DISORDERS OF EATING Identifying and Treating Eating Disorders

Transcription

SPRING 2011
DISORDERS OF EATING
Identifying and Treating
Eating Disorders
A Non-Restrictive Approach
to Weight Management
for the Patient Who Has
“Tried Everything”
Connecting the Dots:
Obesity to CAD
Which Comes First: The
Child or The Obesity?
Also…
• MD Tech: 1st in a New Series!
Key to Buying an EMR
• Conversations and
Controversies in Primary Care
2011 MAFP CME Assembly –
Ocean City in June!
This Edition Approved for 2
CME Credits. Complete and
Return Journal CME Quiz.
The Maryland
familydoctor / SPRING 2011 • 1
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2•
The Maryland
familydoctor / SPRING 2011
THE MARYLAND
familydoctor
Spring 2011
Volume 47, Number 4
contents
F EA T U RE S
9
13
17
20
24
26
Identifying and Treating Eating Disorders
by Harry A. Brandt, M.D. and Steven F. Crawford, M.D.
A Non-restrictive Approach to Weight Management
for the Patient Who Has “Tried Everything”
by Michelle May, M.D.
Connecting the Dots: Obesity to CAD
by Jeffrey L. Quartner, M.D.
Which Comes First: The Child or the Obesity?
by Merrell R. Sami, M.D.
Conversations and Controversies in Primary Care
2011 MAFP CME Assembly – Back to Ocean City in June!
MD Tech: Key to Buying an EMR
by Matthew Hahn, M.D.
Mission Statement
To support and promote Maryland family
physicians in order to improve the health of
our State’s patients, families and communities.
d e p a r tm e n ts
4
Board of Directors, Commissions and Committees
5
president
Taking Time To Enjoy My Patients
15
calendar
21
letter
How Many Does it Take?
by Julio Menocal, M.D.
by Eugene J. Newmier, D.O.
8
editor
“…You Know That What You Eat You Are But
What Is Sweet Now Turns So Sour…”
22
journal CME Quiz
28
members
by Joseph W. Zebley, III, M.D.
The Maryland
officers & directors 2010-2011/2012
President
Eugene J. Newmier, D.O.*
[email protected]
President-Elect
Yvette Oquendo-Berruz, M.D.*
[email protected]
Treasurer
Joseph W. Zebley, III, M.D.*
[email protected]
Secretary
Kisha N. Davis, M.D.*
[email protected]
Vice presidents
Central
Eva S. Hersh, M.D.
[email protected]
Eastern
Howard H. Bond, M.D.
[email protected]
Southern
Trang M. Pham, M.D.
[email protected]
commissons & commmittees (effective 6/25/10)
COMMISSIONS AND COMMITTEES
Commission on Membership and Member Services
Vice President Central District
Howard H. Bond, M.D.**
410-256-2580
Bylaws Committee
Yvette Oquendo-Berruz, M.D. **
410-884-7831
Adebowale G. Prest, M.D.
410-546-0447
Finance Committee
Joseph W. Zebley, III, M.D. **
443-524-4481
Eva S. Hersh, M.D. ** 410-545-4481
William P. Jones, M.D. 410-867-2200
Eugene J. Newmier, D.O. 410-228-1325
Yvette Oquendo, M.D. 410-884-7831
Trang M. Pham, M.D.
410-255-2700
Howard E. Wilson, M.D.
202-865-3200
Membership Committee
Charles P. Adamo, M.D.
410-573-4067
Yvette Oquendo-Berruz, M.D. 410-884-7831
Nominating Committee
Yvette L. Rooks, M.D. **
410-328-5012
Kisha Davis, M.D. 410-884-7831
Eva S. Hersh, M.D. ** 410-545-4481
Katina N. Moore, M.D.
443-777-6544
Publications Committee
MFD Editorial Board
Richard Colgan, M.D.**
410-328-2686
Zowie Barnes, M.D.
410-328-8792
Joyce Evans, M.D. 410-328-2273
Jasmine Chen Gatti, M.D.
301-796-2074
Trang M. Pham, M.D.
410-255-2700
Merrell R. Sami, M.D.
410-780-2000
Sandra L. Swann, M.D.
410-328-8792
Tracy A. Wolff, M.D., MPH
301-427-1616
Joseph W. Zebley, III, M.D.
443-524-4481
E-Bulletin
Jocelyn M. Hines, M.D.
410-908-0478
Yvette L. Rooks, M.D.
410-328-5012
443-524-4481
Public Relations and Awards
Kevin S. Ferentz, M.D. **
410-328-4282
Charles P. Adamo, M.D.
410-573-4067
Michael J. LaPenta, M.D.
443-837-1512
443-524-4481
Resolutions Committee
William P. Jones, M.D. **
410-867-2200
Howard E. Wilson, M.D. 202-865-3200
410-546-0447
410-328-5012
Special Constituency Committee
Kisha Davis, M.D. (NP) **
410-884-7831
Randy Angell, M.D. (GLBT)
720-929-1655
Jocelyn M. Hines, M.D. (M)
410-908-0478
Julio Menocal, M.D. (IMG)
301-696-8883
Shana O. Ntiri, M.D. (W)
410-328-8792
Technology Committee
Kwame Akoto, M.D. 410-328-5145
Kristen Clark, M.D.
410-730-8288
Matthew Hahn, M.D.
301-678-7007
Eugene J. Newmier, D.O.
410-228-1325
4•
The Maryland
410-228-1325
410-884-7831
443-524-4481
410-884-7831
410-545-4481
410-256-2580
410-255-2700
Western
[email protected]
Directors
Central
[email protected]
Mozella Williams, M.D.
[email protected]
Eastern
Andrea L. Mathias, M.D.
[email protected]
Rosaire Verna, M.D.
[email protected]
Southern
Kari Alperovitz-Bichell, M.D.
[email protected]
Ramona G. Siedel, M.D.
[email protected]
Western
Kwame Akoto, M.D.
[email protected]
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301-427-1616
410-908-0478
404-918-1278
410-632-1000 x 1004
410-745-6617
410-867-4700
410-518-9808
410-328-5145
Matthew Hahn, M.D.
301-678-7007
[email protected]
AAFP Delegates
William P. Jones, M.D.
410-867-2200
[email protected]
Howard E. Wilson, M.D. 202-865-3200
[email protected]
AAFP Alt. delegates
410-641-4200
[email protected]
Yvette L. Rooks, M.D. 410-328-5012
[email protected]
Immediate past president
Yvette L. Rooks, M.D.*
410-328-5012
[email protected]
Resident Director
Katina N. Moore
443-777-6544
[email protected]
Student director
Janna Becker
443-995-4544
[email protected]
*Member of Executive Committee
Commission on Health Care Services and Public Health
Vice President Western District
Tracy A. Wolff, M.D., MPH **
301-427-1616
Public Health Committee
Niharika Khanna, M.D.**
410-328-5145
Zowie Barnes, M.D.
410-328-8792
410-867-4700
Joseph P. Connelly, Jr., M.D.
410-686-9019
Kisha Davis, M.D. 410-884-7831
Lauren Gordon, M.D.
410-780-2000
410-908-0478
Christine A. Marino, M.D.
443-259-3770
Richard Safeer, M.D.
410-752-3010
Mozella Williams, M.D.
410-328-3525
Bernita C. Taylor, M.D.
410-368-8793
Sara A. Vazer, M.D.
301-468-8999
Research Committee
Beth Barnet, M.D.
410-328-3525
Niharika Khanna, M.D.
410-328-5145
Rural Health Committee
Matthew A. Hahn, M.D.
301-678-7007
Andrea L. Mathias, M.D.
(410) 632-1000 x 1004
410-546-0447
Commission on Legislation and Economic Affairs
Vice President Southern District
Trang M. Pham, M.D. **
410-255-2700
Legislative Committee
William P. Jones, M.D.**
410-867-2200
410-867-4700
Howard H. Bond, M.D.
410-256-3580
Patricia Czapp, M.D.
410-286-8974
Kevin S. Ferentz, M.D.
410-328-4282
Natelaine E. Fripp, M.D. 410-328-4283
Robert S. Goodwin, M.D.
410-997-5333
Kenneth B. Kochmann, M.D.
410-683-3330
Louis Kovacs, M.D. 410-404-0889
Ben E. Oteyza, M.D.
410-838-2424
410-328-5012
Gregory H. Taylor, M.D.
410-328-0861
Rosaire M. Verna, M.D.
410-745-6617
443-524-4481
Commission on Education
Vice President Central District
Eva S. Hersh, M.D. ** 410-545-4481
Education Committee
Eva S. Hersh, M.D. ** 410-545-4481
Kwame Akoto, M.D.
410-328-5145
Raygan Harris-Lofton, M.D.
410-255-2700
Tracy Jansen, M.D.
301-498-3150
410-228-1325
Shana O. Ntiri, M.D. 410-328-8792
Adora Otiji, M.D.
410-328-4283
Trang M. Pham, M.D.
410-255-2700
410-546-0447
Vivienne A. Rose, M.D.
410-328-2550
Ramona G. Seidel, M.D. 410-518-9808
301-427-1616
443-524-4481
**Chair
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president
THE MARYLAND
Taking Time To Enjoy My Patients
Spring 2011
Volume 47, Number 4
familydoctor
Beach. It’s always enjoyable for me to spend
a few minutes talking with these remarkable
people about their experiences. So, before I
left the room, I asked Mr. B if he had ever been
in the service. His face lit up and he started
out by telling me that he joined the Marine
Corps three days after Pearl Harbor and went
ashore at Guadalcanal on the first day of the
invasion. After Guadalcanal, he was involved
in the battles at Port Gloucester and Guam.
Out of his wallet, he pulled a weathered pho-
In our busy lives and practices,
to of himself in his Marine uniform. We spent
where so much of our time is spent worrying
the next several minutes talking about his
about meaningful use, NCQA certification,
War experiences. I honestly could have talk-
EHR’s and prior authorization, it’s easy to for-
ed to him for the entire morning. When we
get what makes Family Medicine so special.
I recently had a day that reminded me why I
went into Family Medicine.
It was a typical day as most of us know;
the day was filled with diabetics coming in for
their 3 month follow up, sick calls and a couple annual exams. One of the first patients
of the day was a new patient to my practice,
a 90 year old gentleman who I will call Mr.
We spent the next
several minutes
talking about his
War experiences. I
honestly could have
talked to him for the
entire morning.
B. Mr. B was a healthy, active man who was
only on an ACE inhibitor for hypertension. I
finally ended the visit, I thanked him for shar-
introduced myself and went through the
ing his story with me and wished him well
usual questions while I filled in the medical
until his next appointment. By then, I was
record. There was nothing special about the
behind, but in a good way. I was so glad that I
visit, Mr. B felt well and just needed a refill on
asked him the question about his service and
his meds. I glanced at my watch and realized
I look forward to future visits with this very in-
that I had a few minutes before the next pa-
teresting gentleman.
tient arrived.
The rest of the day in the office was un-
Now, I am a bit of a history buff and I have
eventful; however, I had to go back to the
particular interest in World War II. I love talk-
hospital in the evening for a meeting with
ing with my patients who are members of the
the family of Mrs. M, who has been seeing me
“Greatest Generation” and served during the
since I started practice in 1997. Mrs. M was
War. Over the years, I have had conversations
a 95 year old lady who up until one month
with a patient who went into Omaha Beach
prior to admission had been living indepen-
in the second wave on D Day, one who was
dently. However, she had fallen and broken
a B17 pilot, another who flew P38 fighters in
some ribs. That had led to pneumonia and
the Mediterranean and one patient who was
a nursing home admission. Unfortunately,
a 19 year old corpsman on an LST at Omaha
continued on page 6
Editor-in-Chief
Richard Colgan, M.D.
Edition Editor
Managing Editor
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Editorial Board
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The Maryland
she was now admitted with evidence of a
name. It was then that I realized that every
tients.
massive stroke. Her living will had been clear
single family member in the room was also
unanimously that Mrs. M’s care would be pal-
We held our meeting and decided
that she wanted no heroic measures. I was
my patient. Both daughters, as well as each of
liative and work toward providing comfort as
now meeting with her family to discuss op-
the 3 grandchildren and the one great grand-
she approached the end of her life. As I left,
tions. When I went into Mrs. M’s room, I was
child present in the room come to my prac-
the family thanked me for my help. However,
greeted by several family members who were
tice. I also realized that there were numerous
I was the one who was thankful to them. I was
at the bedside. Mrs. M was minimally respon-
other grandchildren and great-grandchildren
thankful for their trust and for allowing me to
sive but seemed to arouse when I called her
who were not present who were also my pa-
be a part of their lives and Mrs. M’s life.
As I rode home that night, I reflected
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familydoctor / SPRING
•7
*
editor
“…You Know That What You Eat You Are
But What Is Sweet Now Turns So Sour...”
George Harrison: Savoy Truffle (White Album)1968,
a reference to Eric Clapton’s chocolate addiction and dental health
we must remember the word’s of Moliere’s
with a way to discharge waste.
Although as a species we have progressed
Miser “one must eat to LIVE... not live to EAT”
a bit from the tubeworms, our digestive tract
(il faut manger pour vivre and non VIVRE pour
keeps many of the same attributes.
MANGER) and that from a Frenchman!
The
mouth with sense organs, digestive enzymes
If we unbalance the mind-body-spirit con-
and grinding tools. Peristaltic transport tub-
nection around eating and food, this can have
ing dumping into a complex gastric reservoir
serious consequences not only for the indi-
with a prostaglandin protective layer and an
vidual involved but also for the person’s fam-
asepsis inducing acid bath and, then, a series
ily and even dire consequences for society, as
of specialized conduits ending in a large co-
you will see in the following articles.
As life evolved on this little blue planet,
cortical control.
lon and rectum with sphincters under higher
Our Resident Editor Dr. Sami puts us face
to face with the issue of childhood obesity. I
cellular life forms began to organize them-
The gut contains serotonin receptors,
hope you enjoy the review of eating disorders
selves into more complex entities. On the
lymphatic tissue patches, secretes hormones,
by Drs. Brandt and Crawford. A person can die
road to us, creatures developed digestive
communicates with the stomach (gastro-col-
when the brain and the gut get disconnected.
systems. We still see such organisms as tube-
ic reflex) and also the brain. The mind is, how-
Dr. Quartner’s article takes us on a tour of the
worms and sea cucumbers, which are much
ever, as much under control of the gut as the
personal and societal consequences of the
more complex then we realize.
gut of the brain! In addition, as you are well
obesity epidemic.
Finally, we can all prac-
Organisms appeared with an os to ingest
aware, I am grossly simplifying, and I must
tice mindful eating techniques presented by
nutrients, tubular structures with complex
refer you to current first-year medical school
our colleague Dr. Michelle May MD who also
functions and specialized cells that secrete
texts for a further review of the evolving mar-
demonstrated these techniques at MAFP’s
incretins, absorb nutrients, exchange electro-
vels of the digestive system of which we learn
Annual Assembly in 2009.
lytes and also engage in cellular information
more and more every day.
through serotonin and other cellular media-
When all works well, we grow and thrive,
tors. The whole business ending in a cloaca
however the system is very finely tuned and
So enjoy this spring edition, eat wisely
and, as the late Julia Child would say Bon
Appetit!
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■
Identifying and Treating Eating Disorders
Anorexia Nervosa
Harry A. Brandt, M.D.
percentage of AN patients seem to maintain
Anorexia nervosa (Table 1) was first identi-
some degree of menstrual function. Finally,
fied by Richard Morton in 1689, but modern-
an important diagnostic consideration in
ized by Sir William Gull and Charles Lasègue in
AN is the distinction between the “restrictor
the mid 1800’s. Understanding of the diagno-
subtype,” those that utilize restriction of food
sis, medical complications, etiologic factors,
intake as their primary means of weight loss,
and treatment continues to evolve. AN is an
and the “binge-purge subtype,” those who
illness of extreme morbidity and high mor-
engage in recurrent episodes of binge eat-
tality affecting approximately ½ to 2 percent
ing coupled with a counteractive measure
of populations at risk, primarily adolescent
such as vomiting, laxative abuse, compulsive
and young adult women, but with recent
exercise, or fasting. Many of the restrictor
Table 1: DSM-IV-TR Criteria for Anorexia Nervosa (AN)
A. Refusal to maintain body weight at or above a minimally normal weight for age
and height (e.g., weight loss leading to maintenance of body weight less than
85% of that expected; or failure to make expected weight gain during periods of
growth, leading to body weight less than 85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one’s body weight or shape is experienced; undue
influence of body weight or shape.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three
consecutive menstrual cycles. (A woman is considered to have amenorrhea if her
periods occur only following hormone (e.g., estrogen) administration).
Steven F. Crawford, M.D.
Introduction
increases in the male population, older indi-
patient subtype will cross over at some point
The eating disorders rank among the
viduals, and younger children. The cardinal
to the bulimic subtype of the illness. Others
most serious public health concerns in
symptom of AN is a profound fear of weight
will maintain a fairly consistent pattern of re-
the United States. They cause significant
gain, leading to self-induced starvation and
duced intake without bingeing throughout
morbidity and mortality and pose vexing
significant weight loss. Affected individuals
the course of their illness.
clinical challenges for treatment provid-
are generally at least 15% below their expect-
Outcome from anorexia nervosa is poor
ers. The primary care physician (PCP) is in a
ed weight for age and height. Despite their
with only about 1/3 of patients reaching sub-
unique position to aid in the early identifi-
low weight, patients tend to fear weight gain
stantial recovery and the remainder having
cation of individuals at risk and be a critical
to the extent that they engage in behaviors
varying degrees of sustained illness. With a
provider of medical treatment. This paper
to induce further weight loss. An interesting
mortality rate of approximately 5% per de-
will provide a summary including anorexia
diagnostic element is that many patients will
cade, AN is widely considered the most medi-
nervosa (AN), bulimia nervosa (BN), binge
describe a physical, visual, and cognitive sen-
cally serious of psychiatric illnesses. Patients
eating disorder (BED) and eating disorder
sation of themselves as grossly obese, despite
are adversely affected by the physical sequel-
not otherwise specified (EDNOS).
The
their degree of emaciation. However, some
ae of severe weight loss, which further con-
reader is also referred to guidelines for the
patients may deny or fail to endorse this body
tributes to and exacerbates the psychologi-
evaluation and treatment of eating disor-
image distortion and instead, report that
cal comorbidities of depression, anxiety, and
ders from the American Psychiatric Associ-
they experience themselves as thin despite
personality disorders. The suicide rate in AN is
ation, the American Academy of Child and
continuing to starve. Absence of menstrual
the highest in any psychiatric syndrome and is
Adolescent Psychiatry, and the American
periods is likely to be removed as an absolute
another factor in the high mortality statistics.
Academy of Pediatrics.
diagnostic criterion in females, because some
continued on page 10
The Maryland
The patient with anorexia nervosa re-
Bulimia Nervosa
factors. Clearly, the diagnoses fall on a continuum and crossover during the evolution
quires careful, ongoing physiological man-
Bulimia nervosa (BN) (Table 2) was first
agement and monitoring. The body at di-
characterized as a defined medical syn-
minished weight and energy balance enters
drome in the late 1970’s. While more com-
Findings on physical examination are
a state of metabolic downregulation with di-
mon than AN (2-4% of populations at risk),
less likely to establish the presence of illness
minished temperature, pulse, and blood pres-
the illness may be more difficult for the pri-
in BN. Often patients are in the expected
sure. Patients should be routinely monitored
mary physician to detect because patients
weight range, however, there may be some
for dehydration and electrolyte disturbances
are not clearly emaciated and are often too
abnormal findings available to the observant
that can predispose to cardiac arrhythmias.
self-conscious or ashamed to directly reveal
physician on physical and laboratory evalu-
Hypokalemia and hypomagnesemia may
their abnormal eating behavior. Patients
ation. Calluses or abrasions on the dorsum
require methodical electrolyte replacement.
with BN engage in recurrent episodes of
of the hand over the metacarpalphalangeal
Metabolic alkalosis is commonly seen in pa-
binge behavior, consuming inordinately
joints (Russell’s Sign) are the result of trauma
tients who are actively bingeing and purging.
large amount of food over a relatively short,
introduced during the manual induction of
Hypophosphatemia may develop as a patient
circumscribed period of time with a sense
vomiting by pushing the fingers to the back
begins to gain weight in treatment leading to
of loss of control during the episodes. This
of the oropharynx. Dental erosions or tooth
concerns about refeeding syndrome. There
eating pattern is coupled with counterac-
discoloration may result from excessive acid
may be wide shifts in electrolytes and fluids
tive measures such as self-induced vomiting,
in the oral cavity. Diminished bowel function
requiring careful replacement of phosphorus
laxative and/or diuretic use in the “purging
and recurrent constipation can result from
with monitoring of vital signs and cardiac sta-
subtype,” or excessive exercise, and/or fast-
laxative abuse. Recurrent, mild to moderate
tus. While abnormal labwork may alert the
ing or strict dieting in the “non-purging
electrolyte disturbances including hypoka-
clinician to the severity of the patient’s current
subtype.” Patients with the bulimic sub-
lemia, metabolic alkalosis, or hypochloremia
medical status, normal labwork should not al-
type of AN are distinguished from patients
absent other findings may provide an addi-
leviate or minimize concerns about medical
with BN by their marked degree of weight
tional clue.
risk for any patient with an eating disorder.
In addition to the acute physiological issues associated with starvation and
refeeding, the patient with AN is subject to
long-term health consequences including
osteopenia and osteoporosis, sequelae that
are multifactorially determined. Weight restoration is the most effective means of restoring bone in this patient population, but even
with full return to a healthy body weight, the
individual will most likely never achieve full
of illness in an individual is not uncommon.
Table 2: DSM-IV-TR Criteria for Bulimia Nervosa (BN)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized
by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2 hour period), an amount
of food that is definitely larger than most people would eat during a similar
period of time and under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain,
such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other
medications, fasting or excessive exercise.
bone restoration. Biphosphonate treatment
C. The binge eating and inappropriate compensatory behaviors both occur, on
average, at least twice a week for 3 months.
has been controversial, and is generally not
D. Self-evaluation is unduly influenced by body shape and weight.
recommended with the exception of cases
E. The disturbance does not occur exclusively during episodes of AN.
of severe osteoporosis in treatment resistant
10 •
Binge Eating Disorder
individuals. Estrogen replacement therapy is
loss. By definition, individuals with anorexia
not effective in bone restoration in AN and
nervosa, bulimic subtype are at a weight at
Binge eating disorder (BED) has been
therefore, is not recommended. Estrogen in-
least 15% below expected weight while in-
studied and validated as a research diagno-
duced periods only serve to further diminish
dividuals with bulimia nervosa have not met
sis over the past several years, and will likely
nutritional stores. Additionally, the absence
this weight threshold.
However, both AN
be included in the upcoming release of diag-
or presence of menses can no longer be used
and BN patients place undue emphasis on
nostic criteria. As in BN, BED is characterized
as a sign of unhealthy weight and a marker of
body shape, weight, and appearance, and
by consumption of large amounts of food
weight restoration.
self-esteem is excessively governed by these
in a 2-hour time frame, accompanied by a
The Maryland
perceived loss of control. Additional symp-
been noted to be more common in individu-
toms include feeling uncomfortably full, eat-
als with BED than in the general population.
A screening tool that has been validated
ing alone, eating rapidly, eating when not
hungry, and feeling ashamed or disgusted
following the behavior. Distinguishing BED
Effective Screening for Eating
Disorders in Primary Care Settings
Eating Disorder Not Otherwise
Specified
and effectively used in primary care settings
is the SCOFF. This brief instrument consists
from BN is the lack of the use of counterac-
A majority of patients with significant eat-
of 5 questions, can be completed in several
tive measures such as vomiting, fasting, or
ing disorder pathology do not fall into the spe-
minutes, and provides information regarding
laxative abuse. BED is much more prevalent
cific criterion for AN or BN and are classified as
the core symptoms of AN, BN. The questions
than either AN or BN and some estimates
having eating disorder not otherwise specified
are as follows: (1) Do you make yourself Sick
suggest an incidence in community popu-
(EDNOS). Examples of EDNOS include individ-
because you feel uncomfortably full? (2) Do
lations of 4-8%. It is even more prevalent in
uals with well defined patterns of AN who have
you worry that you have lost Control over how
Table 3: DSM-IV-TR Criteria for Binge Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized
by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2 hour period), an amount
of food that is definitely larger than most people would eat during a similar
period of time and under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three or more of the following
1. eating much more rapidly than normal
2. eating until feeling uncomfortably full
3. eating large amounts of food when not feeling physically hungry
4. eating alone because of being embarrassed by how much one is eating
5. feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least 2 days a week for 6 months.
E. The binge eating is not associated with the regular use of inappropriate
compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not
occur exclusively during the course of anorexia nervosa or bulimia nervosa.
much you eat? (3) Do you believe yourself to
be fat when Others say you are too thin? (4)
Have you recently lost more than Fourteen
pounds in a 3-month period? And (5) Would
you say that Food dominates your life. Clearly,
affirmative answers to any of these questions
warrant further exploration and may be indicative of eating disorder pathology. Substantial shifts in body weight for adults, younger
patients with deviations from growth chart
expectations, or the presence of self-induced
vomiting behavior should all prompt further
clinical inquiry.
New Directions in the Treatment of
Eating Disorders
The major practice guidelines mentioned
earlier all recommend a multimodal approach
weight management programs and in the
not lost a sufficient amount of weight to meet
including urgent medical management, nutri-
significantly obese. Unlike AN and BN which
full criteria, or patients who are bingeing and
tional intervention, psychotherapy, and when
differentially affect more females than males,
purging regularly, but not at the twice weekly
indicated, pharmacotherapy. Unfortunately,
BED seems to occur with closer frequency in
frequency required for BN. Patients meeting
the evidence base for ED treatment is limited
both sexes and over a wide age range. The
criteria for BED are formally diagnosed with
to relatively few clinical trials. For younger pa-
physical comorbidities of BED are usually re-
EDNOS at this time, pending newer diagnostic
tients with AN, a new, specific form of family
lated to obesity and therefore, may include
criteria currently in development. Individuals
treatment in which the parents and family are
cardiovascular disease, diabetes, hyperten-
not meeting full criteria for AN or BN may still
educated and utilized as a strong treatment
sion, kidney disease, obstructive sleep ap-
have a significant eating disorder with a high
resource has recently demonstrated efficacy
nea, and various forms of cancer (i.e., colon,
level of cognitive distress and associated physi-
in randomized studies.
breast, esophageal, uterine, ovarian, kidney,
cal and psychological comorbidities with med-
The most promising psychotherapy is
and pancreatic). Increased rates of irritable
ical risks. Clearly, since the diagnosis of EDNOS
Cognitive-Behavioral Therapy (CBT), a well-
bowel syndrome, fibromyalgia, and insom-
is far more prevalent than AN or BN, the various
researched and proven method for the treat-
nia have also been reported. In terms of psy-
syndromes (including night eating syndromes,
ment of BN and BED. Although research on the
chiatric comorbidities, major depression, bi-
pica, purging behaviors absent binge episodes
effectiveness of CBT for the treatment of AN is
polar disorder, anxiety disorders, substance
and others) subsumed under this broad diag-
much more limited, clinical evidence and data
use disorders, and personality disorders have
nosis need further study.
The Maryland
Table 4. Summary of Indications for Inpatient Eating Disorder Unit
1. Significant weight loss – generally < 85% of healthy weight for age and height, or
rapid weight decline secondary to marked food restriction or refusal.
2. Medical status
a. For adults: Heart rate <40bpm; blood pressure <90/60mmHg; glucose <60
mg/dl; potassium <3mEq/L; electrolyte imbalance; temperature <97.0F;
dehydration; hepatic, renal, or cardiovascular organ compromise requiring
acute treatment; poorly controlled diabetes.
b. For children and adolescents: Heart rate near 40bpm, orthostatic blood
pressure changes (>20 bpm increase in heart rate or >10mmHG to 20mmHG
drop), blood pressure <80/50 mmHG, hypokalemia, hypophosphatemia, or
hypomagnesemia.
3. Suicidality – Specific plan with high lethality or intent; admission may be indicated
in the patient with suicidal ideas or after a suicide attempt, depending on
presence or absence of other factors modulating suicidal risk.
12 •
Indications for Hospitalization
Several guidelines have been proposed
for determining if a patient with an eating
disorder requires in-hospital care. The most
compelling reasons for hospitalization center on the medical indications listed in Table
1. Many patients are hospitalized because of
their inability to block the core, perpetuating
symptoms of illness such as marked food restriction, excessive and compulsive exercise,
or purging behavior including self-induced
vomiting, and/or laxative abuse. Exacerbation of comorbid psychiatric illness also may
4. Motivation – Very poor to poor motivation; patient preoccupied with intrusive
repetitive thoughts; patient uncooperative with treatment or cooperative only in
highly structured environment.
factor in the need for intensive in-hospital
5. Comorbidity – Any co-existing psychiatric disorder that would require
hospitalization.
pacitating obsessions and compulsions re-
6. Purging behavior (including laxatives and diuretics) – Needs supervision during
and after all meals and in bathrooms; unable to control multiple daily episodes
of purging that are severe, persistent, or disabling, despite appropriate trials of
outpatient care, even if routine laboratory test results reveal no obvious metabolic
abnormalities.
necessitate hospitalization.
7. Environmental stress – Severe family conflict or problems or absence of family
so patient is unable to receive structured treatment in home; patient lives alone
without support system.
men and/or the need for a highly structured
From: American Psychiatric Association (2006). Practice Guidelines for the treatment of patients with eating
disorders, third edition.
with significant environmental psychosocial
care. For example, the presence of psychotic
depression and/or suicidal ideation, or incalated or unrelated to the eating disorder may
Another com-
mon factor in the decision to hospitalize a patient is the repeated failure of the patient to
respond to a well-structured outpatient regienvironment to break a cycle of continued
destructive symptomatology. Some patients
stressors coupled with inadequate social support system may require use of a structured
in support of its utility are emerging. Essential-
Pharmacotherapy in AN is usually directed
ly, the cognitive-behavioral model emphasizes
toward the comorbid depression and anxiety.
the important role of both the cognitive (i.e.,
However, a majority of placebo controlled
attitudes regarding the importance of weight,
studies in AN including Selective Serotonin
shape, and their control) and behavioral (i.e.,
Reuptake Inhibitors (SSRI) compounds have
The eating disorders are serious illnesses,
dietary restriction, binge-eating) factors that
not shown that these medications improve
which can cause progressive distress, reduc-
maintain the eating disorder and associated
weight gain, body image distortion, or as-
tion in quality of life, high utilization of health
pathology. The treatment is presented in addi-
sociated eating disorder pathology. There is
care resources, and extreme morbidity and
tive stages with an initial emphasis on stabiliza-
current research evaluating the effectiveness
mortality. The primary care provider is in a
tion of symptoms and behavioral change. As
of second-generation antipsychotics, mostly
unique position to positively influence the
treatment progresses, the behavioral coping
olanzapine, with some evidence that this
course of these illnesses through screening
strategies are supplemented with cognitive
class of medication may induce faster weight
and early identification of illness when inter-
restructuring techniques including work on
gain. Additionally, there is some evidence for
ventions may be more effective.
interpersonal issues, body image, and affect
the treatment of bulimic behavior with SSRI’s,
regulation. The final stage of CBT concentrates
although responses improve when coupled
Dr. Brandt is Director, Center for Eating Disor-
on relapse prevention and maintenance plan-
with nutritional counseling and psycho-
ders, Sheppard Pratt Health System.
ning. In general, the combination of CBT and
therapy. A number of pharmacologic agents
Dr. Crawford is Associate Director, Center
nutritional support increases the likelihood of
(sibutramine, topirimate, orlistat) have been
for Eating Disorders, Sheppard Pratt Health
clinical improvement.
tried in BED with limited success.
System.
The Maryland
inpatient program to facilitate treatment.
Summary
■
A Non-Restrictive Approach to Weight Management
for the Patient Who Has “Tried Everything”
view and meta-analysis of weight-loss clini-
emphasize different facets and utilize dif-
cal trials with a minimum 1-year follow-up
ferent methodologies, their approaches
was, “Weight-loss interventions utilizing a
are typically weight neutral and focus on
reduced-energy diet and exercise are as-
recognition of internal regulatory process-
sociated with moderate weight loss at 6
es, awareness of the present experience of
months. Although there is some regain of
eating, and pursuit of physical activity that
weight, weight loss can be maintained.”
is pleasurable.
However, the weight loss amounted to only
Research on these various approaches
5 to 8.5 kg during the first 6 months from
is slowly accumulating with results show-
interventions with weight plateaus at ap-
ing improved nutrient intake,xix improved
proximately 6 months. In studies extending
health
On the surface, weight management
to 48 months, only 3 to 6 kg of weight loss
weight xxiii,xxiv,xxv or maintenance, xxvi reduced
appears to be straightforward: calories in
was maintained.iv These are hardly the re-
eating disorder symptomatology, xxvii,xxviii
versus calories out. However, while more
sults that patients—and their physicians—
improvements in psychological and be-
is known now than ever before about the
hope for.
havioral outcomes, including self-esteem
Michelle May, M.D., F.A.A.F.P.
complex genetic, metabolic, physiological,
In a recent narrative review of dietetic
cultural, social, and behavioral determi-
articles in the Journal of Human Nutrition
nants, 72 percent of men and 64 percent
and Dietetics, the author concluded that,
of women are overweight or obese, with
“Dietetic literature on weight management
about one-third of adults being obese.i
fails to meet the standards of evidence
indicators, xx,xxi,xxii
lower
body
and eating behavior xxix and reduction in
food cravings. xxx
Web-based Resources for
Non-Restrictive Approaches
Americans in Motion –
www.americansinmotion.org
These statistics suggest that traditional
based medicine. Research in the field is
approaches to weight loss have been inef-
characterized by speculative claims that fail
fective. In a review of 31 long term stud-
to accurately represent the available data.
ies on dieting, the authors report, “there is
There is a corresponding lack of debate on
little support for the notion that diets lead
the ethical implications of continuing to
to lasting weight loss or health benefits.”
promote ineffective treatment regimes and
The Association of Size Diversity and Health –
http://www.sizediversityandhealth.org/
They found that the majority of individuals
little research into alternative non-weight
The Center for Mindful Eating – www.tcme.org
are unable to maintain weight loss over the
centered approaches.”v
Health at Every Size – www.haescommunity.org
long term and one-third to two-thirds of
dieters regain more weight than they lost.ii
Non-restrictive Approaches
Am I Hungry? Mindful Eating Workshops and
Facilitator Training –
www.AmIHungry.com
Intuitive Eating – www.intuitiveeating.org
Become an Effective Agent of
Change
As concern about childhood obesity
There is a growing trans-disciplinary
grows, it is important to recognize that re-
movement away from dieting toward a
sults are similar for children. Research on
non-restrictive approach. There are a vari-
Family physicians are in a unique posi-
nearly 17,000 kids ages 9-14 years old con-
ety of organizations, programs, and authors
tion to introduce a non-restrictive approach
cluded, “...in the long term, dieting to con-
advocating a this paradigm shift.vivii,viii,ix,x,xixii
to the patient who has “tried everything to
trol weight is not only ineffective, it may
Various terms have been used to describe
lose weight.” Their long-term therapeutic
actually promote weight gain.”
these approaches in the lay and academic
relationships allow them to support their
literature, including intuitive eating,xiii non-
patients to adopt sustainable lifestyle
there continues to be a strong cultural bias
diet, mindful eating,
changes over time.
in the general population and among re-
(HAES),xv,xvi Am I Hungry?,xvii instinctive eat-
The remainder of this article describes
searchers and clinicians toward dieting. For
ing, attunement, conscious eating, normal
six specific strategies based on the Mind-
example, the conclusion of a systematic re-
eating, xviii and others. While they each may
iii
Despite these compelling findings,
xiv
Health at Every Size
The Maryland
ful Eating Cycle™ developed by this author.
triggers or meet their true bio-psycho-
a variety of appealing alternative activities
The Mindful Eating Cycle incorporates
social needs.xxxiii,xxxiv,xxxv These triggers and
available such as reading, puzzles, journal-
the common elements of a non-restrictive
underlying unmet needs will continue to
ing, or woodworking.
approach, while offering a structure that is
drive overeating.
xxxi
They can also decrease some of their
environmental triggers by putting food
helpful for the clinician and patient alike.
Encourage the patient to approach this
out of sight, avoiding the break room, and
process with curiosity and non-judgment.
Hunger is a primitive yet reliable meth-
ordering half-portions or sharing meals.
Change takes place in a climate of accep-
od of regulating dietary intake.xxxvi,xxxvii
With practice, this process will help them
tance so help them view their mistakes as
Research has demonstrated that normal
break the habitual association between
an expected part of the process and an op-
weight individuals are more likely to eat
certain activities, people, and places, and
portunity to increase awareness about the
in response to internal cues like hunger
overeating.
drivers of their eating behaviors.
whereas people who are overweight tend
The Mindful Eating Cycle
Why? Why do I eat?
14 •
When? When do I eat?
to eat in response to other cues.
xxxviii
All people eat for emotional reasons, including comfort, celebration, and pleasure.
A simple but useful approach for help-
Cross culturally, social events often revolve
ing the patient re-establish hunger as
around eating and emotional connections
their primary cue for eating is to suggest
to food are part of “normal” eating. Emo-
that they ask themselves, “Am I hungry?”
tional eating becomes maladaptive when it
whenever they feel like eating.xxxix Hunger
is the primary way that a person copes with
is differentiated from other environmental
emotions. To be clear, this does not imply
and emotional cues by identifying physical
that every overweight person has major
symptoms such as a growling stomach, dif-
psychological problems. It simply means
ficulty concentrating, and irritability. Once
that they are using food for purposes other
they are able to accurately identify hunger,
than energy and nutrition at times.
patients can fine tune their awareness by
Emotional triggers include boredom,
determining how hungry they are. Through
stress, sadness, anger, loneliness and even
trial and error they usually discover that
happiness. Eating can be a way to comfort,
Many people lack awareness about why
waiting to eat until they are sufficiently
avoid, numb or distract oneself from emo-
they make their eating decisions despite
hungry increases satisfaction, while waiting
tions. If someone has been using food to
the fact that the underlying reason they
too long can lead to overeating.
help them cope with stress and other emo-
are eating will affect every decision that fol-
Environmental and emotional cues can
tions, dieting will disrupt their primary cop-
lows. For example, if a person is eating for
also trigger an urge to eat (or to continue
ing strategy. If they do not learn alternative
fuel and nourishment, they may be interest-
eating) whether there is a physical need
means of coping then distress will increase
ed in energy balance and nutrition. If they
for fuel or not. Examples of environmen-
and overeating will eventually return. Ad-
are eating in response to environmental or
tal triggers include appetizing food, meal
dressing emotional eating is a significant
emotional cues such as stress, boredom,
times, holidays, advertising and large por-
challenge for many people, and probably
pleasure, they are more likely to choose
tion sizes.xl,xli,xlii While opportunistic eating
the most common reason that diets fail. xlv,xlvi
foods that are convenient, energy dense,
may have been adaptive through much of
Alternatively, when a person is able to
and highly palatable.xxxii They may also be
evolutionary history, it is problematic in the
gain insight into their emotional triggers,
more likely to eat an excess amount of food
current food abundant environment.xlii,xliv
they can improve their ability to identify
when eating doesn’t address the underly-
When an individual recognizes that an urge
feelings and expand their range of cop-
ing trigger.
to eat was triggered by something in their
ing mechanisms. Examples include stress
Further, since diets focus on what and
environment, they can choose to redirect
management, positive thinking and set-
how much people should eat without ad-
their attention to another activity until the
ting boundaries in relationships. Often,
dressing why they are eating in the first
urge passes, reminding themselves that
new skills and tools are needed so it is best
place, dieters usually don’t learn to recog-
they will eat when they get hungry. They
to approach this as a process, referring for
nize and effectively cope with their eating
can prepare for these situations by having
counseling when necessary.
The Maryland
calendar
When patients learn more effective strategies for coping
with their emotions and use food less often for comfort or
to avoid dealing with feelings, two things will happen. First,
their desire to overeat diminishes. Second, and most importantly, they begin to find fulfillment in experiences other
than eating and meet their true needs more effectively.
What? What do I eat?
A restrictive approach requires the dieter to maintain
willpower indefinitely in order to comply with the rules
of the diet they are attempting to follow. Dieters exhibit
an increased preoccupation with food, feelings of deprivation and guilt, and resignation if they break from their
diet.xlvii,xlviii,xlix,l,li Consequently, they develop feelings of
failure, lowered self-esteem and decreased self-efficacy
that often leads to more overeating. Most people have
difficulty maintaining the willpower to avoid pleasurable
foods indefinitely—even when threatened by negative
health consequences.
A non-restrictive approach acknowledges that a “normal” diet consists of a variety of foods, including foods
eaten for pleasure. When pleasurable foods are not forbidden and can be eaten without guilt, there is less drive
to overeat them. When deprivation is no longer a factor,
the individual will begin to recognize that they are hungry for a variety of foods, including healthy foods. The
desire for healthier foods will increase further through
education and personal experience about the effects that
different foods have on their body. They may gradually
modify their diet as they learn nutrition information that
will make them feel better and improve their health.
A simple yet effective way to communicate these concepts to patients is that all foods can fit in a healthy diet
using the principles of balance, variety and moderation.
lii
This flexible approach can be applied in any situation
and is particularly effective when supported by education
about nutrition, shopping, cooking, dining out, and social
eating strategies. The goal is to find a balance between
eating for enjoyment and eating for nourishment.
How? How do I eat?
Mindful eating is non-judgmental awareness of physical
and emotional sensations associated with eating.liii,liv Each
2011
May 9-10
AAFP Family Medicine Congressional Conference
Washington, DC
May 4-7
AAFP Annual Leadership Forum and National
Conference for Special Constituents
Hyatt Regency Crowne Center
Kansas City, MO
June 23-25
MAFP Annual CME Assembly & Trade Show
Clarion Resort Fontainebleau Hotel & Conference Center
Ocean City
August 18-20
Southeastern Family Medicine Forum
Grand Hotel
Natchez, MI
2012
February 25
MAFP Winter Regional Conference
Hunt Valley Resort
Hunt Valley
June 21-23
MAFP Annual CME Assembly & Trade Show
Turf Valley Resort
Ellicott City
AAFP Scientific Assembly Schedule
2011 Sept. 14-17 Orlando
2012 Oct. 17-21 Philadelphia
2013 Sept. 25-29 San Diego
2014 Oct. 22–26 Washington D.C.
2015 Sept. 30 - Oct. 4 Denver
2016 Sept. 21-25 Orlando
2017 Oct. 18-22 Phoenix
2018 Sept. 26-30 Boston
2019 Oct. 23-27 Las Vegas
2020 Oct. 14-18 Chicago
2021 Sept. 29 - Oct. 3 San Francisco
CME Author Disclosure Statements
The authors of CME articles in this publication, except for those listed
below, disclose that neither they nor any member of their immediate families have a significant financial interest in or affiliation with any commercial supporter of this educational activity and/or with the manufacturers
of commercial products and/or providers of any commercial services discussed in this educational material.
Dr. Michelle May: Discloses that she is a full-time employee, owner of “Am I
Hungry?: Mindful Eating” Workshops and Facilitator Training Program.
MAFP receives no commercial support to offset costs in the production
of The Maryland Family Doctor Publication.
decision point in the Mindful Eating Cycle contributes to this
awareness. When one gives food, eating, and their physical
cues their full attention, they are more likely to experience
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The current challenges posed by lifestyle choices
cannot be adequately addressed with a math
equation: calories in versus calories out. Therefore
family physicians should discourage strict and fad
dieting and support their patients in the process of
discovering why, when, what, how, and how much
they eat and where they invest their energy.
tion. Explain that exercise has numerous
well-documented health and psychological benefits, with or without weight loss.
lv,lvi,lvii,lviii,lix,lx,lxi,lxii
Elicit the patient’s feelings
about exercise and work with them to write
a physical activity prescription tailored
to their preferences and level of fitness. If
they are not ready to begin exercising, they
can be coached to come up with ideas for
increasing their lifestyle activity such as
optimal satisfaction and enjoyment without
parking further from the building and walk-
eating to excess.
ing to the mailbox. They can increase their
Following are suggestions for increas-
activity as their tolerance increases; always
ing mindfulness while eating: Eliminate or
keeping in mind that exercise must be com-
minimize distractions while eating includ-
fortable, convenient, fun and rewarding in
ing watching television, working, driving,
order for it to become a long-term habit.
and reading. Sit down to eat, preferably at
However, one’s energy requirements
a table designated solely for that purpose.
are much greater than just exercise. Take
Take a deep breath to calm and center your-
a whole-person approach to the question
self. Appreciate the appearance and ambi-
“Where?” by asking your patients to consid-
ence—a feast for the eyes—before taking
er specifics steps for improving the health
the first bite. Savor the aromas and flavors of
of their body, mind, heart, and spirit. Food
the food. Put your fork down between bites;
becomes fuel when they are focused on
if you are loading your next forkful, that is
creating a balanced, fulfilling life.
where your attention will be focused. Pause
The current challenges posed by lifestyle
in the middle of eating to identify physical
choices cannot be adequately addressed
signals of satiety. After eating, notice how
with a math equation: calories in versus calo-
you feel physically and emotionally.
ries out. Therefore family physicians should
Often, the positive results from eating
comfortably holds only a couple of hand-
discourage strict and fad dieting and sup-
mindfully will motivate individuals to become
fuls of food before stretching and placing
port their patients in the process of discov-
more mindful in other aspects of their lives,
pressure on other areas of the body. This
ering why, when, what, how, and how much
increasing enjoyment and effectiveness.
approach helps the patient see that eating
they eat and where they invest their energy.
the right amount of food isn’t about being
The goal is to guide patients to develop a
good but about feeling good.
healthy, satisfying, mindful approach to eat-
How Much? How much do I eat?
ing, physical activity, and living.
With increased awareness, patients can
also learn to avoid the physical discomfort
of fullness as an internalized mechanism of
16 •
Where? Where do I invest my
energy?
Dr. May is the founder of the Am I Hungry?®
portion control. This is critical in the cur-
Unfortunately, chronic dieting and
Mindful Eating Workshops and Facilitator
rent food abundant environment where
popular messages lead many individuals to
Training Program, www.AmIHungry.com. She
eating until the plate is clean, the pack-
equate exercise with punishment for eat-
is the award-winning author of Eat What You
age is empty, they’ve gotten their money’s
ing. Further, lack of time and discomfort
Love, Love What You Eat: How to Break Your Eat-
worth, or feel physically uncomfortable is
contribute to negative associations and
Repent-Repeat Cycle that guides readers to eat
all too common.
avoidance of exercise. It is helpful to ap-
fearlessly and mindfully.
■
One simple but memorable strategy is
proach physical activity and exercise with
to realize that the stomach is only about
your patients just as you would any other
Note: references for this article are posted at
the size of their fist when it is empty so it
highly beneficial therapeutic interven-
www.mdafp.org; publications and news tab.
The Maryland
Connecting the Dots:
Obesity to CAD
Jeffrey L. Quartner, M.D., F.A.C.C.
vancements in medications, specifically
State had a prevalence of less than 10% and
statin drugs, beta-blockers and ACE inhibi-
seven States had a prevalence of obesity be-
tors. Despite these advances, this metabol-
tween 20 and 24%, but no State had a preva-
ic syndrome epidemic threatens to undo
lence equal to or greater than 25%. In 2006,
all of the exciting hard work we have done
only four States had a prevalence of obe-
over the years. Of course there is always
sity less than 20%. Twenty-two States had
the aggressive approach to diagnostics and
prevalence equal or greater than 25%. Two
therapeutics with catheter techniques as
States (Mississippi and West Virginia) had
well as coronary artery bypass surgery but
a prevalence of obesity equal to or greater
secondary and tertiary care actually repre-
than 30%. By 2009, nine States had a preva-
sents a failure on our part.
lence greater than 30% and 23 States had a
prevalence greater than 25%. Clearly we are
Editor’s note: although this issue addresses
So why call this an “epidemic?” The word
eating disorders Dr. Quartner expands the
epidemic originated from a late Latin cor-
consequences of poor nutrition and ties it into
ruption of the Greek word epidemia, literally
Obesity, however, is not in and of itself
the nation’s # 1 killer, atherosclerosis and car-
among the people (Demos: the people). “Ep-
the metabolic syndrome. That requires the
diovascular disease. JWZ
idemic” in medicine refers to a widespread
development of insulin resistance which can
occurrence of a disease or condition.
occur as a consequence of aging, obesity, a
facing an EPIDEMIC of obesity.
sedentary lifestyle and/or genetic factors.
I graduated medical school in 1975 and
Now lets take the progression of obesity
never heard of ‘The metabolic syndrome.”
to metabolic syndrome and review the im-
Insulin resistance leads to altered fibri-
I never heard it mentioned while I was in
plications for the development of coronary
nolysis, hyperinsulinemia, hypertension,
residency or as a cardiology fellow at Johns
artery disease.
hyperglycemia, and dyslipidemia including
Hopkins Hospital but it was killing my pa-
Obesity is defined as having a very high
the lipid triad of decreased HDL, increased
tients the whole time. There is not a day
amount of body fat in relation to lean body
triglycerides, and small dense LDL. Interest-
that goes by without some mention about
mass or a body mass index (BMI) of 30 or
ingly this specific dyslipidemia complex
the obesity epidemic and attempts that are
higher. As you know the body mass index
occurs commonly both in the metabolic
being made by legislatures, school systems
(BMI) is a measure of an adult weight in re-
syndrome and in Type 2 Diabetes with an
and many others to stem this growing health
lation to his or her height, specifically, the
increased level of triglycerides, VLDL, LDL
threat. So let’s try to connect the dots.
adult’s weight in kilograms divided by the
and small dense LDL and Apo B. There is
The dots begin with the poor eating
square of his or her height in meters. There
a decrease in HDL and Apo A- in the meta-
habits in childhood and adolescence, then
are fascinating data from the CDC Behavior-
bolic syndrome and diabetes.
progress to the middle age obesity epi-
al Risk Factor Surveillance System (BRFSS)
So now, let’s follow those dots; the
demic and end with the development of
that plot the obesity trends among US
metabolic signs consistent with diabetes
coronary artery disease which is the num-
adults between 1985 and 2009. Each year
lead to increased atherosclerosis risk and
ber one killer of Americans; both men and
State Health Departments use standard-
increased coronary risk.
women. In the last 30 years, we have made
ized procedures to collect this data through
The OASIS Study (Organization to As-
great strides in treating coronary artery
a series of monthly telephone interviews
sess Strategies for Ischemic Syndromes) a
disease and heart attacks and we have re-
with United States adults.
two-year analysis demonstrated striking
duced cardiac mortality by addressing the
In 1990, among States participating in
results. Overall mortality with diabetes and
the Behavioral Risk Factor Surveillance Sys-
NO prior cardiovascular disease was equal
First identified through the Framingham
tem, 10 States had a prevalence of obesity
to having previous cardiovascular disease
Study, initiated in 1948, we have learned
less than 10% and no states had prevalence
without diabetes, or a 13% of the study
we must couple lifestyle changes with ad-
equal to or greater than 15%. By 1998, no
modifiable risk factors.
The Maryland
population had metabolic syndrome.
participants. This information is now well
The NHLBI/AHA consensus on metabolic
known. If a study subject had had prior car-
syndrome identified the components that
So what is the metabolic syndrome? Is it
diovascular disease and had diabetes, the
relate to the development of cardiovascular
simply obesity? No. The WISE Study looked
mortality percentage jumped to 20.3%. We
disease. These include abdominal obesity,
at 780 women referred for coronary artery
now understand that Type 2 Diabetes leads
atherogenic dyslipidemia, high blood pres-
angiograph.
to a two-to-four fold greater risk of devel-
sure, insulin resistance plus glucose intoler-
cant angiographic coronary artery disease
oping CAD than a non diabetic individual.
ance, a pro-inflammatory state and a pro-
(equal to or greater than a 50% stenosis)
thrombotic state.
and a three year risk of cardiovascular dis-
Many physicians consider the “Meta-
The prevalence of signifi-
bolic Syndrome” as a relatively new disease.
The metabolic syndrome
is an increasingly common
disorder that affects
approximately 60 million
people in the United States
and many more worldwide.
However in 1947, Jean Vague, a French
diabetologist described increased cardiovascular risk with abdominal obesity when
compared to gluteofemoral obesity.
In
1988, Gerald Reaven described a clustering
of cardiovascular risk factors as “syndrome
X” with insulin resistance as the cause. In
1999, the World Health Organization created a definition for the metabolic syndrome
ease was compared by BMI and metabolic
that was based specifically on clinical crite-
status. The BMI was used to define normal,
ria. Insulin resistance (type 2 diabetes, im-
overweight, and obese participants.
paired fasting glucose or impaired glucose
In each category having the metabolic
tolerance) was added to any two of the fol-
syndrome or diabetes (defined as dys-
lowing:
metabolic) was associated with a two to
1. Elevated blood pressure (equal to or
three times greater risk of significant coro-
greater than 140/90 or drug treatment).
The NHANES Study (National Health and
nary disease and a two-fold increase in the
2. Plasma triglycerides equal to or greater
Nutritional Examination Survey) demon-
three-year risk of death or major adverse
strated the prevalence of ATP III metabolic
cardiovascular event over the obese indi-
syndrome by age. So we have many ways
viduals not defined as dysmetabolic. The
we can define the metabolic syndrome.
conclusions were that it is the metabolic
than 150 mg/dL.
3. HDLC less than 35 mg/dL (in men) and
less than 40 mg/dL (in women).
4. BMI equal to or greater than 30 kg/m2
Now the bad news; overall, in the United
syndrome and not simply obesity or an
and/or a waist hip greater than 0.9 (for
States, the incidence of the metabolic syn-
elevated BMI that predicts future cardio-
men) or 0.85 for women.
drome is approaching 24%, or a quarter of
vascular risk in women. The clinical evalu-
the population. The incidence increases
ation of abnormal metabolism should play
min and albumin/creatinine greater
as one ages so that in the 20-29 year age
a much more important role than simply a
than 30 mg/g.
group, the incidence is approximately sev-
diagnosis of obesity in cardiovascular risk
The ATP III criteria for the metabolic
en percent (7%). By the time one reaches
stratification.
syndrome establishes the diagnosis when
60-69 or older, it is 40-45%! This is bad news
Lets follow the dots some more. Is the
three or more of these risk factors are pres-
and may lead to a reversal in our longevity
metabolic syndrome mostly dyslipidemia?
ent. They include abdominal obesity by
statistics. The same survey looked at the
No. The 4S Study (Scandinavia Simvastatin
waist circumference, triglycerides again
prevalence by gender and race/ethnicity.
Survival Study) demonstrated a remarkable
greater than 150 mg/dL, HDLC less than 40
African-American men are least affected
reduction in event rate when the treatment
mg/dL in men, less than 50 mg/dL in wom-
and Mexican-American women are most
of the lipid triad (elevated LDL, elevated tri-
en, blood pressure equal to or greater than
affected. The prevalence of coronary vas-
glycerides, reduced HDL) was compared to
130/ equal to or greater than 85 mmHg or
cular disease by metabolic syndrome in
the treatment of just an isolated elevated
fasting glucose equal to or greater than 110
diabetes in that same NHANES population
LDL. Remarkable but only at best a 30%
mg/dL.
age 50 or greater identified that 85% of this
reduction in events. What else is going on?
5. Urinary albumin greater than 20 mg/
18 •
The Maryland
less than 130/80 mmHg in all patients.
Is it mostly inflammation? No. In the
Finally, does treating the metabolic syn-
Women’s Health Study, a very remarkable
drome matter? The Finnish Diabetes Pre-
study evaluated close to 15,000 women
vention Study looked at 522 middle-aged
tively in post MI patients.
aged greater than 45 years or older, with no
overweight (BMI 31 kg/m2 or greater) in-
The LIFE Study compared the effects of
history of cardiovascular disease, cancer, or
dividuals. Impaired glucose tolerance was
losartan and atenolol on cardiovascular
diabetes, and not using hormone replace-
present. Each person was randomized to
morbidity and mortality in high-risk pa-
ment therapy at baseline and looked at
one of two groups for a mean duration of
tients with hypertension and left ven-
C-reactive protein, metabolic syndrome,
3.2 years. The interventional group included
tricular hypertrophy.
and the risk for cardiovascular events. In
individualized counseling that specifically
All endpoints including cardiovascu-
this study, elevated C-reactive protein was
targeted the reduction of weight by equal to
lar death, stroke, myocardial infarction
defined as greater than 3 mg/L. The follow
or greater than five percent (5%). The reduc-
and total mortality favored losartan
up period was eight years. As one might
tion of total intake of fat to less than 30% of
over atenolol.
expect, women with elevated heart specific
total calories, and saturated fat to less than
Also noted over the 66 months of the
C-reactive protein and the metabolic syn-
10% of total calories increasing the uptake
study, the losartan group had a 25% re-
drome were at the greatest risk.
of fiber to equal to or greater than 15 g/1000
So then what exactly is the metabolic
calorie and increasing physical activity to at
syndrome and where do eating disorders
least 30 minutes per day. The control group
come in? Multiple apparently minor risk
had regular care by physicians.
Beta-blockers, which should be used ac-
duction in new onset diabetes.
C Cholesterol management as well as of
course Cigarette smoking Cessation.
The CARDS (atorvastatin) trial as well as
factors create a cumulative risk, and this
As one would anticipate, the interven-
the VA-HIT (gemfibrosil) each showed
increases the risk of developing CAD. Fram-
tional group was much more successful.
reduction in coronary events in their re-
ingham bar graphs show this very nicely.
What it shows is that after four years, the
The total severity of multiple low-level risk
risk of developing diabetes was reduced
factors often exceeds that of a single se-
by 58%. This suggests that lifestyle change
tes control.
verely elevated risk factor.
can reduce risk for CAD as diabetics have as
The goal remains optimal BMI and a
We now get near the goal. In the presence of the metabolic syndrome fatty acid
high a risk for coronary events as non-diabetics with known CAD.
spective populations.
D Dietary weight management and Diabe-
Heme A1c under seven percent (7%).
E Exercise for 30 minutes per day and also
Education for optimizing awareness of
intake leads to central obesity and impair-
And now it is our turn, the clinical doctors.
ment of fat digestion. This can lead to insu-
What do we do to counter the epidemic and
lin resistance in the skeletal muscles which
treat the metabolic syndrome? Initial thera-
In summary, the obesity epidemic has
leads to elevated blood pressure. The in-
py should consist of life style counseling in
contributed to the increased prevalence of
creased fatty acids go to the liver causing
adolescence and then caloric restriction and
the metabolic syndrome and diabetes. The
N.A.S.H. or fatty liver which will lead to in-
encouraging increased physical activity in
epidemic nature of the metabolic syndrome
creased fibrinogen, hypertriglyceridemia,
middle-aged adults. Conventional cardio-
leads to a greatly increased risk of developing
increased C-reactive protein, and elevated
vascular risk factors such as dyslipidemia
coronary artery disease and puts our society
Apo B. This leads to atherogenesis, and to
and blood pressure should be treated ag-
at risk with markedly increased morbidity,
coronary artery disease.
gressively and may require polypharmacy.
increased health care costs and eventually re-
Smoking cessation applies to ALL patients.
duced longevity. Physicians can prevent or at
There are multiple implications to this
I call this the ABCs of cardiovascular dis-
epidemic of the metabolic syndrome. It is
coronary artery disease risk factors.
least try to treat the metabolic syndrome and
an increasingly common disorder that af-
ease risk management:
thus get ahead of the end organ diseases with
fects approximately 60 million people in
A Antiplatelet therapy and anticoagulants
a multifactorial “ABC” approach.
for treating all high-risk patients.
the United States and many more world-
ACE inhibitors or ARBs to optimize blood
wide and an important determinant of
cardiovascular disease risks, specifically the
risk of developing type 2 diabetes. In patients where one feature is identified, careful assessment for other features is critical.
■
Dr. Quartner is Chief of Cardiology at the Union
pressure.
Memorial Hospital and Clinical Assistant Pro-
Anti-anginals should be used to relieve
fessor of Cardiology, University of Maryland
anginal symptoms once CAD is present.
School of Medicine. He is Partner, Midatlantic
B Blood pressure control with a target of
Cardiovascular Associates in Baltimore.
The Maryland
Which Comes First: The Child or The Obesity?
work up for co-morbidities. His work up in-
BMI 5th-85th percentile for age and sex ➔
cluded fasting glucose, lipid panel, TSH and
Normal weight
a sleep study to rule out Obstructive sleep
BMI 85th -95th percentile for age and sex ➔
apnea. Except for mild OSA, his now annual
Overweight
work up has been negative for 3 years. How-
BMI > 95th percentile for age and sex ➔
ever, he may not remain as fortunate as he
Obese
gets closer to adulthood.
BMI > 99th percentile for age and sex ➔
Scott is one of many children on this path
Extreme obesity
to an adulthood laden with hypertension,
Syndromic overweight often has onset
hyperlipidemia, diabetes and increased risk
before two years of age. Laboratory evalu-
for cardiovascular disease. Almost a third of
ation for overweight and obesity in chil-
Scott, walked into our office four years ago
children and adolescents in the US are either
dren and adolescents is not standardized.
with a BMI of 36. He now, at 14 years of age, has
overweight or obese. The breakdown of the
Suggestions include fasting glucose, insu-
a BMI of 45. His step mother and father, both
obese subset, as measured in 2007/2008,
lin, lipid panel, LFTs (NAFLD) and vitamin
obese, report that he has always been “bigger”
consisted of 19.6 percent of school age chil-
D in children with BMI >85th or >95th per-
than other kids his age. After all, like the rest of
dren (ages 6-11) and 18.1 percent of adoles-
centile to evaluate for presence of common
his family, he is tall! They believe that since he
cents. These rates are more than triple what
co-morbidities.
always eats everything and never gets sick, he
they were about 30 years prior. Even preva-
As these numbers increase, we see an
must be healthy. His only medication is Ritalin
lence of obesity in preschool aged children
increase in obesity co-morbidities such as
for ADHD. His appetite has not changed, nor
(2 to 5 years of age) doubled to 10.4 percent
sleep apnea and gall bladder disease. Co
has he lost weight since starting Ritalin (on and
over the same time period.
morbidities will only increase as these children grow into childhood since 35% of obese
It is clear that obese and overweight children
outnumber those who present with bulimia or anorexia
nervosa. However, we do not treat these children’s
eating disorder as aggressively as their counterparts.
preschool children, 50% of obese school age
children and 80% of obese adolescents persisted into adulthood.
Prevention of this increasing trend requires very early screening. This might be a
significant challenge when caring for a two
off) 2 years ago. He does not usually eat break-
It is clear that obese and overweight chil-
year old, but with some diligence, it is not so
fast and eats lunch at school. He eats dinner
dren outnumber those who present with
difficult in those preschool and school age
when he comes home, usually having about 3
bulimia or anorexia nervosa. However, we do
children. Risk factors for childhood obesity
servings and then he has chips and whatever
not treat these children’s eating disorder as
include being American Indian, non-Hispan-
else is in the pantry for a bed time snack. His
aggressively as their counterparts. This is like-
ic black or and Mexican American. Also, hav-
mom says that he will only drink soda, but she
ly because the general trend of our society is
ing an obese parent increases the incidence
tries to get him to drink more juice.
an increasing average BMI, so larger children
by two to three fold (2-3x). Other, more ob-
Did Scott’s doctors and parents fail him?
do not look as out of place as they should. In
vious associations include a sedentary life-
Are his genetics too strong? Is it too late to
order to treat these children appropriately we
style and a caloric intake that is greater than
undo his current habits? How could his phy-
need clinical criteria by which to diagnose,
needs. While ethnicity is not a modifiable
sicians have prevented this trend which may
test and aggressively treat them.
risk factor, we as family physicians, should be
very well follow him into adulthood? Every
20 •
Weight classification for children 2 to 20
most qualified to alter those which are modi-
well child check, in Scott’s office chart, docu-
years old:
fiable. Family Physicians are more invested
ments obesity counseling, including infor-
BMI <5th percentile for age and sex ➔
in aggressively bringing down the BMI of
mation on diet and exercise and appropriate
Underweight
both the parent and the child.
The Maryland
The concepts of a healthy life style can be
parents can even hold each other account-
ball. In three months, he will follow-up with
simplified and are applicable to the whole
able to the goals they establish in their
his progress and more changes.
family. A number of studies have shown as-
well child visit.
■
sociations between intake of sugar-contain-
After three years of annual screening for
Dr. Sami is a Family Medicine resident phy-
ing beverages or low physical activity and
co-morbidities which both his parents cur-
sician in her 2nd year at the Franklin Square
obesity or metabolic abnormalities. While
rently have, Scott has decided to give up
Hospital Center in Baltimore. As resident ed-
these studies were carried out on children,
soda and junk food at bedtime. His parents
itor on the MAFP Editorial Board, she writes
similar studies, with the same conclusions,
agreed to stop buying soda and juice and
this, her 3rd article for The Maryland Family
have been carried out on adults.
decrease pantry supplies of junk food. Once
Doctor. Her prior articles appear in the Fall,
his grades improve, he will be able play foot-
2010 and Winter, 2011 editions.
Family physicians are in the perfect position to counsel parents that juices, soda
and other sugary drinks are just as lacking
in benefit for them as it is for their toddler
and preschool age children. There is no
reason to even have them in the house.
This unique position allows us, to counsel
parents on the importance of healthy eating habits and physical activity for themselves as well as their elementary and
middle school aged children. Children and
Resources for parents and children:
Produce for Better Health Foundation – 5aday.com
The child Care Nutrition resource System – nal.usda.gov/childcare/
Weight Control information Network – win.niddk.nih.gov/index.htm
The Maternal and child Health library knowledge Path –
mchhlibrary.info/knowledgepaths/kp_overweight.html
The American Academy of Pediatrics – aap.org/obesity
The centers for disease control and prevention – cdc.gov/nccdphp/dnpa/obesity
letter
How Many Does It Take?
Being a Family Physician is usually a most
rewarding experience. However, at times, it
is a very trying endeavor. In my particular
situation in Frederick County, MD, I find this
immense reward in providing a service that
is unique to our community. I have a practice
that specializes in underserved children. I
also take care of adults, but the majority of
my patients are children enrolled in CHIP
I could describe to you many instances that have
brought front and center how special this kind of
service is. Suffice it to say, though, that the image
most of those students rotating through here
remember is the relief mothers feel that their child is
finally getting to see a physician… any physician.
(Children’s Health Insurance Plan).
Even though I do have about 30 % mix
environment, I was terrified that making a
the relief mothers feel that their child is final-
between self-pay, Medicare, and commer-
move would be a financial disaster. But so
ly getting to see a physician… any physician.
cial insurance, the majority of the clients
far, going into my fifth year of operations, we
One of the surest ways that I know that
have Medical Assistance. It is no secret that
eke out a modest but rewarding existence.
my office has done its job well is when a cli-
most of the adults on MA in Maryland do so
I could describe to you many instances
ent complains about waiting times in the
because they have major psychiatric disor-
that have brought front and center how
office or on the phone. I know that sounds
ders. We try and take care of them, too.
special this kind of service is. Suffice it to
counterintuitive. Yet, this is a disenfran-
I must admit that after 21 years of hard
say, though, that the image most of those
chised population who grew callous at the
clinical practice in a suburban, middle class
students rotating through here remember is
The Maryland
journal CME quiz
many instances that care was denied to them.
So recently, I was startled when a Hispanic mother (we
Articles
have a large population that, like me, is from Latin America)
1. Identifying and Treating Eating Disorders
p. 9
requested that her child’s records be transferred to a local pe-
2.A Non-restrictive Approach to Weight Management
p. 13
diatrician. I immediately called her to ask her why. I try and do
3.Connecting the Dots: Obesity to CAD
p. 17
that since many times a parent’s reason for a transfer is based
4.Which Comes First: The Child or The Obesity
p. 20
on non-clinical interactions between them and my staff. If so,
corrective action may be needed on our end.
That was not the case. The mother informed me that she
had been told that her child needed a pediatrician to care for
him. She was told that by none other than a case worker with
a government program through our local Health Department.
Indignant is a mild word to describe my feelings. I called
the supervisor of this program. After explaining my frustration, she acknowledged that she cannot control every conversation her case workers have, though she would admonish
them to steer clear of physician choice.
Later that night, while I sat in my tub soaking my aching
The Maryland Family Doctor has been reviewed and is acceptable
for Prescribed credits by the American Academy of Family Physicians
(AAFP). This Spring, 2011 edition (vol. 47, No. 4) is approved for 2
Prescribed credits. Credit may be claimed for two years from the date
of this edition (expiring April 30, 2012).
AAFP Prescribed credit is accepted by the American Medical
Association (AMA) as equivalent to AMA PRA Category 1 credit toward the AMA Physicians Recognition Award. When applying for
the AMA PRA, Prescribed credit earned must be reported as Prescribed credit, not as Category I.
NEW CREDIT REPORTING PROCEDURE FOR ONLINE COMPLETION
feet, the blur of the day’s events went through my mind. The
AND SUBMISSION OF MAFP JOURNAL CME QUIZZES NOW AT
84 visits and the fatigue from the effort involved in providing
WWW.MDAFP.ORG! Beginning with this Spring, 2011 edition,
sufficient care for all the clients were hidden by my frustration.
the process for completion and submission of MAFP Journal CME
Then realization came to me. In 4 years, we had improved
quizzes is now fully automated. Access this quiz at www.mdafp.
the Latino’s rate of on-time vaccinations (series up-to-date at
org (CME Quiz tab on home page). Complete quiz and click the
18 months) from a dismal 21% to 93%. I know this because our
“send” button. You will receive an immediate confirmation that
local VFC (Vaccines for Children) program provider told me
your quiz has been received by MAFP. MAFP will report the credit
just 5 weeks ago. I had asked for an award, but you only get
to AAFP for posting on your member record at www.aafp.org
one if you “hit” 100%. She was sorely disappointed that we
were below 95%, and couldn’t understand my elation.
The quiz may be copied from this journal or printed from the
online posting. Those who do not use the automated option must
Now, I was feeling frustration that clients were being di-
report their credits. Please keep a copy of the quiz for your records.
verted to pediatricians’ offices. I chuckled then, as I recalled
Questions? Contact the MAFP office at [email protected] or 410-747-1980.
Answers p. 30
the struggle to see newborns in the first 4 days after hospital
discharge. No one was willing to see them without a valid ID
Instructions: Read the articles and answer all questions by indicating
card (which takes 3 weeks to arrive) or cash payment. No one
the correct answers. Mail, fax or e-mail the entire quiz form within
except an FP. I had managed to find work-around solution
two years (by April 31, 2012) to:
through a very skilled nurse at our Health Department.
So I guess now I have come full circle. There is active competition for Medical Assistance patients among providers.
Don’t get me wrong, there are still only a few of us in this arena, but a lot more than 5 years ago.
As a parting comment, allow me the privilege of giving
you a talking point for your next social gathering. When some-
Maryland Academy of Family Physicians
5710 Executive Drive, #104; Baltimore, MD 21228
410-747-1980, 410-744-6059 (fax) • [email protected] (e-mail)
Name:
AAFP Membership #:
Address:
body asks you rhetorically, “How many physicians does it take
to help address your community’s health problems?” Answer
them proudly, “It only takes one FP …… you!”
Julio Menocal, MD
Menocal Family Practice
Frederick, Maryland
City:
State:
Phone #:
Fax #:
E-Mail Address:
22 •
The Maryland
Zip Code:
Questions Article #1:
7. In intuitive eating, the primary drive to
13.Clinicians must use an aggressive
eat is triggered by:
multifactorial approach to help their
morality in the populations at risk
A.Stress
patients with the metabolic syndrome
A.True
B.Hunger
A. True
B.False
C.Mealtimes
B.False
1. In AN there is a 5% to 10% incidence of
2. Two AN subtypes are “restrictor” and
“binge-purge”
A.True
B.False
3. By definition individuals with bulimia
nervosa (BN) have a weight at least 15%
below their expected weight.
D. Social pressure
E. Appetizing food
8. Use of hunger and satiety for regulation
14.One third of children and adolescents in
of fuel intake:
the US are either overweight or obese.
A. is an instinctive, natural, and effective
A.True
mechanism that can be unlearned
B. is helpful for managing intake
B.False
15.Which of the following is not suggested
A.True
and weight in a food-abundant
in the screening blood work for obesity
B.False
environment
related co morbidities:
4. Binge eating disorder (BED) is more
prevalent than either AN or BN and may
reach over 4-8% in weight management
programs and in the significantly obese.
C. requires attunement to physical cues
A.TSH
D. can be relearned with appropriate
B.CBC
coaching and awareness
E. All of the above
A.True
B.False
C.LFTs
D.insulin
E.glucose
9. The Metabolic Syndrome or a BMI of >
16.Childhood obesity is defined as BMI >
85th percentile.
30 are equivalent coronary risks.
A.True
5. Most non-restrictive approaches to
A.True
B.False
lifestyle change incorporate all of these
concepts, except:
A. Lifestyle changes are beneficial even
without weight loss
B. Learning to recognize internal
10. According to the CDC, in the last 20
years the prevalence of obesity in the
USA has gone from 0 states with an
obesity prevalence of 15% or more to
regulatory processes such as hunger
23 states with an obesity prevalence of
and fullness
equal or greater than 25%.
C. Awareness of the current experience
of eating
D. Avoidance of foods known to be
calorically dense but nutrient poor
E. Identification of physical activity that
is enjoyable for the individual
6. In a non-restrictive approach, the
individual:
A. Earns the privilege of eating
A.True
B.False
11. Pharmacotherapy is always necessary
to prevent the metabolic syndrome and
supersedes behavioral management
with diet and exercise.
A.True
B.False
12.The dyslipidemia triad common in
additional calories by exercising
the metabolic syndrome (low HDL-C /
B. Is taught to resist certain bad foods
ApoA, elevated Triglycerides / ApoB /
C. Follows a specially designed meal
non HDL-C, and elevated LDL-Particles)
plan to reach their goals
D. Has unconditional permission to eat
all types of food
E. Counts calories, exchanges, fat
■
B.False
requires aggressive lipid management
with diet and pharmacotherapy.
A.True
B.False
grams, points, or carbs to lose weight
The Maryland
CONVERSATIONS AND
CONTROVERSIES IN PRIMARY CARE
2011 MAFP ANNUAL CME ASSEMBLY
Thursday-Saturday
June 23-25, 2011
Clarion Fontainebleau Resort Hotel
Ocean City, Maryland
In addition to learning and networking in a beautiful
beach location, expect…
• A Streamlined Format Offering 20 CME Credits* • An ABFM SAM Study Hall Module on Diabetes
• A 2-Day Technical Trade Show
SEE POSTED AT WWW.MDAFP.ORG
•
•
•
•
Event Brochure Includes Schedule, Registration Options,
Facility Information
Program Faculty
SAM Study Hall Registration Form
Questions?
Contact MAFP at [email protected] or 410-747-1980.
From the
Program Chair
Dear Colleagues:
The theme of the 2011 Assembly conference is
“Conversations and Controversies in Primary Care”
where attendees can pursue enhanced knowledge in an atmosphere of learning and professionalism. The topics are included mostly in response
to member and past-attendee requests and are
provided to you in a new streamlined format (1/2
day shorter than prior years). Members of our planning committee, your peers, have listened to you
and developed this educational activity with YOU
in mind.
Balmy ocean breezes are also in store
for you at Maryland’s beautiful seaside resort. We
personally look forward to the conference and to
seeing you there!
Eva S. Hersh, M.D.
2011 Assembly Program Chair
24 •
The Maryland
Program Committee
Eva S. Hersh, M.D., Chair
Kwame Akoto, M.D.
Niharika Khanna, M.D.
Shana O. Ntiri, M.D.
Adora Otiji, M.D.
Trang M. Pham, M.D.
Vivienne A. Rose, M.D.
Ramona G. Seidel, M.D.
Tracy A. Wolff, M.D.
Joseph W. Zebley, M.D.
Special Participants
A Glimpse of Topics and Speakers
ADD in Adults and
The 4-Ds of Assessing
Altered Mental Status in
the Cognitively Disable
Retirement from Driving
Adrienne A. Williams, Ph.D.
Carl A. Soderstrom, M.D.
Celiac Disease 2011
Practical Care at the End
of Life
Todd D. Heller, M.D.
Andrea M. Allen, M.D.
Limits of Evidence-Based
Medicine
Alternative Physician
Payment in the New
Reformed Healthcare
Environment
Glenn J. Treisman, M.D., Ph.D.
Bruce Bagley, M.D.
Bioidentical Hormones
and Management of
Menopause
Workshop: Optimizing
Fracture Prevention in
Patients with Osteoporosis
Netra Thakur, M.D.
Steven T. Harris, M.D.
MAFP President,
Welcome to One and All!
Glen R. Stream, M.D.
President-Elect, AAFP
Bringing Greetings from AAFP
and Presiding at Installation of
MAFP Officers
Pamela R. Kushner, M.A., M.D.
Karl N. Watts, M.D.
Keynote Address
Think and Act Globally and Locally
Acute Grief Counseling
Nancy Beth Grossman Barr, M.D.
*Attention active and supporting AAFP/MAFP
members: credits from this conference are applicable
to AAFP and MAFP CME requirements.
The Maryland
MD Tech – 1st in a New Series
Key to Buying an EMR
guiding question being, “how can it be
produce the ideas and organization that
done better?” Almost always, the answer
underlie the best writing.
involved new technology to fully enable
redesigned and improved processes.
Most doctors understand the two most
basic problems that plague paper chart-
This initial MD Tech column will focus
ing: paper charts get lost and handwritten
on the most important medical-technolog-
notes often are illegible. We understand
ical issue of our generation: the electronic
that an EMR should solve those two issues
medical record.
but, beyond that, have thought too little
Matthew Hahn, M.D.
As it is with many doctors, I was once
resistant to the use of computers in health
care. Early in my career, though, I had a
transformative experience, back in 1998,
when a colleague introduced me to one
There are no administrative benefits or
government incentives worth the trouble or cost
of an EMR that does not help you to chart better
or help you to be a better doctor.
of the first hand held computing devices, a
Palm PDA, that was running the Epocrates
Why has medicine’s transition to EMR
about the potential benefits and pitfalls of
Rx drug guide. My life was changed forever.
been so rocky? One of the most significant
computerized medical care. The fact is, our
success or failure is often in those details.
That experience opened my eyes to a
reasons may come as a surprise: because
liberating concept: that we can re-imagine
many doctors do not have a sufficient
Where do we start if we want an EMR to
the way work in medicine is done and, with
understanding of medical charting. Our
make our lives easier and improve the qual-
the help of technology, recreate the medi-
charts, which we know to be the bedrock
ity of our care? The answer is to analyze
cal world in a way that makes our lives eas-
of good medical care, have traditionally
medical charting and re-imagining how it
ier and our care better. The way I practice
been a mess. Purchasing and using an EMR
might be done. At its heart, medical chart-
medicine has changed for the better and
doesn’t necessarily change that.
ing consists of past medical history and
the use of technology has been integral to
SOAP notes. When we meet a new patient,
care that fail do so because the clinical team
we should obtain a history that consists of
Most recently, we opened a successful,
fails to appreciate the process of medical
past and present problems, social history,
nearly-paperless private practice, where
charting, merely recreating many of their
family history, a history of hospitalizations
information technology (IT) has enabled
previous charting errors, albeit now com-
and surgeries, medications and allergies.
us to dramatically lower our overhead,
pounded by the use of an often cumber-
Each time we see a patient, we need to
changing the math of running a medical
some, buggy technology, as EMR software
update that information. We also create a
practice so dramatically that we are able
can often be. The result is that computer-
SOAP note that consists of a history, exam,
to spend 30-minutes per patient, on av-
ized charts are also often a mess, maybe
assessment and plan. We have all been
erage, while producing a comfortable in-
also introducing new problems.
taught, both for clinical purposes and for
that transformation.
26 •
Most attempts to computerize medical
coding thoroughness, the detailed ele-
come. The key in each successful practice
My own transition to word processing
improvement endeavor in which I have
during the 1980s-90s provides a useful anal-
participated was to first analyze and inti-
ogy. Even the best word processor can’t
If you look at your charts today, is that
mately and honestly understand the pro-
transform someone with no writing ability
how they are organized? Often, the answer
cesses involved in each of the functions
into an award-winning novelist. A word
is no. Many, if not most, of the paper (and
we hoped to better. The second part was
processor may help a good writer write
even electronic) charts that I see, do not con-
to re-imagine those processes, with the
more effectively and efficiently but won’t
tain the basic elements of the medical his-
The Maryland
ments of each step.
Reduce your billing
and collections headaches.
tory, nor is that information organized
in a useful format nor kept up to date.
The key to successfully choosing and
implementing an EMR is to first understand, then commit to, great charting
standards. When we first evaluate an
EMR, we want to evaluate that aspect
of our day that is most crucial, the
charting of basic clinical information.
Does the EMR present, in a readable, organized format, the basic elements of a patient’s up-to-date medi-
Annapolis Billing Services is better than Aspirin.
cal history? Does the EMR enable you
to chart, simply and quickly, the basic
Annapolis Billing Services billing and account management
services are handled effectively and professionally,
returning your staffs focus to patient care and practice
enhancement rather than the headaches of collections.
elements of the patient’s history; does
it enable and encourage you to update that information as it changes;
does the EMR enable you to chart a
SOAP note, with single or multiple
complaints, for an acute complaint,
a chronic diagnosis checkup, or well
621 Ridgely Avenue, Suite 404, Annapolis, MD 21401
Tel: 410-266-1588 • Fax: 410-266-6931 • www.annapolisbilling.com
visit, easily and efficiently?
How will you know? Only by giving
the software a try and attempting to
view and enter the information. If you
are evaluating an EMR and the answer
to the above questions is yes, then
continue to look at that product. If the
answer is no, or the answer is unclear,
then go no further in considering the
product. There are no administrative
benefits or government incentives
worth the trouble or cost of an EMR
that does not help you to chart better
or help you to be a better doctor.
■
Dr. Hahn is co-owner of Hahn and
Nelson Family Medicine in Hancock,
Mobile Paper Shredding & Recycling
Maryland. A MAFP Western District
•
•
•
•
•
Director and member of MAFP’s new
Technology Committee, he writes this,
the first of a series of articles which
will focus on various aspects of technology and practice automation to assist readers in that important aspect of
medical practice management.
Est.
1988
The top law enforcement
agencies and corporations
in the world use Shred-it!
Security-cleared personnel
Offices coast to coast
Locked containers supplied
Shredded in our truck at your location
Call for a free estimate
ON-SITE PAPER
SHREDDING
410-796-1500
1-800-697-4733 (1-800-69-SHRED)
www.shredit.com
The Maryland
members
News For and About MAFP Members
2011 MAFP Nominations Slate for
Member Vote in June
DIRECTORS
tion 1, the MAFP Nominations Committee recom-
2011 MAFP Nominations
Slate
TREASURER
mends the following slate. Elections will take place
2011-13; two year term
Jocelyn Hines, M.D., Baltimore
at the Annual Business Meeting Luncheon on Friday,
Christine L. Commerford, M.D.,
Mozella Williams, M.D., Baltimore
June 24, 2011 at the Clarion Resort Fontainebleau
Baltimore
Eastern District
In accordance with MAFP Bylaws Chapter XVI Sec-
Central District
Andrea Mathias, M.D.,
Hotel in Ocean City, MD. Nominations from the floor
will be accepted. Newly elected officers will be in-
VICE PRESIDENTS
Snow Hill
stalled later that day by AAFP President-Elect Glen R.
2011-13; two year terms
Rosaire M. Verna, M.D.,
Stream, M.D. at the Installation Luncheon.
Eastern District
St. Michaels
2011 MAFP Nominations Committee
Howard H. Bond, M.D.,
Southern District
Yvette L. Rooks, M.D., Chair
Baltimore
Ramona G. Seidel, M.D., Annapolis
Western District
Patricia A. Czapp, M.D., Annapolis
Yvette Oquendo-Berruz, M.D.
Kari Alperovitz-Bichell, M.D. ,
Western District
Eva S. Hersh, M.D.
Columbia
Kwame Akoto, M.D., Columbia
Kisha N. Davis, M.D.
Katina Moore, M.D.
28 •
2011-12; one year terms
The Maryland
Matthew A. Hahn, M.D., Hancock
DELEGATE TO AAFP
VICE PRESIDENTS
MAFP’s 2011 Winter Conference –
A Look Back
William P. Jones, M.D.,
Central District
”Case-Based Presentations and Travel
Davidsonville
Eva S. Hersh, M.D., Baltimore
Medicine for Primary Care,” held February
Southern District
12, 2011 in Baltimore was a huge success
ALTERNATE DELEGATE
TO AAFP
Trang M. Pham, M.D., Pasadena
on every level. Take a look…
DELEGATE TO AAFP
Adebowale G. Prest, M.D.,
Hebron
Howard E. Wilson, M.D.,
■
Bowie
IN MID-TERM
PRESIDENT-ELECT
2010-2012; two year
ALTERNATE DELEGATE
TO AAFP
Yvette Oquendo-Berruz, M.D.,
Columbia
Yvette L. Rooks, M.D.,
Ellicott City
■
SECRETARY
2010-2012 ; two year
Kisha N. Davis, M.D., Gaithersburg
Congratulations to MAFP Members for Special
Appointments, Honors, Features, Achievements!
Lots of activity in the exhibit area.
Kevin S. Ferentz, M.D. of Baltimore was a featured guest on Maryland
Public Television’s Direct Connection with Jeff Salkin airing on February 14,
2011. Dr. Ferentz discussed the perils of smoking and methods for smoking
cessation. Link to the segment: http://video.mpt.tv/video/1797278065
J. Richard Lilly, M.D. of Hyattsville received a Governor’s appointment in
October, 2010 to the Maryland Board of Physicians for a 4-year term.
A well-deserved lunch break!
Neil Siegel, M.D. of Silver Spring was featured in “Away from the E.R.:
State joins program to keep patients healthier, cut costs,” an article about
two Patient Centered Medical Home programs underway in Maryland, appearing in the December 13, 2010 edition of The Baltimore Sun.
Joseph W. Zebley, III, M.D. of Baltimore co-hosts The Medical Hour with
Jim Novick airing on WCBM-AM in Baltimore every Sunday from 5-6pm. In
addition, Dr. Zebley has been re-appointed by the AAFP Board of Directors
to a 2-year term, beginning January, 2011, as AAFP Delegate to the AMA. ■
A busy SAM Study Hall preceded the conference.
The Maryland
list of advertisers
Medical Mutual Insurance
.............................................................................2
Merit Medical...............................................6
Civilian Corps ..............................................6
Take Shape for Life...................................7
Annapolis Billing Services ................ 27
Shred-it........................................................ 27
Righttime Medical Care......................28
Patient First .............................................. 31
Concierge Choice Physicians .......... 31
Cryopen ...................................................... 32
In Memory
The Maryland Academy of Family Physicians
deeply regrets the passing of its members
John Darrell, M.D. (Randallstown)
Robert Thibadeau, M.D. (Silver Spring)
Frank Thomas, M.D. (Handcock)
Memorial contributions have been made in
their names to the MAFP Foundation.
Answers to Journal
CME Quiz p. 22
30 •
The Maryland
1. B
7. B
13. A
2. A
8. E
14. A
3. B
9. B
15. B
4. A
10. A
16. B
5. C
11. B
6. D
12. A
■

 
 


 

Are
Are you
you looking
looking for
for a
a satisfying
satisfying career
career and
and aa life
life outside
outside of
of work?
work?
Are
you
looking
for
a
satisfying
career
and
a
life
outside
of work?
Enjoy
both
to
the
fullest
at
Patient
First.
Are you
looking
forfullest
a satisfying
careerFirst.
and a life outside of work?
Enjoy
both
to the
at Patient
Enjoy
both
toa physician,
the fullest
at
Patient
First.
Founded
and
led
by
Patient
First
has
been
a
regional
Founded and
led by
Patientat
FirstPatient
has been aFirst.
regional healthcare
healthcare leader
leader in
in Maryland
Maryland
Enjoy
both
toa physician,
the fullest
and
Virginia
Patient
First
30
medical
centers
where
Founded
andsince
led by1981.
a physician,
has been a neighborhood
regional healthcare
leader
in Maryland
and
Virginia
since
Patient Patient
First has
hasFirst
30 full-service
full-service
medical
centers
where our
our
Founded
and
led by1981.
a physician,
Patient
First
hasdays
beeneach
a neighborhood
regional
healthcare
leader
in Maryland
physicians
provide
primary
and
urgent
care
365
year.
In
fact,
over
200
physicians
have
and
Virginia
since
1981.
Patient
First
has
30
full-service
neighborhood
medical
centers
where
our
physicians
provide
primary
and
urgent
care
365
days
each
year.
In
fact,
over
200
physicians
have
and Virginia
sincewith
1981.
Patient
First
has
30currently
full-service
neighborhood
medical
centers where
our
chosen
a
career
Patient
First.
We
are
looking
for
more
Full
and
Part-Time
Internal
physicians
provide
primary
and
urgent
care
365
days
each
year.
In
fact,
over
200
physicians
have
chosen
a career
with
Patientand
First.
Wecare
are currently
looking
for more
Fullover
and200
Part-Time
Internal
physicians
provide
primary
urgent
365
days
each
year.
In
fact,
physicians
have
and
Family
Medicine
in
Maryland
and
First,
each
chosen
a career
with Physicians
Patient First.
We are currently
for more Full At
andPatient
Part-Time
and
Family
Medicine
in Virginia,
Virginia,
Marylandlooking
and Pennsylvania.
Pennsylvania.
First,Internal
each
chosen
a career
with Physicians
Patient First.
We are currently
looking
for more Full At
andPatient
Part-Time
Internal
physician
enjoys:
and
Family
Medicine
Physicians
in
Virginia,
Maryland
and
Pennsylvania.
At
Patient
First,
each
physician
enjoys:
and Family Medicine Physicians in Virginia, Maryland and Pennsylvania. At Patient First, each
physician
enjoys:
• Unique Compensation
• Malpractice Insurance Coverage
physician
enjoys:
•
• Malpractice Insurance Coverage
Unique Compensation
•
•
Compensation
Insurance
Coverage
• Unique
• Malpractice
Flexible
Schedules
Team-Oriented
Workplace
• Flexible
• Team-Oriented
Schedules
Workplace
•
•
Unique Compensation
Malpractice Insurance
Coverage
•
•
Schedules
Workplace
• Flexible
• Team-Oriented
Personalized
Benefits
Packages
Career
Advancement
Opportunities
•
•
Benefits Packages
Advancement
Opportunities
• Personalized
• Career
Flexible Schedules
Team-Oriented
Workplace
•
• Career Advancement Opportunities
Benefits
Packages
• Personalized
Generous
&
Allowances
• Personalized
Generous Vacation
Vacation
& CME
CME
Allowances
•
• Career Advancement Opportunities
Benefits
Packages
• Generous Vacation & CME Allowances
• Generous Vacation & CME Allowances
To
To discuss
discuss available
available positions
positions please
please contact
contact Donna
Donna Maskell,
Maskell,
To
discuss
available
positions
please
contact
Donna
Maskell,
[email protected]
or
(804)
822-4449.
We
will
[email protected]
or
(804)
822-4449.
We
will arrange
arrange
To discuss available positions please contact Donna Maskell,
[email protected]
or
(804)
822-4449.
We
will arrange
the
opportunity
for
you
to
spend
time
with
one
of
our
physicians
to
the
opportunity
for
you
to
spend
time
with
one
of
our
physicians
to
[email protected] or (804) 822-4449. We will arrange
the
opportunity
for
you
to
spend
time
with
one
of
our
physicians
to
experience
firsthand
how
Patient
First
offers
each
physician
an
experience
firsthand
how
Patient
First
offers
each
physician
an
the opportunity for you to spend time with one of our physicians to
experience
firsthand
how
Patient
First
offers
each
physician
an
exceptional
career.
exceptionalfirsthand
career. how Patient First offers each physician an
experience
exceptional career.
exceptional career.
ConciergeChoice_halfpage_color.pdf 12/17/2010 1:52:11 PM
M
M
Y
Y
Y
The Maryland
MARYLAND Academy of Family Physicians
5710 Executive Dr., Suite 104
Baltimore, MD 21228-1771
Presorted Standard
U.S. Postage Paid
Little Rock, AR
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Moving Cryosurgery into the 21 st Century!
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DISORDERS OF EATING Identifying and Treating Eating Disorders

Transcription

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