The management of eating disorders and obesity

386 Pages·20.473 MB·English

by  R Goldstein

T M E D O
HE ANAGEMENT OF ATING ISORDERS AND BESITY
N H
UTRITION (cid:57) AND (cid:57) EALTH
Adrianne Bendich, Series Editor
The Management of Eating Disorders and Obesity,
edited by David J. Goldstein
Vitamin D: Physiology, Molecular Biology, and Clinical Applications,
edited by Michael F. Holick
Preventive Nutrition: The Comprehensive Guide for Health Professionals,
edited by Adrianne Bendich and Richard J. Deckelbaum
T M
HE ANAGEMENT
E D
OF ATING ISORDERS
O
AND BESITY
Edited by
D J. G ,
AVID OLDSTEIN MD, P D
H
Lilly Research Laboratories; Indiana University School of
Medicine, Indianapolis, IN
Foreword by
ALBERT J. STUNKARD, MD
University of Pennsylvania Medical Center, Philadelphia, PA
H P
UMANA RESS
T , N J
OTOWA EW ERSEY
© 1999 Humana Press Inc.
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Library of Congress Cataloging-in-Publication Data
The management of eating disorders and obesity/edited by David J. Goldstein; foreword by Albert J. Stunkard.
p. cm.—(Nutrition and health)
Includes index.
ISBN 0-89603-407-0 (alk. paper)
1.Eating disorders—Prevention. 2. Obesity—Prevention. 3. Anorexia nervosa. 4. Bulimia.I. Goldstein, David
J. (David Joel), 1947— Series: Nutrition and health (Totowa, NJ)
[DNLM: 1.Eating Disorders—therapy. 2. Obesity—therapy. WM 175 M266 1999]
RC552,E17N364 1999
616.85'2606—dc21
DNLM/DLC
for Library of Congress 98-53443
CIP
SERIES INTRODUCTION
The mission of the Nutrition and Health Series of books is to provide health profes-
sionals with texts that are considered essential, because each book includes (1) a synthesis
of the state of the science, (2) timely, in-depth reviews by the leading researchers in their
respective fields, (3) extensive, up-to-date-fully annotated reference list, (4) a detailed
index, (5) relevant tables and figures, (6) identification of paradigm shifts and their
consequences, (7) virtually no overlap of information between chapters, but targeted
interchapter referrals, (8) suggestions of areas for future research, and (9) balanced, data-
driven answers to patients' questions, which are based on the totality of evidence rather
than the findings of any single study.
The series volumes are not the outcome of a symposium. Instead, each editor has the
potential to examine a chosen area with a broad perspective, both in subject matter as well
as choice of chapter authors. The international perspective, especially with regard to
public health initiatives, is emphasized where appropriate. The editors, whose training
are both research and practice oriented, have the opportunity to develop a primary objec-
tive for their books, definite the scope and focus, and invite leading international authori-
ties to be part of their initiative. The authors are encouraged to provide an overview of
the field, discuss their own research, and relate their research findings to potential human
health consequences. Because each book is developed de novo, the chapters can be
coordinated so that the resulting volume imparts greater knowledge than the sum of the
information contained in the individual chapters.
The Management of Eating Disorders and Obesity, edited by David J. Goldstein, MD,
PhD, represents a significant contribution to the Nutrition and Health Series. Dr.
Goldstein is to be congratulated for his forward-looking vision and sensitivity toward the
treatment of individuals with eating disorders. As Dr. Goldstein indicates, obesity is not
technically considered to be an eating disorder; however, the health professionals who
care for overweight individuals also often see those with eating disorders. Thus, for many
health-care providers, this book targets several related treatment areas. Dr. Goldstein has
carefully ensured that this book is up to date and provides chapters by the most respected
members of the medical as well as the research community. The Foreword by Dr. Alfred
J. Stunkard reminds us of the past difficulties of developing safe drugs for the treatment
of obesity, and the authors of chapters related to bulimia and anorexia candidly discuss
new options for patients.
Yet, the overriding, consistent message from the editor and chapter authors is that
prevention is the most effective course. Moreover, preventing further deterioration by
the patient's health is given iln-depth analysis in several key chapters. Dr. Goldstein
includes chapters related to the opportunities that are presented to many health care
providers (1) to raise the warning flag and enhance early diagnosis, (2) to provide varied
options including psychological counseling, and (3) to encourage exercise programs and
long-term commitments to healthy eating patterns. Equally important, The Management
of Eating Disorders and Obesity includes informative chapters on the role of heredity in
obesity development as well as insights into the mechanism of action of bioactive mol-
ecules identified recently as being critical for weight management. Finally, the book
v
vi Series Introduction
contains authoritative analyses of the latest data concerning new therapeutic options and
related case studies to enhance patient care. Thus, The Management of Eating Disorders
and Obesity provides the reader with authoritative options for managing some of the
fastest growing problems in U.S. health care today. Thus, the book represents a compre-
hensive, essential resource for health-care providers interested in improving the manage-
ment of patients with eating disorders and obesity.
Adrienne Bendich
FOREWORD
As I sit down to write the foreword for The Management of Eating Disorders and
Obesity, the world of weight control is still stunned by the accumulated bad news of the
recent past. The August 1996 report by Abenhaim (1) alerted us to the devastating
complication of primary pulmonary hypertension among persons who had been receiv-
ing fenfluramine (1). The blow was somewhat softened by the realization that the disorder
was extremely rare. It took 200 cardiology and pulmonary medicine centers two years to
find Abenheim’s 95 cases; the risk was 28 cases per million person-years of exposure,
about that of penicillin-induced anaphylaxis.
Then came the new blow—valvular heart disease—and this time the problem was not
rare (2). Still, fragmentary reports suggest that nearly one-third of persons receiving
fenfluramine suffered from this complication, usually in combination with another
appetite suppressant, phentermine.
Dexfenfluramine and its racemic mixture of DL-fenfluramine were promptly with-
drawn from the market amid predictions of the end of the drug treatment of obesity, and
it is still unclear what to expect. Two entirely different scenarios are possible.
One scenario is that drug therapy of obesity will come to a screeching halt. A report
in the Wall Street Journal of October 24, 1997 described a meeting of 100 product
liability lawyers who discussed what could be the largest class action suit in American
legal history. Even smaller legal actions will make physicians think twice about prescrib-
ing drugs and pharmaceutical companies about developing drugs for them to prescribe.
There is a precedent for such an unfavorable scenario. In the 1970s, congressional
hearings on the abuse of amphetamines for weight reduction led, quite appropriately, to
their removal from the market. Quite inappropriate was the radical reduction in the
prescription of all other appetite-suppressant medication that followed. It was only the
landmark report of the effectiveness of the fen/phen in 1992 that emboldened the medical
profession to once again prescribe medication for obesity(3). It is entirely possible that
the late 1990s has seen a replay of the 1970s and the abandonment of drug therapy for
obesity.
An entirely different scenario, however, may well unfold. Driven by the remarkable
effectiveness of the fen/phen combination, pharmaceutical companies may decide to
embark on a reinvigorated program of drug discovery. Two agents, sibutramine and
orlistat, have been approved, and a larger number of agents are in various stages of devel-
opment. Furthermore, the recent discoveries of fundamental mechanisms of metabolism
and of the control of food intake mean that new and far better targeted drugs can be
designed. The fenfluramine experience will certainly mean that far greater vigilance and
safety will be required. However, the fen/phen successes may be only the prelude to a far
more extensive use of pharmacotherapy of obesity.
A major problem that will affect most pharmacotherapy for obesity is the need to
assess safety over long periods of time. It has become clear that any weight lost with the
aid of medication is promptly reversed when the medication is withdrawn. The consis-
tency of this finding has evoked the theory that appetite-suppressant medication acts
primarily to lower a body-weight set point and only secondarily to suppress appetite. The
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viii Foreword
implication is clear: medication to treat obesity must be used indefinitely or not at all.
Long-term use means long-term monitoring for safety, a requirement that we have not
appreciated and to which we will have to become accustomed.
The bad news about drug therapy has had one salutary consequence for the treatment
of obesity. It means that physicians and patients must carefully weigh the risks and
benefits of the treatments that they consider and they must share the decision as to how
to proceed. For behavior therapy, the risks are small and they may be acceptable to most
people, even those who simply want to lose a few pounds for a wedding. For medications,
however, we must assume that there will be risks and that the extent of the risks will be
uncertain. However, the benefits to an obese person with severe comorbidity may well
be worth taking. Here is an area in which the wisdom of the physician will be tested as
never before.
This foreword has dealt with the treatment of obesity, as that is the area that presents
the greatest current problems. However, the same issues apply to treatment of eating
disorders. For both obesity and eating disorders, The Management of Eating Disorders
and Obesity should achieve its goal of providing guidance to the general practitioner to
improve success and end the cycle of recurrent attempts and failures. I commend it to you.
Albert J. Stunkard, MD
Department of Psychiatry
University of Pennsylvania School of Medicine, Philadelphia, PA
References
1. Abenheim L, Monde Y, Brenot F, et al. Appetite suppressant drugs and the risk of primary
pulmonary hypertension. N Engl J. Med 1996; 335:609–616.
2. Connolly HM, Crary JL, McGoon MD, et al. Valvular heart disease associated with
fenfluramine–fentermine. N Engl J Med 1997; 337:581–588.
3. Weintraub M, Sundaresen PR, Schuster B. Long-term weight control study. Clin Pharm
Therapeut 1992; 51:586–607.
PREFACE
Eating disorders—bulimia nervosa, anorexia nervosa, and binge eating—are com-
monly seen in office practice. Symptoms associated with bulimia nervosa are seen in at
least 5% of college-age women. Obesity, not generally considered an eating disorder, is
prevalent in a third of the US adult population. Binge-eating disorder, which is present
in as many as a quarter of obese patients, has been proposed as a separate entity with an
obese phenotype. All of these conditions are becoming more prevalent and it can be
expected that they will continue to have a substantial impact on the health of those
affected and on direct and indirect costs to society.
All health practitioners encounter patients with eating disorders and obesity. Popular-
press articles on eating disorders are alerting many to the risks of the eating disorders, yet
patients often conceal their condition from family, friends, and health professionals as
long as they can. Although treatment of bulimia nervosa and anorexia nervosa is often
considered the realm of the specialist, there is much that the general practitioner can do.
It is important to recognize the signs of these conditions since early intervention may be
more successful than intervention when the patient has later developed additional psy-
chiatric comorbidities and physical disabilities. Patients need to be evaluated both medi-
cally and psychologically because of the high comorbidity associated with these eating
disorders. Uncomplicated cases can be managed by generalists; because the treatment of
eating disorders and obesity is often multimodal, occasional input from specialists may
still be necessary.
Obesity is much more amenable to treatment by the generalist, in part because signifi-
cant psychiatric comorbidity is less common than for the eating disorders, although input
may be required on selected patients with particularly difficult comorbid conditions.
Further, the health care practitioner needs a foundation of basic information to guide
patients toward effective, long-term solutions. This is particularly important since obese
patients are bombarded with lay information on the latest diet, medication, or other
magical way to reduce weight and keep it off, and health care professionals need to be able
to offer sound, knowledgeable advice. Thus, a major objective of The Management of
Eating Disorders and Obesity is to provide information regarding those treatments that
are more amenable to general health care. It is hoped that the health care practitioner will
be more comfortable intervening earlier, before comorbidities make medical interven-
tion more urgent.
Often, health care professionals fail to diagnose these conditions until late in their
course. When a diagnosis is made, treatment is frustrating for both the health care prac-
titioner and the patient, because both eating disorders and obesity tend to be chronic and
relapsing conditions, requiring lifelong therapy. There is a need for improvement in the
treatment of eating disorders and obesity; without more effective treatments, these con-
ditions will continue to impact health care adversely, as well as to incur high individual
and societal costs. Thus, the main objective of The Management of Eating Disorders and
Obesityis to provide clinical health care practitioners with practical information on the
management of eating disorders and obesity.
For all eating disorders and obesity, the first step toward effective therapy is a thorough
medical and dietary assessment. Based on this information, the initial program is devel-
ix