m a ssi m o cu zzo l a r o editor-in-chief di · anorexia nervosa by proxy - a (honjo s, 1996)...
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Vicenza, 4 novembre 2016
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obes i t á e d i s turb i de l l ’ a l imen taz i on e
M a s s i m o C u z z o l a r o
già Università di Roma Sapienza
Editor-in-Chief di Eating and Weight Disorders. Studies on Anorexia Bulimia Obesity
2 0 1 5 wo r l d
p o p u l a t i o n :
a b o u t 7 . 5 b i l l i o n
•
I t i s c u r r e n t l y
g r o w i n g ( b i r t h s –
d e a t h s ) a t 2 . 4 p e o p l e
p e r s e c o n d
•
wi l l we b e
9 . 6 b i l l i o n p e o p l e
b y 2 0 5 0 ?
0,0
2,0
4,0
6,0
8,0
18001900
19502000
2015
1,0 1,52,5
6,0
7,5
g l o b a l h u m a n p o p u l a t i o n : b i l l i o n s
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2014
1975
0
2
4
6
8
10
12
14
16
women underweight women obese men underweight men obese
10
15
9
11
15
6
14
3
a g e - s t a n d a r d i s e d p r e v a l e n c e s ( % )
2014 1975
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1980 2008
5
10
8
14
Adult Men obese % Adult Women obese %
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Anorexia Nervosa
incidence stable
Bulimia Nervosa
incidence declining
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Au s t r a l i a • D S M - 5 E D s : o n e - m o n t h p r e v a l e n c e
(Kar ina L Al len et a l , 2013)
0
2
4
6
8
10
12
14
16
men women
2,9
15,2
Australian men andwomen 20 years old: one-month prevalence %
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anxiety disorders > 50 %
mood disorders > 40 %
self-harm > 20 %
substance use disorders > 10 %
m a in r i s k fa c t o r s
• parental psychiatric disorders
• prenatal maternal stress
• various family factors
• childhood overweight
• body dissatisfaction in adolescence
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obesity … ED
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obes i t yea t i ng
d i s or de r s
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i d i s turb i de l l ’ a l im en taz i one
ne l DSM-5
✦
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B u l i m i a
N e r v o s a
Oth
er S
pe
cif
ied
Fe
ed
ing
o
r E
ati
ng
Dis
ord
ers
DSM - 5 f eed i ng and ea t i ng d i s o r de r s( A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , 2 0 1 3 )
B i n g e
E a t i n g
D i s o r d e r
A n o r e x i a
N e r v o s a
re
str
ictin
g
bin
ge
-e
atin
g/p
urg
ing
Un
sp
ec
ifie
d
Fe
ed
ing
o
r E
ati
ng
Dis
ord
ers
Av
oid
an
t/R
es
tric
tiv
e
Fo
od
In
tak
e D
iso
rd
ers
Ru
min
ati
on
D
iso
rd
er
Pic
a
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DSM-5 • three major eating disorders(American Psychiatr ic Association, 2013)
ANr - ANbp
BN
BED
OSFED
BM I
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a t y p i c a l a n o r e x i a n e r v o s a n o t u n d e r w e i g h t
atypical anorexia nervosa not underweight ✦ definition( W h i t e l a w M e t a l , 2 0 1 4 ; S a w y e r S M e t a l , 2 0 1 6 )
Adolescents
with atypical anorexia nervosa
have lost significant weight
but
are not underweight
✦
They are presenting to
pediatric eating disorder services
at an increasing rate
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Atypical AN considerably affects
physical and psychological functioning,
despite adolescents presenting
within or above
the normal weight range
✦
The morbidity
of adolescents with atypical AN
does not appear less severe
than that
of adolescents with full-threshold AN
atypical AN not underweight vs. typical AN ✦increasing rate of inpatients
( W h i t e l a w M e t a l , 2 0 1 4 )
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2005 2009 2010
atypical
AN
______
typical
AN
8% 47% 43%
atypical AN vs. typical AN ✦ physical features - a( S a w y e r S M e t a l , 2 0 1 6 )
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atypical AN typical AN p
age 15.5 15.4 ns
female gender 88% 88% ns
current BMI 21.4 16.0 < .001
currently overweight or obese 17% 0% < .001
highest premorbid BMI 27.7 20.1 < .001
overweight or obese in the past 71% 12% < .001
loss of weight kg 17.6 11.0 < .001
age at menarche 11.9 12.4 .05
amenorrhea 32% 61% .003
atypical AN vs. typical AN ✦ physical features - b( S a w y e r S M e t a l , 2 0 1 6 )
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atypical AN typical AN p
bradycardia
(< 50 bpm)24% 33% ns
orthostatic instability
(> 20 bpm, > 10 mm Hg)43% 38% ns
hypothermia
(< 35.5oC)10% 13% ns
admitted to hospital at
presentation41% 52% ns
age at menarche 11.9 12.4 .05
amenorrhea 32% 61% .003
atypical AN vs. typical AN ✦ psychological features( S a w y e r S M e t a l , 2 0 1 6 )
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atypical AN vs. typical AN ✦ EDE( S a w y e r S M e t a l , 2 0 1 6 )
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The weight
adolescents with atypical AN
are currently at
is still higher
than the weight they
would secretly like to be.
✦
Being
overweight or obese before
they developed the ED
could fuel a "fear of fatness”
and perpetuate the disorder itself.
atypical anorexia nervosa: not underweight( S a w y e r S M e t a l , 2 0 1 6 )
Adolescents
with atypical anorexia nervosa
have lost significant weight
but
are not underweight
✦
They are presenting to
pediatric eating disorder services
at an increasing rate
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Atypical AN considerably affects
physical and psychological functioning,
despite adolescents presenting
within or above
the normal weight range
✦
The morbidity
of adolescents with atypical AN
does not appear
less severe than that
of adolescents with full-threshold AN
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0
100
200
300
400
500
600
700
800
900
1000
AN BN
community
primary care
mental health care1 : 131 : 3
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a n o r e x i a n e r v o s a b y p r o x y
( M ü n c h a u s e n b y p r o x y s y n d r o m e )
anorexia nervosa by proxy(Katz RL et a l , 1985)
Katz RL, Mazer C, Litt IF
Anorexia nervosa by proxy.
J Pediatr
107 (2):247-248, 1985
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anorexia nervosa by proxy - a(Honjo S, 1996)
Honjo S
A mother's complaints of
overeating by her 25-month-
old daughter: a proposal of
anorexia nervosa by proxy.
Int J Eat Disord
20 (4):433-437, 1996
a case of a 25-month-old girl
brought in by her mother
with complaints of overeating.
The mother indicated
the patient to have begun
overeating
before the age of 1 year.
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anorexia nervosa by proxy - b(Honjo S, 1996)
However,
the patient was
of
low height
and
low body weight,
and appeared underfed
The issue was
the mother placing
severe restrictions
on the child's diet,
pathologically afraid
of the child overeating.
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anorexia nervosa by proxy(Si ro is F, 2011)
Sirois F
Anorexie mentale par procuration : une présentation inhabituelle.
La Presse Médicale
40 (5): 547-550, 2011
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anorexia nervosa by proxy - c(Honjo S, 1996)
The mother seemed
to have been suffering
from
a disorder similar to
anorexia nervosa,
although not typical.
Her fear that
her child might eat too much
appeared as
a projection
of the fat phobia
characteristic of anorexia nervosa
on to her child,
which would justify labeling
the child's condition
a n o rex i a n e rvosa b y p ro xy
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anorexia nervosa by proxy - a(Russel l G et a l , 1998)
Russell GF, Treasure J,
Eisler I
Mothers with anorexia
nervosa who underfeed
their children: their
recognition and
management.
Psychol Med
28 (1):93-108, 1998
Women with anorexia nervosa
have a reduced fertility
but they may have borne children
before the onset of their illness
or after partial recovery.
Little is known on how to identify the
anorexic mothers who underfeed their children
and how to manage them.
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anorexia nervosa by proxy - b(Russel l G et a l , 1998)
Eight such mothers
were identified
as a result of obtaining
serial measurement
of the children's weights
and heights over time.
Nine children
(eight boys and one girl)
were found to have suffered food deprivation:
with
severe reduction in weight-for-age in six
and
in height-for-age in eight.
Five siblings were not affected.
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anorexia nervosa by proxy - c(Russel l G et a l , 1998)
The mechanisms
underlying
the privation
of the children
stem
from the mother's
abnormal concerns
with body size
extending
to her chi ldren .
The children
may become
unduly accep t ing
of the underfeeding.
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anorexia nervosa by proxy - d(Russel l G et a l , 1998)
It is essential
to obtain
the conf idence
of mothers
suspected of underfeeding
their children
and
to adopt
a whole fami ly app roach
to treatment.
Long-t erm t reatment
of one mother,
combining
fami ly therapy
with
admiss ions to hosp ita l ,
resulted in
catch-up growth in her two sons.
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p u r g i n g d i s o r d e r
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DSM-5 Other specified feeding or eating disorders
Purging Disorder (PurD)
Purging D isorder ( PurD )
In the final version of the DSM-5,
PurD is not listed as a discrete diagnosis
but named as part of
‘‘other specified feeding or eating disorders’’
and defined as
• r ecur rent purg ing behav iour to in f luen ce we igh t or shape
• i n the absence o f b inge eat ing
Limited to our sample
the mortality of PurD
seems to be
• lower than the mortality reported
for AN
• nearly twofold higher than the
mortality reported for BN and
EDNOS.
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In conclusion,
our results suggest that
patients with behaviours specified
with the term PurD
should be considered as
individuals with
serious disordered eating behaviour,
who need
attention and treatment.
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b i n g e e a t i n g d i s o r d e r
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DSM-5 Feeding and eating disorders
Major changes: Binge Eating Disorder
The most impactful change was to add BED as a
d i s t i nc t , f o rm a l d i s o rde r
The diagnostic criteria note that episodes must occur, on average, at least
o n c e a w e e k o v e r th r e e m o n ths
ED pr e v a l e n c e be f or e bar i a t r i c sur ger y(James Mitchell et al , 2015)
0
5
10
15
20
25
30
35
40
45
BN BED NES loss ofcontroleating
2
15,717,7
43,4
problematic eatingbehaviours prevalence %
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Eating pathology after bariatric surgeryA review from January 1985 to May 2010
Marino JM et al.
The emergence of eating
pathology after bariatric
surgery: a rare outcome
with important clinical
implications.
The International Journal
Of Eating Disorders.
2012;45(2):179-84.
• classical eating disorders: a rare occurrence
• eating problems: far more common
• it is highly likely that such problems are
underreported
• no typology exists to classify such eating
problems
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o r t h o r e x i a n e r v o s a
orthorexia nervosa
orthorexia
a preference for foods that one
considers healthy.
orthorexia nervosa
a medical condition in which the
sufferer systematically avoids
specific foods that they believe to be
harmful.
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DSM-5 Feeding and eating disorders • definition(Am er ican Psychiatr ic Associat ion , 2013)
Feeding and eating disorders are characterized by
a pers i s ten t d i s tu rban c e
of eating or eating-related behavior
that results in
the altered consumption or absorption of food
and that
s i gn i f i can t l y impai rs
phys i ca l hea l th o r ps ychos oc ia l f unc t i on ing
orthorexia nervosa by proxy - a(Cuzzolaro M & Donin i LM 2016)
Cuzzolaro M & Donini LM
Orthorexia nervosa by
proxy?
Eat Weight Disord
2016
DOI 10.1007/s40519-016-
0310-8
In July 2016
a 13-month-old child
in danger of death
was hospitalized in Milan
against his parents’ will.
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orthorexia nervosa by proxy - b(Cuzzolaro M & Donin i LM 2016)
Lab values
were alarming
and
consistent with
extreme undernutrition.
The physicians
found that
the infant’s weight was 5.2 kg,
the growth was below the 3rd percentile
with
serious hypotonia
and
psychomotor impairment.
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orthorexia nervosa by proxy - c(Cuzzolaro M & Donin i LM 2016)
An inflexible vegan diet
imposed by the parents
was reported as
the main cause
of the problem.
In the last few years
newspapers reported
several stories
similar to the previously examined case.
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orthorexia nervosa by proxy - d(Cuzzolaro M & Donin i LM 2016)
Veganism in adults
requires
a well balanced diet
including
supplements
or
fortified products.
As regards infants and toddlers
uncontrolled vegan diets
may be particularly dangerous.
___________
Composition of breast milk from vegan women,
appropriate breast milk substitutes,
supplements
(e.g., vitamin B-12, vitamin-D, iron, zinc, calcium)
and type and amount of dietary fat
should be evaluated on a regular basis
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obes i t à e d i s turb i de l l ’ a l imen taz i one
✦
d i f f e r enze e in te r sez i on i
d e f i n i z i o n e
c la s s i f i c a z i o n e
c o m p l i c a n z e
m e d i c h e
t r a t t a m e n t o
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d i f f e r enz e
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... tuttavia ...
s i m i l a r i t i e s i n phenot y p e
There are s im i l ar i t i es in phenot yp e such as :
• excess i v e at tempts at we ight contro l
• b inge eat ing behav iour s
• f ood crav ing/ ad d i c t i on
• . . .
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s i m i l a r i t i es i n r i s k f a c t o r s
There are s im i lar i t i es in r i sk fac tor s such as :
• l o w s e l f - e s t e e m
• e x t e rn a l l o c u s o f c o n t ro l
• c h i l d h o o d a b u s e a n d n e g l e c t
• d i e t i n g
• m e d ia e x p o s u re
• b o d y i m a g e d i s s a t i s f a c t i o n
• w e i g h t - r e l a t e d t e a s i n g
• s h a re d s u s c ep t i b i l i t y g e n e s
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Numero di articoli (PubMed) che contengono nel titolo,
insieme, le parole Obesity e Eating Disorders
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0
10
20
30
40
50
60
70
1990-1999 2000-2009 2010-2016
articoli PubMed
l i t e r a t u r e on obes i t y & ea t i ng d i s or de r s
Bruch, H. (1973). Eating Disorders: Obesity, Anorexia Nervosa and the
Person Within. New York: Basic Books.
Williamson, D. (1990). Assessment of Eating Disorders: Obesity, Anorexia
and Bulimia Nervosa. New York: Pergamon Press.
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Brownell, K., & Fairburn, C. (Eds.). (1995). Eating Disorders and Obesity.
New York: Guilford.
Goldstein, D. (Ed.). (1999). The Management of Eating Disorders and
Obesity. Totowa, NJ: Humana Press.
Fairburn, C., & Brownell, K. (Eds.). (2002). Eating Disorders and Obesity. A
Comprehensive Handbook (Second Edition ed.). New York: Guilford.
Goldstein, D. (Ed.). (2005). The Management of Eating Disorders and
Obesity. 2nd edition. Totowa, NJ: Humana Press.
04/11/2016 massimo cuzzolaro 53
l i t e r a t u r e on obes i t y & ea t i ng d i s or de r s
Thompson, J. K. (Ed.). (1996). Body Image, Eating Disorders and Obesity.
An Integrative Guide for Assessment and Treatment. Washington D.C.:
American Psychological Association.
Thompson, J., & Smolak, L. (Eds.). (2001). Body image, eating disorders
and obesity in youth. Assessment, prevention and treatment. Washington,
DC: American Psychological Association.
Fairburn, C., & Brownell, K. (Eds.). (2002). Eating Disorders and Obesity. A
Comprehensive Handbook (Second Edition ed.). New York: Guilford.
Latner, J., & Wilson, G. (Eds.). (2007). Self-help approaches for obesity and
eating disorders: Research and practice. New York: Guilford.
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l i t e r a t u r e on obes i t y & ea t i ng d i s or de r s
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Excess i v e Appe t i t e s
A Psyc h o l o g i c a l V i ew of Add i c t i o n s( J i m O r f o r d , 1 9 8 5 & 2 0 0 1 )
a l c o h o l a n d o t h e r d r u g a b u s e
e a t i n g d i s o r d e rs a n d o b e s i t y
c o mp u l s i v e e x e r c i s e
p a t h o l o g i c a l g a mb l i n g
s e x a d d i c t i o n
c o mp u l s i v e s h o p p i n g
… o t h e r c o mp u l s i o n s
2013 2016 Feb 2017
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eating and weight disorders (from 1996)
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t w o s i des o f t he sam e co i n ?( D a y J e t a l , 2 0 0 9 )
We be l i eve that
th i s po lar i s a t i on
i s fundamen ta l l y f l awed ,
and r esearch and t r eatmen t o f both types o f d i sorder
wou ld be be t te r served by gr eate r apprec ia t i on o f :
• the psychosoc i a l component s o f obes i ty
• the b io l og i c a l and genet i c componen ts o f eat ing d i sorders .
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The interface between the eating disorders and obesity fields:
moving toward a model of shared knowledge and collaboration. ( N e u m a r k - S z t a i n e r D , 2 0 0 9 )
The . . . r ecommend ed mode l ,
i s one in wh ich
the two f i e lds
share knowledge
to enhance the d i f f i cu l t work
o f p revent i ng and t r eat in g
both eat ing d i sorders and obes i ty .
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associazioni e/o migrazioni transdiagnostiche
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disordered
eating
behaviour
eating disorders
weight and
metabolism
dysregulation
A broad spectrum of ...
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Eating
DisordersObesity
Weight-related Disorders
or
Non-homeostatic Eating
Disorders
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