Body Image, Eating Disorders and Polycystic Ovary Syndrome Terrill Bruere APD 2014

2011. Evidence based guideline for the assessment and management of

PCOS. PCOS Australian Alliance. www.jeanhailes.org.au

PCOS Statistics

PCOS - A syndrome, not a disease.

• 25% of women have PCO

Metabolic:

Diagnostic: ( 2 of 3 )

Genetic- Family diabetes or PCOS, infertility Metabolic syndrome indicators Weight and dieting problems

PCO (ultrasound) ReproductiveMenstruation issues Ovulation and fertility concerns Androgens – Biochemistry – Hormonal changes (androgens) Hirsute, hair loss, acne, Acanthosis nigrans

Genetics

• 70% remain undiagnosed • 50-70% have insulin resistance

Emotional and Psychosocial:

Depression and anxiety Body image disturbance Eating problems Psychosexual concerns

Lifestyle

↑ Body weight

Hormonal changes ↑ Insulin

↑ Androgens

Hirsutism, acne

• Up to 20% of women have PCOS

PCO, anovulation, ↑ oestrogen

Diabetes Metabolic syndrome

Menstrual disturbance

• 40 % normal weight, 60% overweight (abdominal fat tissue and shape difference) • 5 - 10 (7) times risk NIDDM, CVD

PCOS hormonal changes including insulin resistance Genetic advantage in times of feasting and fasting Genetic disadvantage in current environment

i.e. Understandable

Psychosocial issues: body image, self esteem, depression, anxiety, sexual health

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Simple CBT-E model of ED’s: Predisposing factors

Precipitating factors

DSM 5 (recent change to diagnostic criteria) Over-evaluation of body shape and weight and its control

Or Restriction (control) of intake, exercise

A continuum idea is useful

Independent of weight

‘Living well’ with self and body

Binge eating

Distress, preoccupation, less helpful behaviours and relationship with self and body

Starvation effects

Compensatory behaviours There are reasons why a vulnerable woman with PCOS can potentially enter this cycle - once in, it becomes self maintaining.

Some evidence of links to bulimia and BED Less specific: HRQOL Chronic dieting Risk for Eating Disorders (adolescents) Moderate = 5 x more likely Severe = 18 x more likely

Insulin resistance - chicken and egg or mainly the chicken? Body composition, shape and metabolic risk factors are different independent of weight as well BMI – when is and isn't a population measure useful? Survivors advantage - The more you starve the more you gain Lower weight women – PCOS or ED related changes to menstruation?

Mood and body image disturbance Appetite dysregulation

Strong enough to recommend routine screening for treatment

PhysicalIncreased food seeking behaviour - ‘cravings’ (to carbs), excessive hunger Poor satiety with habitual larger serve sizes

So how to assess and negotiate weight and weight management goals?

Anxiety 34-57% (N 18% ) Depression 28-64% ( N 7.1-8%) •

Emotional – Disconnection from body and appetite Overeating as a normal emotional response to food restriction Emotional regulation

Cannot rely on usual eating cues to guide food quantities eaten

•

Likely to experience more severe anxiety and depression ED risk factors

HRQOL PCOSQ well validated - Significant reduction in HRQOL 5 domains: weight/menstruation/fertility/emotions/hair Psychological/sexual disturbance high BMI is a primary mediator for adolescents

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PCOS and Body Image - Risk Factors Body dissatisfaction is a cultural norm in western society • Cultural norms + Body shape/weight difference

Body image is linked to:

• Testosterone – the ‘male’ hormone • • • •

Poor self worth Less helpful exercise and eating behaviours & Inability to carry out more helpful behaviours Eating, exercise, dieting, body dysmorphic disorders Mood disorders

• Facial/other hair, ‘male’ pattern balding •

Acne

• Fertility and menstruation

Triggers can include teasing, bullying, media, body size, family modelling, depression, and --- PCOS symptoms

• Sexuality

Women need understanding, diagnosis, education, treatment, support …. And some self-defence strategies

PCOS Number one therapy – Lifestyle management 1.

Understanding of PCOS

2.

Reduce insulin resistance with lifestyle change

3.

Prevent weight problems and if there is an issue aim to realistically reduce by 5-10%

4.

Screen for and avoid/treat dieting, eating or body image concerns

5.

Prevent long term complications

FIRST - Settle biological hormone issues (consistent with ED treatment) • • • •

Discussion of history re weight, appetite, body and their own views (empathic) Education (PCOS, dieting, appetite, ??) Reviewing the history in the light of the new information Collaborative goal setting and problem solving

• Explain rationale • Manage blood glucose to reduce insulin demand and improve excessive hunger and poor satiety. i.e. well balanced food distributed regularly over the day • Sensible, flexible structure in menu planning (avoid food ‘rules’ and any moral inferences) • Metformin if clinically indicated

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THEN - Follow with appetite work to rebuild and retain an internal locus of control around eating behaviour and food quantity management

• Validate need for treatment of PCOS symptoms including hair management, fertility and mood concerns – then refer carefully • Place in a cultural and environmental context – build awareness of community conflicting attitudes and beliefs about body and weight

eg identifying personal food preferences, exploration of normal physical hunger cues vs habit/emotional eating triggers vs hormonal effects on appetite - then development of better responses to eating cues

• Develop strategies for difficult situations eg meeting a new health professional

… or refer for further specialist treatment

• Look at everyday body image triggers – mirrors, clothing, shopping, parties, beaches, swimming pools, gyms – along with the thoughts and beliefs that accompany them (You don’t have to love all your body but you do have to accept it as it is now to care for it) • www.cci.wa www.nedc.com.au Resources, CBT treatment manual for body dysmorphic disorder

Some hints to recognise potential PCOS in ED clients • Weight and hormone history during adolescence and early adulthood. (Remember high exercise levels etc. may have masked PCOS symptoms)

My soapbox – odd thoughts How well is this person living with and managing their body, their health and their symptoms – and their self respect?

• Menstruation not as expected

You can help insulin resistance without a specific weight emphasis

• Rapid weight gain or PCOS symptoms emerging during treatment or recovery

There is a difference between providing some flexible structure to guide someone's food and eating and providing a new set of rules to follow

• Development of bulimia or BED during AN recovery (? accompanied by excessive hunger) • History of being a much higher weight in the past that doesn't make a lot of sense • Having more severe AN symptoms at a higher BMI than expected, often associated with having dieted from a higher weight initially

Unrealistic goals sets someone up for future guilt, shame, self blame – but can be hard to resist for both the client and the professional If talking about food immediately triggers ‘deprivation/dieting’ thinking and reactions – it usually isn't the right time to give specific dietary advice

But at what point do you pursue diagnosis?

www.nedc.com.au www.ceed.org.au or your state equivalent www.jeanhailes.org.au www.cci.health.wa.gov.au

General PCOS reference: Assessment and Management of Polycystic Ovary Syndrome: summary of an evidence- based guideline. MJA. 19th September 2011. Vol 195. No6. Supplement.

Do you worry you have lost control over your eating? Do you ever feel disgusted, depressed or guilty about eating? Have you tried vomiting, laxatives, diuretics, fasting or skipping meals or excessive exercise to control your weight? Do you have significant ( >5-7% ) weight fluctuations? Have you ever thought you had or been diagnosed with an eating problem?

What to do: Discuss, assess further, Eat – 26 or refer if required

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Body Image - Screening During the last month Have you often been bothered by feeling down, depressed or hopeless? Have you been bothered by having little interest or pleasure in doing things? Have you been bothered by feeling excessively worried or concerned?

What to do Explore and establish safety, explain links with hormones and mood. Refer.

Do you worry a lot about the way you look and wish you could think about it less? On a typical day do you spend more than 1 hour worrying about your body/appearance? What specific concerns do you have about your appearance? What effect does it have on your life? Does it make it hard to do your work or be with friends and family?

What to do Explore more, screen for mood and eating disorders, identify if there is significant body image distortion eg as with AN. Refer.

Do you feel that PCOS affects your sexuality or sex life? Does this affect your relationships? During the last few months have you often been bothered with problems with your sex life such as pain, less desire or satisfaction etc.? What to do ? - Refer

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