2.4 Eating Disorders

"Obesity Paradox"

- overweight has the best health outcomes •Meta-analysis of 97 studies (with ~3 million people) these 97 studies are mostly correlational, but temporal precedence makes it clear that its not death causing BMI, BMI is causing death (too high or too low) - third variables could be causing both BMI and death - graph doesn't say one area is the healthiest. A model fit to all data shows this curve best fits the data •BMI 25-29.9 lowest risk of death from any cause •BMI > 35 increased risk •BMI < 18.5 increased risk Often correlational research; however, almost everything has temporal precedence over death, meaning that almost every human attribute and activity that is meaningful in psychological research precedes death, so greater death rates are found at higher BMIs, and we do not have to ask what the causal direction is: Death cannot cause higher BMI in a living human, but higher BMI in a living human is correlated with death, so either higher BMI contributes to death (directly or indirectly) or some third variable or set of third variables leads to both outcomes (and almost certainly both of these things are happening at the same time). Also, the graph does not say that 25-29.9 is the healthiest BMI range, only that a model fit to the data shows the lowest death rates at those BMIs. First, we have to separate out mortality and health, which are generally overlapping but not identical, because someone can suffer from something that is not lethal but not suffer as much from something that is lethal. Second, we have to consider that lots of people dying at low and at high BMIs will affect what the curve that fits the data looks like. Spline means piecewise A recent meta-analysis looked at 97 studies that included nearly 3 million individuals. The researchers found that people who were slightly overweight (BMIs 25−30) had a lower probability of dying from any cause during the study periods than people with recommended BMIs of less than 25. Slightly obese individuals (BMIs less than 35) did not have a greater risk of death than those with BMIs under 25 . Individuals with BMIs over 35, however, were much more likely to die. Individuals with low BMIs are at increased risk for premature death, particularly if they are elderly. Another meta-analysis examined 32 studies of nearly 200,000 people over age 65. Those with BMIs around 28 had the fewest deaths, and those whose BMIs were under 23 or over 34 were much more likely to have died. The take-home message is that being slightly over the recommended BMI is not as unhealthy as once believed and may even be protective.

Binge Eating Disorder (BED)

1.Recurrent (occurring at least 1/wk on average for 3 months) episodes of binge eating (same core features as in BN required). 2.Binge episodes accompanied by ≥3 associated symptoms: a.Eating much more rapidly than normal. b.Eating until feeling uncomfortably full. c.Eating large amounts of food when not feeling physically hungry. d.Eating alone because of feeling embarrassed by how much one is eating. e.Feeling disgusted with oneself, depressed, or very guilty afterward. 3.Distress regarding binge eating is present. 4.Not low weight and no compensatory behaviors. •i.e., it's not AN or BN

Bulimia Nervosa (BN)

1.Recurrent episodes (occurring at least 1/week on average for 3 months) of binge-eating characterized by both: a.Eating within a 2-hour period an amount of food that is definitely larger than most people would eat in a similar cultural context. b.A sense of loss of control during the episode. 2.Recurrent (occurring at least 1/week on average for 3 months) inappropriate compensatory behaviors (self-induced vomiting, laxatives, compulsive exercise, etc.) in order to prevent weight gain. 3.Self-evaluation is unduly influenced by body shape and weight (same as w/ AN—see pie chart example). 4.Not occurring exclusively during AN •i.e. if the person is underweight, they have AN, not BN

Bulimia Nervosa (BN)

1.Recurrent episodes (occurring at least 1/week on average for 3 months) of binge-eating characterized by both: a.Eating within a 2-hour period an amount of food that is definitely larger than most people would eat in similar conditions. b.A sense of loss of control during the episode. - if they are in control it is NOT a binge eating episode - felt in control of eating is NOT a binge eating disorder 2.Recurrent (occurring at least 1/wk on average for 3 months) inappropriate compensatory behaviors (self-induced vomiting, laxatives, compulsive exercise, etc.) in order to prevent weight gain. - reason for compensation is inappropriate: felt guilty or ashamed, guilt for what they ate = inappropriate compensatory behavior - method of compensation is inappropriate: vomiting, etc. 3.Self-evaluation is unduly influenced by body shape and weight (same as w/AN - see pie chart example). - if weight and shape is in the top five things that people value abt themselves and it is not in the cultural context for that to be the case, then it would be an undue influence on weight and shape on evaluation 4.Not occurring exclusively during AN •i.e. if the person is underweight, they have AN, not BN - can't have anorexia nervosa and bulimia nervous at the same time. Can have one or the other, but never both. - not underweight and have other 3 criteria = bulimia nervosa - syndrome and impairment(3 criteria) =disorder

Bulimia Nervosa (BN)

1.Recurrent episodes (occurring at least 1/wk on average for 3 months) of binge eating characterized by both: a.Eating within a 2-hour period an amount of food that is definitely larger than most people would eat in similar conditions. b.A sense of loss of control during the episode.

AN first criteria

1.Restriction of energy intake leading to significantly low body weight. How thin is too thin? •General guidelines for adults: less than 85% of weight expected based on age/height •BMI ≤ 18.5 •DSM-5 lets clinician determine what is low weight for a given individual and cultural context Specific AN symptoms Children/Adolescents: BMI ≤ 5th percentile of what is expected for age/sex/height How do we determine whether a person is too thin? According to the World Health Organization, a person may be underweight if they weigh less than 85% of what would be expected, given the person's age and height (that is, less than or equal to 18.5 BMI) People with AN almost always do have a BMI below 18.5. At a body weight that low, a person will typically look emaciated; you can see their skeleton (not just "skinny"). But, again, a BMI of 18.5 is not a hard-and-fast rule. The clinician should also consider the person' s build and weight history. Petite people are going to have a harder time getting their BMI up. There are usually medical complications that go along with being this thin.

Anorexia Nervosa (AN)

1.Restriction of energy intake leading to significantly low body weight. 2.Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain. 3.Disturbance in experience of body weight, undue influence on self-evaluation, or denial of the seriousness of low weight. Overall criteria for AN The term anorexia is of Greek origin: an- (ἀν-, prefix denoting negation) and orexis (ὄρεξις, "appetite"), thus "absence of appetite". Anorexia nervosa: an eating disorder characterized by excessive fear of becoming fat and restriction of energy intake to obtain a significantly low body weight. 1 in 100 prevalence in general population Those who have anorexia often view themselves as fat even though they are at a significantly low weight About 15 to 20 percent of those with anorexia eventually die from the disorder. Restricting type: Not engaging in recurrent episodes of binge-eating or purging behavior Binge-eating/purging type: Recurrent binge-eating or purging behavior • Severity Based on BMI (body mass index) range; lower BMI indicates greater severity of anorexia nervosa Mild, Moderate, Severe severity levels

AN 2nd criteria

2.Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain. The second feature of AN is an intense fear of becoming fat. The fear of becoming fat often becomes more intense as an individual loses more weight. You can imagine this makes treatment very difficult. As we'll talk about later, one of the treatments for AN is eating during the treatment session, but many AN patients refuse to eat because they are afraid that this one meal will make them fat.

Bulimia Nervosa (BN)

2.Recurrent (occurring at least 1/wk on average for 3 months) inappropriate compensatory behaviors in order to prevent weight gain. •DSM-5 severity ratings based on weekly frequency of compensatory behaviors. - Bulimia nervosa: an eating disorder characterized by binge eating and inappropriate compensatory behaviors such as purging but also can be nonpurging such as fasting and exercise purging: vomiting, laxatives non-purging: excessive exercise

AN third criteria

3.Disturbance in experience of body weight, undue influence on self-evaluation, or denial of the seriousness of low weight. The third feature of AN is that the patients see themselves as heavier than they are. They will frequently overestimate the size of various body parts. Individuals with anorexia deny that they are too thin because they do not accurately perceive their low body weight. Individuals with AN may, alternatively, think that they are thin overall but that their stomach, thighs, etc. are still too fat. art therapy: Draw out what you think your body looks like. Your body doesn't have the shape it has. See evidence.

Problems with BMI

Body mass index (BMI): a ratio of body weight to height, used to measure obesity or underweight BMI < 18.5 = underweight (cut off for being diagnose with AN) BMI 18.5-25 = "recommended" "normal" weight BMI 25-30 = overweight BMI > 30 = obese BMI > 35 morbid obesity There are at least two problems with the use of BMI to predict health. 1. Only takes into account body weight and height. BMI does not take age, sex, bone structure, muscle mass, or body fat mass/distribution into account 2. A clear relationship between BMI and health outcomes does not exist except for the underweight and very obese (< 18.5 and > 35 BMIs are linked to negative health outcomes) According to the traditional view, beyond or below the recommended weight range of 18.5-25 means you are at greater risk for health problems. Recent evidence suggests that a BMI between 25 and 30 may be more optimal, on average (but the optimal BMI will differ from person to person)

AN Subtypes

Both subtypes meet same criteria 1-3 that we just went over. Restricting and Binge/Purge START HERE? People with AN can usually be separated into two groups, or subtypes: 1)Restricting - weight loss accomplished primarily through dieting, fasting, excessive exercise (restricting from getting calories to begin with) 2)Binge/purge - person regularly engages in binge-eating episodes, where they eat a lot of food, and then purging episodes, where they try to get rid of calories (1-2 times per week). To have this subtype of AN, the person ALSO has to restrict food intake and be underweight. compensatory behaviors: compensate for eating too much - vomitting, laxatives, there are other ways that don't accomplish this but that people believe are accomplishing this Binge/purge subtype is associated with a worse prognosis: more chronic course, more NSSI, more impulsivity, and more comorbidity

large amount of food

For example, a quantity of food that might be regarded as excessive for a typical meal might be considered normal during a celebration or holiday meal. Let's take Thanksgiving... if you have two servings of dinner, and a slice or two of pie, that would generally not be thought of as excessive under the circumstances In fact, that would be pretty normal... NO, not an amount of food that is definitely larger than most people would eat in similar conditions.

Eating Disorders (EDs)

In DSM-5, eating disorders appear as part of category of Feeding and Eating Disorders. 1.Pica 2.Rumination Disorder 3.Avoidant/Restrictive Food Intake Disorder (ARFID) 4.Anorexia Nervosa (AN) 5.Bulimia Nervosa (BN) 6.Binge-Eating Disorder (BED) 7.Other Specified Feeding and Eating Disorders: •Atypical Anorexia Nervosa, Purging Disorder, Night-Eating Syndrome, BN of low frequency or limited duration, BED of low frequency or limited duration

Sociocultural Theories

Media influences: Sociocultural theories alone can't explain the patterns of eating disorder prevalence we see. Almost everyone is exposed to the thin ideal, but not everyone develops an eating disorder. The biopsychosocial model is relevant here: There are more influences on eating pathology than social/cultural influences alone. 1)Media Influences: We want to look like the famous people we see on tv and in magazines. 2)Media propagates the "thin ideal." That is, we are often surrounded by images that tell us it is ideal to be very thin. Even though the media is not (usually) explicitly saying, "You need to lose weight," we still internalize that message. - everyone has diff body types. Detrimental to ppl that don't have that body type. - western cultures heavily focus on weight and shape, in other cultures they might turn into anxiety or phobias but here they can turn into anxiety or phobias or eating disorders

A single episode of binge eating need not be restricted to one setting.

What about if you ordered drive-through mcdonalds and you got two big macs, and fries? What if you then swung by the dairy queen and got a milk shake on your way home? Do you think that would make it definitely large? A single episode of binge eating need not be restricted to one setting. For example, an individual may begin a binge in a restaurant and then continue to eat on returning home.

example definietly larger amt of food?

What if you were out by yourself and had IHOP's Country Fried Steak and Eggs breakfast special with pancakes? definitely larger or not? what if I told you it has 1,760 calories? Would that impact your decision if this was definitely large? As a rule of thumb, for an eating episode to be definitely large it needs to be over 1000 calories, but just being over 1000 calories does not make it definitely large. USUALLY something that is sold as ONE dish/ONE order at a restaurant wouldn't be considered definitely large given the circumstances because it's sold as just that, ONE dish. But there are some exceptions depending on context. For example, what if you went with friends and they only had half of their steak and eggs meal but you ate all of yours? then it WOULD (might?) be considered definitely large given the circumstances, based on social norms. SO AS YOU CAN SEE THIS IS NOT A BLACK OR WHITE THING, AND DOES TAKE SOME CLINICAL JUDGMENT

say you're at home by yourself and you're watching some netflix, and you have a large pizza, a bag of chips, and a pint of ice cream. Why do you think that would or would not be considered a definitely large amount of food given the circumstances?

YES, an amount of food that is definitely larger than most people would eat in similar conditions.

Biological Theories: Hormones

set points = where ur body wants to be •GLP-1 (Ghrelin) EAT •Short-term regulatory hormone •Abnormalities in EDs involving binge-eating in particular •Leptin (signals to hypothalamus à reduce appetite) STOP EATING •Long-term regulatory hormone •Lipostatic theory: set-point for body fat •Loss of body fat (& leptin) à increase hunger •Weight set-point theory •Heritability of body weight 60-80% (very genetic) maintain that amt of weight we have •Most dieting --> weight gain - dieting, then binge to get back to normal weight •Ghrelin: "hunger" hormone (originates in the stomach) •Short-term regulatory hormone - triggers eating •Many others signal satiety Leptin produced by fat cells. More fat stored = more leptin produced by those fat cells -> more goes to hypothalamus --> more being told to reduce appetite - Reason is to maintain a stable amt of body fat. Human bodies aren't designed to rapidly lose or gain body fat. Some bodies have different amts of body fat. Leptin is associated with long-term body fat regulation, whereas ghrelin motivates eating behavior. Leptin: released from fat cells as more fat is stored and travels to the hypothalamus, where it acts to inhibit eating behavior. Ghrelin: originates in the stomach; surges before meals, then decreases after people eat—may play an important role in triggering eating. Lipostatic theory: set-point for body fat (maintaining the same amt of body fat) Set Point - value that establishes a range of body fat and muscle /// we don't' know what sets the set point Leptin: hormone that signals the hypothalamus and brain stem to reduce appetite and increase amount of energy used. Leptin resistance - In obese people, leptin levels high in blood, but not in brain The lipostatic theory proposes a set-point for body fat. When an animal loses body fat, hunger signals motivate eating and a return to the set-point. Related to the hormone leptin (stored in fat cells) More fat stored = more leptin - signals to brain to reduce appetite and increase amount of energy used Loss of body fat (&leptin) à hunger (so return to set-point)

BN: Prevalence & Course

• 1-3% lifetime prevalence • More common in women (among men, more common among gay men) • Equally prevalent in Hispanic and White women (In AN white woman had a much higher prevalence) • Onset in adolescence to young adulthood (ages 15-29) • Chronic: ~50% remission rate • 7.5x higher suicide rate than general population • Comorbidity with depression and NSSI (non-suicidal self injury)

AN: Prevalence & Course

•1-2% lifetime prevalence (0.3% for men) • More common in women • More common in Caucasian women • Onset in adolescence (ages 15-19) • Very chronic: 7 years on avg, ~50% remission rate • Death rate is 5-10% • High rate of suicide - starvation symptoms •Some studies suggest AN has the •highest suicide rate of any mental disorder

Biological Theories: Neurotransmitters

•Abnormalities implicated in eating behavior and EDs: •Dopamine •Serotonin - assoc w/ detecting hunger and satiation of eating once u are full (stopping eating) - abnormal levels can lead to increased cravings which can lead to binging and can make regulation of eating more difficult •Related to the rewarding & pleasurable aspects of eating

Treatments for Eating Disorders

•Cognitive-Behavioral Therapy •Regular eating (behavioral) •Exposure to feared foods (behavioral) - behavioral activation therapy can work but if they say their goal is to be thin... change therapies CBT •Challenging thoughts (cognitive restructuring—often then implemented behaviorally) •Emotion regulation, coping strategies, interpersonal effectiveness (again, often implemented behaviorally) Family Therapy: - teach parents to be the therapist for the kid. Maybe parents were making comments about diet and weight. - especially w/ the mother if she had previous eating pathology (in terms of data) •Most effective for adolescents with AN Treatment for anorexia nervosa is different from that for bulimia treatment. 1)Cognitive Behavioral Therapy works well for Bulimic patients. During these sessions the patient's cognitions about the importance of weight and shape would be challenged and coping strategies other than purging would be introduced. For Anorexic patients, the importance of weight restoration would come first, followed by in-session eating to talk about the anxiety that is caused by eating and figure out what coping strategies should be used instead of just not eating. 2)Family therapy is quite effective for adolescents who are still living at home. The family needs to learn what is, and what is not, helpful in the treatment of patients with restrictive eating behaviors. Parents are taught to give their kids more autonomy, freedom, and the kids are challenged on their perfectionistic ideals. ● Overall there are: 1.Usually more medical problems related to initial treatment in AN ● 2.In treatment for eating disorders there are different themes depending on the disorder: AN = family dynamics, losing control, distorted body image BN = emotion regulation, controlling binge/purge behaviors, adaptive thinking about food & body.

AN: Clinical Features

•Disorder often starts with (and is maintained by) "normative" dieting (restrictive eating) • Perfectionism • Food rituals, strict rules around eating • Highly comorbid with depression and anxiety • Irritability, trouble concentrating, fatigue (the body is starving) • Socially withdrawn • Low sex drive (in starvation mode) • Sensitivity to cold (not enough body fat to regulate room temp) People with anorexia may display strange behaviors while eating. There was a study done at the University of Minnesota in the 40s after WWII - I'm going to call this "the Minnesota study." 36 men volunteered to undergo 24 weeks of starvation (6 months) in order to better understand the psychological states of the people who were in concentration camps during WWII. These men ate every day but not enough to maintain their weight. They each lost approximately 25% of their pre-study body weight. So a 200lb man would have lost 50lbs in the 6 months (see picture). The men developed very strange eating behaviors. They cut their food into tiny little bites and ate their food in a certain order. After a while, some didn't even eat all the food they were given, despite the fact that they were starving. Basically, starvation led to the development of an eating disorder. Who might fit the description of someone with anorexia nervosa? What are some common characteristics? 1) One is perfectionism—People with AN are more likely to have perfectionistic ideals, often trying to reach unattainable standards. They are inflexible and rigid in their beliefs about what they should look like. 2) Many people with AN tend to be fidgety and restless. This is often a result of anxiety, which is highly comorbid with AN, but it is also sometime due to the belief that keeping moving will help to lose weight. They also don't have much body fat, so they tend to be cold much or all of the time. People with AN might also wear baggy clothes to hide their body or cover up their disorder because of potential stigma associated with this disorder. 3) AN often co-occurs (is comorbid with) with depression and anxiety. Close to 100% of the men in the Minnesota study also went through an episode of depression and/or anxiety.

BN: Clinical Features

•Disorder often starts with (and is maintained by) 'normative' dieting (restrictive eating) •Impulsivity, difficulties with emotion regulation/coping •Binge eating episodes frequently preceded by negative emotional states/stress •Binge episode followed by guilt/shame à compensatory behaviors •Cycle develops • Dieting à binging à compensatory behaviors (including dieting) à binging, and so on... COMPENSATORY BEHAVIORS RELIEVE THAT GUILT/SHAME BRIEFLY - THEY ARE REINFORCING - HOW SO? NEGATIVELY! Seen in animals too Disorder often starts with (and is maintained by) 'normative' dieting (restrictive eating) Impulsivity, difficulties with emotion regulation/coping Binge eating episodes frequently preceded by negative emotions/stress May experience short-lasting relief of tension following binge episode, but then increased negative emotions including guilt and shame Compensatory behaviors to reduce feelings of fullness, shame, anxiety, etc. following binge episode Cycle develops Dieting à binging à compensatory behaviors including dieting à binging, and so on...

BN: Medical Complications

•Electrolyte imbalance from self-induced vomiting/diuretic/laxative misuse (can lead to heart failure) - salts in ur body that help to regulate ur body - electrolyte imbalance due to loss of salts and fluids from throwing up • Erosion of dental enamel (acid in vomit) • Hypersensitive gag reflex (can gag by swallowing their own saliva or just from bending over) • Ruptured esophagus or stomach (frequent vomiting) - large salivary glands: puffy appearance of face Purging after a binge episodes can take many forms. It can be self-induced vomiting, abusing laxatives, excessive exercise. Basically, anything to relieve the stress and shame of having just eaten so much food. The most common compensatory behavior is vomiting. Medical complications that accompany frequent vomiting include: 1) Electrolyte imbalance due to losing a lot of fluid and nutrients 2) Erosion of dental enamel 3) Hypersensitive gag reflex - gets to the point where someone can gag just by swallowing saliva; can vomit just by bending over and pushing on the stomach 4) Enlarged salivary glands resulting in puffy appearance of the face 5) Ruptured esophagus or stomach

Psychological Theories

•Emotion regulation - eating disorders are more likely to happen w/ the less good emotion regulation we have. For people with eating disorders, people is designed to help regulate emotion For people w/ eating disorders •Personality factors (especially in AN) •Perfectionism, impulsivity, negative affect •Cognitive models: rigid thinking (inflexible thinking, I need to be this weight or shape even if it is causing them distress and harm) •Family dynamics: enmeshed families People report that they see control over-eating as a way to feel as though they are gaining control over their lives or as a way to regulate emotions. Thus, some symptoms of eating disorders can be seen as an attempted coping strategy. For example, in those with AN, food restriction gives a sense of control over one's life. Similarly, purging behaviors are a strategy to decrease the negative emotions caused by uncontrolled overeating and are a behavior that feels controlled. We talked a little before about how certain personality traits might be inherited risk factors for eating pathology. Perfectionism in particular is one that's related to AN, BN, and BED. It seems to be a risk factor that predicts who will develop an eating disorder, and it is not always addressed through treatment. CBT targeting perfectionism could potentially help to reduce relapse among individuals with EDs. So perfectionism is something that contributes to all the EDs. - Negative affect, or proneness to react with strong negative emotions, is also common across the eating disorders. In contrast, impulsivity/disinhibition seems to be a personality factor that differentiates the eating disorders. People with AN-restricting subtype have lower-than-average impulsivity/disinhibition, with some papers describing the archetype of the AN patient as "dutiful and compliant daughters." On the other hand, those with BN (and possibly also the AN binge-purge subtype) tend to have a lot more impulsivity and sensation-seeking. As bingeing and purging is brought under control, though, impulsivity tends to decrease. Narcissism is an interesting personality trait that's beginning to be studied in relation to EDs. It seems to be specifically related to EDs and not anxiety and mood disorders, suggesting it could be one of the risk factors that guides individuals in the direction of eating pathology and not some other manifestation of internalizing psychopathology. Let's talk a little about cognitive models of eating pathology. As we've discussed, those with eating disorders tend to have preoccupations with weight and shape that disproportionately influence their self-esteem. Rigid, inflexible, black-and-white thinking is an important maintaining factor of this feature. For example, someone with AN might think, "Eating 1 cookie is as bad as eating the whole box." Eating disorders are very difficult to treat because these thoughts are so ingrained and difficult to challenge. Finally, there's been a lot of work on family dynamics in eating disorders. The families of adolescents with eating disorders are often "enmeshed." This means that they are extremely inter-dependent, and interactions are extremely intense. Growing up in a family dynamic like this can interfere with the individual's sense of self and identity, as they are responding to the family's needs rather than their own. This is related to the desire for control we talked about earlier. So what might you see if you were observing the families of adolescents with eating disorders? You might see above-average levels of conflict but in an environment where displaying negative emotions is discouraged. Control and perfectionism are highly valued. All of these factors contribute to a variety of disorders. What makes a family specifically likely to have a child with an eating disorder? If the moms also have a history of disordered eating and have a lot of thoughts/comments about their daughters' weights/shapes

Treatments for Eating Disorders: Barriers

•Even when men recognize they have an ED, they are less likely to seek treatment for one than women with EDs - Binging and purging is a big part of sports, may not see it as an issue. Bulking up for football, slimming down to be the right weight class - embarrassing to ask for help - shame in having an eating disorder as a male - considered a woman's disease

Biological Theories

•Genetic influences •Family & twin studies suggest general risk for EDs (not specific risk for one type or another) •Heritability rates of 40-60% for AN, BN, & BED •Biological (hormonal) changes at puberty activate genetic risk for EDs in girls •Personality traits •Perfectionism •Impulsivity •Negative Affect We know that there is some genetic potential for the development of eating disorders. Family studies of individuals with AN or BN have found a 5-10-fold increase in rates of AN and BN among their relatives. BED is about twice as likely in people who have a relative with BED. All of this suggests that eating pathology is fairly heritable. And actually, some recent studies suggest that some of the risk may be shared across these different eating disorders. From twin studies, too, there's evidence of a substantial genetic liability to eating disorders. It seems likely that once again, it's not the specific disorders that are directly inherited. Instead, it is probably inherited personality traits that are responsible for these statistics.

Instead of stigma for obesity

•Health at Every Size •Healthy behaviors à better health, regardless of weight - Healthy behaviors: consistent and enough sleep, consistent and enough eating, less illness, less inflammation, some stress but not chronic stress, sunlight exposure, social interaction, temperature regulation, waste excretion (included unimpeded sweating), hygiene, appropriate hydration, getting enough nutrients, etc.

Biological Theories: Brain Areas

•Hypothalamus: •Monitors hormones and nutrients in body to maintain state of homeostasis •Damage to lateral/outer region (LH): eat far less than normal (aphagia) •Damage to ventromedial/middle region (VMH): eat far more than normal (hyperphagia) •Lowered hypothalamus functioning in AN (chicken & egg issue) wh/ leads to which? •Cravings related to activity in the limbic system •Reward value of particular foods related to activity in prefrontal cortex (planning, organization, thinking in the future) - how rewarding we see eating a food to be. Contractions and distensions of the stomach can make the stomach growl; however, research has established that these movements are relatively minor determinants of hunger and eating. People who have had their stomachs removed continue to report being hungry. The hypothalamus monitors various hormones and nutrients and operates to maintain a state of homeostasis. The hypothalamus integrates the various inhibitory and excitatory feeding messages, and it organizes behaviors involved in eating. Damage to the hypothalamus dramatically changes eating behavior and body weight. Ventromedial/middle region (VMH): eat far more than normal Hyperphagia leads to obesity. Lateral/outer region (LH): eat far less than normal Aphagia leads to weight loss and eventual death unless force fed.

Biological Treatment of EDs

•Inpatient or partial hospitalization (help guide u through eating) •Weight restoration in AN (get people eating regularly and eating more) •Medications •SSRIs effective for BN & BED but •No medications found effective for treatment of AN (yet) but weight restoration treatment is affective for AN. Somebody sits down with u and eats food with u. They make sure its food that is giving u enough calories and nutrients. The volume of food is not the same as how much energy and calories the food provides. Carbohydrates, proteins, fats, are more important than volume of food. -psychotherapy is effective, but if BMI is less than 17 they are on the verge of death and need to get eating under control first 1)Inpatient hospital treatment is commonly used to force AN patients to gain weight. When a person's BMI is less than 17, it is dangerous for an outpatient therapist to even treat that patient because the patient could actually die from low bodyweight. This is not a first-line treatment, but it is necessary when extremely low weight is present. Some people with BN are hospitalized when the bingeing and purging are very severe (e.g., following every meal) ● 2)As far as medication goes, SSRIs have shown some effectiveness for BN and BED but NOT for treating AN

Sociocultural Theories

•Media influences •Internalization of "thin ideal" •Correlational and experimental research: among women, media exposure linked to: ◦increase body dissatisfaction, ◦increase investment in appearance, ◦increase endorsement of ED behaviors. (increased reporting of having eating disorder symptoms) •Body dissatisfaction is a risk factor for EDs causal link b/t social media and these feelings

BED: Prevalence & Course

•Most prevalent of EDs, overall • 2-4% lifetime prevalence •~ 30% in weight-loss programs • Slightly more common in women than in men (more comparable than other EDs) - AN and BN are much more common in women than men • No major racial/ethnic differences • Onset in adulthood (later than other EDs) • Chronic: Duration 8-15 yrs on avg.

Treatments for Eating Disorders: Barriers

•Poor understanding of EDs among the general public (poor mental health literacy) •Individuals with EDs often fail to see the severity of their problem (may not know it is a problem) •Doctors undertrained (can unintentionally encourage ED behaviors) •Poor detection among health professionals of EDs, esp. in minorities and men •Appropriate, effective treatment hard to find and expensive • Unless severely underweight (AN) Insurance often won't cover unless severely underweight

AN: Medical Complications

•Symptoms of starvation: •Dry, brittle hair, skin, nails •Fine hair grows on body (lanugo) - our ancestors would have developed hair to help them stay warm as they decrease body fat. not very effective, but a common indicator that the body is in starvation mode. •Constipation • Amenorrhea (abnormal absence of menstruation) - the body doesn't have the energy to go through the normal menstrual cycle. So the uterine lining isn't built in the first place and thus does not need to be shed. • Osteoporosis & bone fractures - the body doesn't have the energy to repair the little cracks we get in our bones as we go about our life we get microfractures and they are filled in. Doesn't happen much in starvation mode. • Impaired immune functioning - the body can't expend too much energy on fighting off diseases when starvation is happening • Muscle loss - muscle will be autocannabilised to keep the body functioning • Major organ failures - less necessary organs are given less and less attention •Cardiovascular complications •E.g., arrhythmia, heart failure

The Stigma of Obesity

•Weight-based bias & weight-based discrimination •Stereotypes of obesity unrelated to weight arise as early as age 3 •Perceiving self as overweight associated with: •Increased depression, anxiety, low self-esteem •Increased dieting (& weight cycling) - cycling b/t dieting and gaining weight back. Weight cycling to the point where it is causing impairment in someone's life. •Obesity stigma is associated with: adverse health outcomes, including increased stress response (e.g., cortisol release), increased blood pressure, and weight gain Weight cycling is losing weight and then regaining it, or gaining weight and then losing it, cyclically (over and over again) Extensive research has supported widespread negative stereotypes of obese individuals, many of which are unrelated to weight. In children as young as 3 years old, obese children were described as lazy, stupid, ugly, selfish, mean, and as having few friends or as being a less suitable playmate (Bell, & Morgan, 2000). Studies have found that weight-based stigma can actually interfere with a person's intentions and ability to perform the types of healthy behaviors associated with weight loss and can, in fact, result in weight gain. In most Western cultures, obese individuals are viewed as less attractive, less socially adept, less intelligent, and less productive than their "normal"-weight peers. Perceiving oneself as overweight is linked to depression, anxiety, and low self-esteem. Not all cultures stigmatize obesity. In the United States the standard represented by models (e.g., for clothing, makeup) is 7 inches taller and 55 pounds lighter than the average woman.