • plasma levels are inversely correlated
Oby-trim with body mass index (BMI).
Resin Ionamin 15-30 • suppress metabolic abnormalities that
lead to type 2 diabetes, obesity, and
Diethylpropion Tenuate 75
atherosclerosis.
hydrochloride
Surgery
Mazindol Sanorex, Mazanor 3-9
 gastric bypass - smaller stomach by transecting or
Sibutramine Meridia 10-15 stapling one of the stomach curvatures
 in gastroplasty the size of stomach stoma is
Orlistat Xenical 360 reduced so that the passage of food slows
 + vomiting, electrolyte imbalance, and obstruction
 dumping = palpitations + weakness +
TREATMENT sweating - if they ingest large amounts of
Diet carbohydrates in a single meal
 simplest way to reduce caloric intake is by means of a  lipectomy – no effect on weight loss in the long run
low-calorie diet  Bariatric surgery
 Ketogenic diets: high-protein, high-fat diets used to • serious obesity-related health complications +
promote weight loss, with high cholesterol content and BMI of > 35 kg/m2
produce ketosis, which is associated with nausea,
hypotension, and lethargy • BMI >40 kg/m2 in the absence of major health
 balanced diet of 1,100 to 1,200 calories complications
 + iron, folic acid, zinc, and vitamin B6

10
Psychotherapy physical activity on most, and preferably all, days
 patients may respond to insight-oriented of the week.
psychodynamic therapy with weight loss, but this 12. The combination of a reduced calorie diet and
treatment has not had much success increased physical activity is recommended since it
 Behavior modification has been the most successful of produces weight loss that may also result in decreases
the therapeutic approaches for obesity and is in abdominal fat and increases in cardiorespiratory
considered the method of choice. fitness.
 Patients are taught to recognize external cues that are 13. Behavior therapy is a useful adjunct when
associated with eating and to keep diaries of foods incorporated into treatment for weight loss and
consumed in particular circumstances, such as at the weight maintenance.
movies or while watching television, or during certain 14. Weight loss and weight maintenance therapy should
emotional states, such as anxiety or depression. employ the combination of LCD's, increased physical
 Patients are also taught to develop new eating activity, and behavior therapy.
patterns, such as eating slowly, chewing food well, not 15. After successful weight loss, the likelihood of weight loss
reading while eating, and not eating between meals or maintenance is enhanced by a program consisting of
when not seated. dietary therapy, physical activity, and behavior therapy,
 Group therapy helps to maintain motivation, to which should be continued indefinitely. Drug therapy can
promote identification among members who have lost also be used. However, drug safety and efficacy beyond
weight, and to provide education about nutrition. 1 year of total treatment have not been established.
16. A weight maintenance program should be a priority after
Key Recommendations for Healthy Weight (formulated from the Obesity the initial 6 months of weight loss therapy
Education Institute, National Institute of Health)
1. Weight loss to lower elevated blood pressure in
overweight and obese persons with high blood
pressure.
2. Weight loss to lower elevated levels of total cholesterol, LDL-
cholesterol, and triglycerides, and to raise low levels of HDL-
cholesterol in overweight and obese persons with
dyslipidemia.
3. Weight loss to lower elevated blood glucose levels in
overweight and obese persons with type 2 diabetes.
4. Use the BMI to classify overweight and obesity and to
estimate relative risk of disease compared to normal
weight.
5. The waist circumference should be used to assess
abdominal fat content.The initial goal of weight loss
therapy should be to reduce body weight by about 10
% from baseline.
6. Weight loss should be about 1 to 2 pounds per week for a
period of 6 months, with the subsequent strategy based
on the amount of weight lost.
7. Low calorie diets (LCD) for weight loss in overweight and
obese persons. Reducing fat as part of an LCD is a
practical way to reduce calories.
8. Reducing dietary fat alone without reducing calories is
not sufficient for weight loss. However, reducing dietary
fat, along with reducing dietary carbohydrates, can help
reduce calories.
9. A diet of deficit of 500 to 1,000 kcal/day
10. Physical activity
• contributes to weight loss in overweight and obese
adults
• decrease abdominal fat
• increases cardiorespiratory fitness,
• maintain weight loss.
11. Physical activity
• 30 to 45 minutes, 3 to 5 days a week,
• least 30 minutes or more of moderate-intensity

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