EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS

ADOLESCENT MEDICINE

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EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS Richard E. Kreipe, MD, and Susan A. Birndorf, DO

Three principles for the medical care of adolescents with eating disorders were proposed by C ~ m e r c i (1) : ~ early restoration of a normal nutritional and physiologic state; (2) establishment of trust; and (3) a team approach (therapeutic partnership). This article reviews and clarifies the definitions, epidemiology, pathogenesis, and clinical aspects of eating disorders in internal medicine practice. The early restoration of health requires early recognition of the disorder from the basis of a broad differential diagnosis. An understanding of eating disorders by the clinician is needed to establish trust with patients, who are often wary of any recommendations to gain weight or change their eating habits. Because patients with eating disorders often present with physical symptoms caused by starvation, induced emesis, or diet pill and laxative abuse, the primary care provider may be the first person to diagnose an eating disorder and to establish the therapeutic team. Many of the psychiatric aspects of eating disorders have been discussed in numerous earlier articles and chapters', 5, 7, 31 and are not discussed in detail here. For the sake of clarity, female pronouns are used in reference to patients because at least 90% of patients with eating disorders are adolescent and young adult women. The approach to males is similar, however. DEFINITIONS AND DIAGNOSTIC CRITERIA

The standard diagnostic criteria for eating disorders are in the DSMIV (see accompanying box).la In practice, anorexia nervosa is defined as a From the Division of Adolescent Medicine, Department of Pediatrics, University of Rochester, Rochester, New York

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syndrome in which caloric intake insufficient to maintain weight is associated with a delusion of being fat and an obsession to be thinner, and neither the delusion nor the obsession diminishes with weight loss. Patients with anorexia nervosa believe they are fat, even when emaciated, and may feel driven to lose weight through a variety of means, including dieting and increasing energy expenditure. Exercise is used by more than three fourths of patients with anorexia nervosa, whereas vomiting and cathartics are less commonly used. A feature that differentiates simple dieting from anorexia nervosa is the difficulty of an affected individual to identify or to be satisfied with a healthy weight goal. An initial weight goal of 110 Ib drops to 105 Ib, then to 100 lb, then to 95 lb relentlessly. True anorexia does not occur until there has been extreme weight loss. Before that time, there is a refusal to acknowledge or to submit to one’s appetite because eating is perceived as a vice, whereas fasting is considered virtuous. Diagnostic Criteria for Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder According to DSM-IV

Anorexia nervosa: 307.10 Refusal to maintain body weight greater than minimally normal (e.g., <85%) weight for age and height Intense fear of weight gain or becoming fat, even though underweight Disturbance in the way in which one’s body weight, size, or shape is experienced Undue influence of body weight or shape on self-evaluation Denial of seriousness of the current low body weight In postmenarcheal girls, the absence of at least three consecutive menstrual cycles Two subtypes Restricting Binge eating/purging Bulimia nervosa: 307.51 Recurrent episodes of binge eating, characterized by both 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 A sense of lack of control during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) Recurrent inappropriate compensatory behavior to prevent weight gain Self-induced vomiting Misuse of laxatives, diuretics, enemas, other medications Fasting Excessive exercise Episodes average at least twice a week for 3 months Self-evaluation unduly influenced by body shape and weight Does not occur exclusively during episodes of anorexia nervosa Subtypes Purging Nonpurging

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Binge-eating disorder (proposed research criteria) Recurrent episodes of binge eating Large amounts of food in a short period of time Lack of control over eating during episode Marked distress regarding binge eating At least three of the following associated findings Rapid eating Eating until becoming uncomfortably full Eating large amounts when not hungry Eating alone because of embarrassment Disgust, depression, or guilt because of eating patterns Frequency of binge eating at least twice a week for at least 6 months Data from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.

The key clinical feature of bulimia nervosa is not, as often assumed, vomiting. Binge eating is the sine qua non for bulimia. An awareness that the eating pattern is abnormal is associated with depressed moods and self-deprecating thoughts. Temporary relief of this distress is sought through methods that are intended to rid the body of the effects of calories. More than 80% of patients with bulimia nervosa engage in selfinduced vomiting or laxative or diuretic abuse for this purpose. Fasting, exercise, or both may be the primary methods used to avoid weight gain, often unsuccessfully, because many patients with bulimia nervosa are normal weight to slightly overweight. Patients with bulimia are more likely than patients with anorexia nervosa to be impulsive, not only in eating behavior, but also in their use of drugs and alcohol, self-mutilation or self-harm, sexual promiscuity, lying, stealing, and other manifestations of personality disturbance.12,29, 30,32 Such character pathology makes it difficult to establish a therapeutic relationship with patients and requires consistency and patience by the provider.23 Anorexia and bulimia are not mutually exclusive. Approximately 40% of patients with anorexia nervosa have a bulimic phase in the course of their illness or recovery.16The three main categories of eating disorders that are presently recognized clinically are (1) anorexia nervosa, restrictive subtype, in which dieting and weight loss predominate; (2) anorexia nervosa, with binge eating, purging, or both, in which dieting and binge eating are intermixed with various forms of purging; and (3) bulimia nervosa, in which binge eating is the predominant behavior in association with behaviors, either purging or nonpurging, to minimize weight gain. Patients not meeting all criteria are categorized as eating disorder not otherwise specified and may represent the largest category of patients in practice. EPIDEMIOLOGY OF EATING DISORDERS

Eating disorders are not distributed uniformly in the population. Of patients that present with classic signs and symptoms of anorexia or

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bulimia, greater than 90% are female, greater than 95% are white, and greater than 75% are adolescents when they first develop the eating disorder. Most patients are from middle-class to upper-middle-class socioeconomic status families, but patients can be of any sex, race, age, or social stratum. Prevalence rates that include the entire population as the denominator grossly underestimate the prevalence of eating disorders in target groups. Age-specific and sex-specific estimates suggest that about 0.5% to 1%of teenage girls develop anorexia nervosa, whereas 5% of older adolescent and young adult women develop bulimia nervosa. Disordered eating that does not meet full diagnostic criteria but that still presents a threat to normal growth and development is common. For example, the 1997 Youth Risk Behavior Survey found that 60% of female students and 23% of male students reported trying to lose weight in the previous month, whereas the rate of taking diet pills was 8% for females and 2% for males.14 Many teenagers and young adults feel a need to diet or lose weight and are at risk of adopting potentially harmful weight-loss habits. The increased prevalence of eating disorders since the 1980s is accounted for mostly by an increased incidence of bulimia nervosa; increased media attention, improved detection, and less stringent diagnostic criteria probably also account for the apparent epidemic of eating disorders. PATHOGENESIS

Eating disorders are extremely complex conditions with roots in biologic, psychologic, and social issues. It is better to view them as a final common pathway having multiple determinants. Rather than seeking the causes, it is more useful to consider predisposing, precipitating, and perpetuating factors. Because each of these factors has important developmental considerations, it is useful clinically to consider eating disorders as developmental, rather than mental, conditions. This consideration also avoids the stigmatization that patients may associate with a psychiatric diagnostic label. Predisposing factors that make an individual vulnerable to developing an eating disorder include (1) being a female, especially in an industrialized country; (2) having a family history of eating disorders; (3) being perfectionistic and eager to please others; (4) having difficulty communicating negative emotions, such as anger, sadness, or fear; (5) having difficulty resolving conflict; and (6) having low self-esteem. Patients who are overweight and receive compliments when they begin to lose weight may be especially vulnerable to developing an eating disorder because the reinforcements to continue to lose weight are powerful. Precipitating factors often relate to developmental tasks of adolescence. Maturation fears are most common in younger patients (10 to 14 years old) and are often related to sexual development. Menarche may be threatening because it is often associated with a spurt of weight gain. Early adolescents who develop an eating disorder often seem to be

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retreating into childhood. Likewise, they may be eager to please, especially with highly revered peers or adults. Independence and autonomy struggles are most common in middle adolescents (15 to 16 years old), and they may be acted out through an eating disorder. These adolescents may have ambivalence about growing up because for some adolescents attaining adulthood is equated with being abandoned, isolated, or lonely. For these individuals, a healthy developmental transition is from dependence to interdependence, rather than to independence. Identity conflicts are most common in older patients (>17 years old) and may be related to transitions, such as graduating from high school, entering college, or getting married. Not certain who they are or where they are going in life, these young adults find solace in the identity of an eating disorder, in which they have a sense of achievement, efficacy, and empowerment. Sexual abuse is frequently identified as a precipitant to eating disorders. Most patients with eating disorders do not have a history of sexual abuse or trauma, however, but individuals who have an eating disorder and a history of sexual misuse tend to be more difficult to treat. Perpetuating factors serve to maintain the eating disorder once the dysfunctional patterns of weight control are established. Biologic as well as psychologic influences can act as powerful reinforcers and sustain the eating disorder. The biologic issues that must be appreciated by the physician include the signs and symptoms of starvation and the principles of refeeding the malnourished individual. In addition, the psychologic coping that the eating disorder engenders must be appreciated. In treating the illness, the clinician may threaten the homeostatic balance that has been achieved within the family system. There may be denial, resistance, and anger directed at the physician treating the eating disorder. In contrast to many conditions in which the patient and the internist are in alliance to eliminate an illness, eating disorders may present a special challenge because the patient frequently is ambivalent: desiring but afraid of recovery. An appreciation of these various factors facilitates the development of a trusting relationship between patient and provider. CLINICAL ASPECTS Symptoms

The symptoms experienced by the patient are related to the various habits used to control weight (Tables 1 and 2). Symptom checklists facilitate taking the symptom history and are generally answered honestly. In this regard, privacy and confidentiality should be respected as it is in any clinical interaction with an adolescent or young adult patient. Likewise, the history should be taken with the goal of developing a plan of action to help the patient feel better and not merely to rule-out an eating disorder. A review of symptoms usually elicits many positive responses that can be interpreted as evidence that all is not well with the patient.17

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Table 1. SYMPTOMS AND SIGNS ASSOCIATED WITH WEIGHT-CONTROL HABITS IN ANOREXIA NERVOSA Symptoms of Inadequate Energy Intake Physical Health

Amenorrhea Cold hands or feet Constipation Dry skin or hair loss Headaches Fainting or dizziness Lethargy Anorexia

Mental Health

Concentration Decisions Irritability Depression Social withdrawal Obsessiveness (food)

Signs of Inadequate Energy Intake Positive

Negative

Hypothermia Acrocyanosis Resting bradycardia Hypotension Orthostatic blood pressure and pulse Loss of muscle mass Abnormal laboratory test values Low blood glucose Elevated liver function tests Low white blood cells ECG low voltage; prolonged Q-Tc; Nonspecific T wave changes

Normal fundi and visual fields No organomegaly No lymphadenopathy No or minimal breast atrophy

ECG = electrocardiogram.

Most commonly, patients with anorexia complain of fatigue, cold intolerance, hair loss, constipation, and amenorrhea. Patients with bulimia complain of the same symptoms if they are underweight. If they are normal or above their ideal body weight range, they likely complain of being overweight and report symptoms related to purging through emesis; restriction of food and fluids; and use of diet pills, diuretics, or Table 2. SYMPTOMS AND SIGNS ASSOCIATED WITH WEIGHT-CONTROL HABITS IN BULIMIA NERVOSA Signs and Symptoms of Binge Eating Physical Health

Mental Health

Weight gain Bloating, fullness Lethargy Salivary gland enlargement

Guilt Depression Anxiety

Signs and Symptoms of Vomiting or Laxative Abuse Physical Health

Weight loss Electrolyte disturbances Hypokalemic, hypochloremic metabolic alkalosis (vomiting) Dental enamel erosion Hypovolemia Knuckle calluses

Mental Health

Guilt Depression Anxiety Confusion

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laxatives. Patients who induce emesis frequently report symptoms of gastrointestinal pain or dysfunction. Symptoms often resemble those of gastroesophageal reflux. They may complain of burning or irritation in the throat. Patients who restrict food or fluid intake or use laxatives or diuretics may complain of dizziness or other symptoms related to hypovolemia. Patients using diet pills may experience palpitations and anxiety. A complete review of systems is helpful to rule out other diseases, such as thyroid dysfunction, inflammatory bowel disease, and cancer, that may present with a similar constellation of symptoms. Because depression is often a component of eating disorders, it is important to screen thoroughly for ideation or intent of self-harm or suicide. Communication with adolescents and young adults with eating disorders is often difficult, yet several considerations may facilitate communication between patient and provider to optimize information gained through history taking. First, it is important to make the office ado2escent friendly. An environment that welcomes adolescents sends a message that they are welcome in the care setting. Second, evidencebased, adolescent-oriented screening forms, such as those provided by Guidelines for Adolescent Preventive Services (GAPS) or Bright Futures Guidelines, save time and effort and provide documentation for the patient’s record. These forms are easily obtained through the Department of Adolescent Health, American Medical Association (http:/ / www.amaassn.org/ adolhlth/ adolhlth.htm), or Bright Futures (http:/ / www.brightfutures.org). They also screen for other risk factors and behaviors associated with eating disorders, such as mental health problems and substance use. Third, it is helpful to focus on the patient’s symptoms, rather than on a diagnosis. Dev’elopmentally, adolescents may or may not have the cognitive ability to identify their poor eating behaviors and their symptoms, whereas adults may still be struggling with unresolved adolescent developmental issues, such as identity development or autonomy. For example, a patient who feels tired and cold and has difficulty concentrating because she is malnourished may not relate her symptoms to lack of food and fluid intake throughout the day. Fourth, interviewing patients with eating disorders takes more time than other patients. If one does not allow for this, either the patient feels rushed, or the physician feels frustrated. Recognizing the individual needs of the patient and focusing on the patient’s symptoms can facilitate communication and help develop a therapeutic relationship.

Signs Regardless of how good a patient may look or how normal the weight is, a detailed physical examination is indicated whenever there is concern about an eating disorder. Patients often dress in baggy clothes that hide their cachexia. Likewise, they may attach weights to their underwear or drink fluids before being weighed to make weight. As is

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true of symptoms associated with weight-control habits, signs found on physical examination can be used as evidence that the patient is not healthy. A thorough physical examination is also important because it may indicate the presence of another condition, such as inflammatory bowel disease (right lower quadrant mass) or central nervous system lesion (papilledema). For patients who primarily restrict their food intake, characteristic findings in severe starvation relate to hypothalamic dysregulation and malnourishment and include cachexia, hypothermia, resting bradycardia with orthostatic hypotension, lanugo, acrocyanosis, dry skin, thinning scalp hair, and a depressed mental status. Patients that primarily binge and purge usually are normal weight or overweight and present with enlarged salivary glands, dental enamel erosion, and calluses over the proximal interphalangeal joint knuckles (Russell sign). Patients with concurrent depression or history of sexual abuse may have signs of intentional self-harm, including cutting. The purpose of physical examination is not only to detect organic pathology, but also to emphasize to the patient that the body is adapting to an unhealthy state.21From a developmental viewpoint, adolescents are often egocentric; one should focus on issues that have direct relevance to their body-signs and symptoms. Concerns about future health problems, such as osteoporosis or infertility, may have less importance to patients than staying thin. Using scare tactics is futile, if the purpose is to motivate change in behavior toward health. For example, thin patients often have slow capillary refill in their cold, blue hands and feet. This can be explained to the patients: ”Your temperature is very low, so your body is conserving energy by not allowing much blood to go all the way out to your hands and feet, where a lot of heat can be lost. What little blood is flowing through the skin is very cold and is moving very slowly. Because so much oxygen is being removed, the blood in your skin is blue. If you take in more energy (calories) by eating more nutritious food, you will feel warmer and less tired.” Likewise, the loss of menstrual periods, fall in blood pressure and pulse, drop in temperature, and growth of lanugo-type hair over the upper body represent physiologic adaptation to starvation, similar to the changes in a hibernating animal. Finally, although the patient tends to focus on the loss of fat as the primary goal of weight loss, the loss of muscle mass that inevitably attends significant weight loss can be described in terms of loss of power, strength, endurance, flexibility, and physical fitness. This loss of muscle mass frequently provides an incentive for patients that can be addressed during the physical examination, especially patients who are athletic or sports-minded, to improve their nutrition and gain weight. Laboratory Tests

Because the diagnosis of an eating disorder is clinical, there are no confirmatory laboratory tests. Laboratory studies used to evaluate patients with eating disorders include the following:

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Complete blood count with erythrocyte sedimentation rate Urinalysis Blood chemistries Other tests as indicated In the presence of an eating disorder, laboratory abnormalities are due to the weight-control habits used or the complications thereof. A routine screening battery could include a complete blood count (with differential), erythrocyte sedimentation rate, and blood chemistries. The results of many tests depend on the state of hydration. Persistently abnormal values should be followed closely and may indicate the presence of an underlying organic illness. Because many patients have normal laboratory studies, it is important to emphasize that studies are obtained as a baseline, not to establish the diagnosis. Imaging studies do not have a place in the routine evaluation of eating disorders but may be indicated in individual cases. For example, bone densitometry may be necessary to determine the extent of osteopenia in a severely malnourished patient with long-standing anorexia. An electrocardiogram may be useful to evaluate for the corrected QT interval in patients who are taking drugs that could place them at risk for a prolonged interval, predisposing them to potentially harmful dysrhythmias. Leukopenia and thrombocytopenia may occur with starvation; leukopenia is due to increased margination of the leukocytes, and patients do not have an increased risk of infection. The erythrocyte sedimentation rate is uniformly normal; an elevated value should trigger a search for an occult organic illness, such as inflammatory bowel disease. The hemoglobin is typically normal, although it may be elevated in dehydration or reduced when iron intake is drastically reduced, as in a vegetarian diet. Because patients with anorexia nervosa are uniformly amenorrheic, menstrual blood loss is rarely an explanation for anemia, which deserves further evaluation if it occurs. The glucose is often low because of lack of glucose precursors in the diet or glycogen stores. Renal function is usually normal, but the blood urea nitrogen can vary between high (dehydration) and low (low protein intake). Electrolytes are usually normal unless the patient is vomiting or taking laxatives and usually revert to normal quickly on cessation of purging. Vomiting is typically associated with hypokalemic hypochloremic metabolic alkalosis; laxative abuse may be associated with acidosis. Serum protein and albumin are generally normal. The small amount that patients eat generally contains high-quality protein so that visceral proteins remain normal; prealbumin, with its shorter half-life, may be low, however. Liver function tests may reveal mildly elevated (1.5 to 2 times normal) enzyme levels but are not in the hepatitic range. Bilirubin metabolism is normal so that total and conjugated levels of bilirubin are normal. Cholesterol levels are often elevated, sometimes dramatically, in starvation states. There appear to be at least three reasons for this elevation: (1) Cholesterol breakdown is related to triiodothyronine (T3)

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levels, which may be depressed; (2) cholesterol binding globulin is often low; and (3) with fatty infiltration, there may be a leakage of intrahepatic cholesterol. When fractionated, most of the cholesterol is in the highdensity lipoprotein form. In most cases, it is advisable to inform the patient and parents that normal results are expected before the laboratory studies are obtained.17 Otherwise, a patient resistant to treatment could use negative results as evidence that nothing is wrong. Some practitioners also routinely obtain thyroid screening; if abnormal, the T, is usually low, a means of reducing the metabolic rate in association with low caloric intake. Patients typically have a clinical picture that suggests both hypothyroidism (fatigue, constipation, bradycardia, hypothermia) and hyperthyroidism (weight loss, excessive activity, anxiety), but the treatment for these symptoms is healthy nutrition and weight gain. The other endocrinopathy that is suggested by the constellation of weight loss, fatigue, and a small heart is Addison's disease; serum cortisol tends to be high in anorexia nervosa, however. MANAGEMENT Early or Mild Stage The DSM-IVIa includes a category eating disorder not otherwise specified, applicable to patients who display subthreshold attitudes, behaviors, or signs. Recognizing that many patients with disordered eating may not progress to develop a classic eating disorder syndrome, it is nonetheless prudent to intervene when patients show dysfunctional eating or weight-control patterns. Features that place a patient in this category include (1) mildly distorted body image; (2) weight 90% or less of average weight for height; (3) no symptoms or signs of excessive weight loss, but (4)use of potentially harmful weight-control methods or a strong drive to lose weight. Treatment begins with the assessment of weight loss or control because the practitioner can emphasize the importance of maintaining health. In this regard, the importance of setting a goal weight early in treatment cannot be overemphasized. If a patient is unable to identify a target weight or seeks an unreasonably low weight, close follow-up is indicated. By setting a limit on weight loss, the primary care provider establishes a boundary for excessive weight loss. The magnitude of the drive for thinness experienced by a patient can be estimated from her reluctance to agree on a healthy weight goal. Referral to a dietitian should be made if there is a request for one or if the patient has become vegetarian or has adopted unhealthy, unusual, or monotonous food choices. Ideally a dietitian should be involved in the evaluation and treatment of adolescents with eating disorders. The dietitian can (1)evaluate the diet and identify specific deficiencies or excesses, (2) educate the

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patient (and family) regarding nutrient needs during adolescence and dispel dietary misconceptions frequently held by patients, ( 3 ) develop a balanced meal plan within a target caloric range to achieve weight gain or maintenance, (4) apply a food exchange system to allow variety and flexibility in food selection, (5) assess diet journals recorded by the patient to identify dysfunctional eating patterns that persist or arise during the course of treatment, and (6) provide feedback to the patient to encourage continued progress toward health.21 The journals used to evaluate nutrition can also be used to determine dysfunctional habits (e.g., eating only a piece of toast for breakfast), associated mood disturbances (e.g., refusing to eat dinner because of an argument), and accomplishments (e.g., eating high-calorie food). All of these issues can be overlooked or forgotten in the course of a primary care office visit, but the data contained in such records assist the patient and the physician to recognize important patterns or events. Also, if the recorded intake in the journal is normal, further diagnostic evaluation may be indicated before definitive treatment because malabsorption could be occurring, or the patient could be vomiting surreptitiously. Reevaluation by the physician within 1 to 2 months ensures that weight is not changing precipitously, that health is being maintained, and that dysfunctional eating habits have not developed. Data obtained on the follow-up visit (e.g., change in eating habits, weight, and physical examination) clarify the diagnosis. Follow-up also provides the clinician the opportunity to evaluate psychosocial development and adjustment. At this time, the patient may declare herself as a more difficult case, requiring referral. The opportunity to show to herself that the patient is not able to maintain health despite the best of intentions, however, often reduces resistance to referral for mental health when it becomes necessary. If the patient responds to treatment by eating normally and attains and maintains a normal weight and health with little evidence of distress, outpatient follow-up should be for routine health maintenance. Even though the diagnosis of an eating disorder might be questioned under this circumstance, anticipatory guidance is indicated. The patient should be aware of the warning signals of out-of-control weight loss, including falling below the established goal weight, feeling guilty after eating but in control when not eating or losing weight, having arguments over meals, and experiencing symptoms or signs of excessive weight loss. Surveillance of these patients may prevent progression to more severe phases of illness or trigger a definitive treatment response should the condition worsen. Established or Moderate Stage

Patients who progress to a clearly established or moderate eating disorder often require the additional services of professionals who have experience in treating eating disorders.21Specialists in adolescent medi-

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cine? nutrition, psychiatry, and psychology each have a role in the treatment of the more-difficult-to-manage patient. Features of patients in this category include (1)definitely distorted body image that has not diminished with weight loss; (2) weight goal less than 85% of average weight for height associated with a refusal to gain weight; (3) symptoms or signs of excessive weight loss associated with a denial that any problems exist; and (4)unhealthy means to lose weight, such as eating fewer than 1000 cal/ day, purging, or excessive exercise. Additional factors that justify placement in this category include evidence of family dysfunction or anticipated lack of cooperation with treatment recommendations. A patient with a distorted body image continues to feel fat despite having lost weight. Treatment of this distortion does not include challenging the patient’s perceptions. To the contrary, it is helpful to acknowledge the desire to lose weight. This desire, however, must be balanced against the reality of being too thin, as manifested by the symptoms and signs of excessive weight loss. This maneuver can be tremendously therapeutic. By noting that feeling fat cannot be challenged because feelings are subjective and that being too thin cannot be challenged because of objective data, the physician indicates an awareness of the dilemma the patient faces. This understanding furthers the development of trust in the physician and is a welcomed relief from common responses, such as ”How can you possibly feel fat, when you’re so skinny?” or ”Why don’t you just eat?” Such statements indicate a lack of appreciation of the patient’s perceptions, potentially increasing resistance to treatment. Similarly, rational arguments for the need to gain weight, such as plotting weight for height on a growth chart, have little place in the treatment of more advanced disease. Because anorexia nervosa is based on certain premises that the patient has regarding herself (being ineffective, inadequate, of low worth), simplistic explanations such as these are usually not compelling. The developmental issues over which the patient perceives no evidence of control are metaphorically embodied in the struggle to restrict eating to achieve weight loss. To make eating and weight gain a battle dooms treatment to failure. If the patient wins the battle by losing weight, health is lost; if the patient loses the battle by gaining weight, perceptions of being ineffective, powerless, and worthless are only reinforced. There is no safe way out. If the physician joins with the patient in gaining control over the eating disorder, a healthy and growth-promoting alternative is available. Contrary to popular belief, it is not necessary to confront denial immediately. Frequently, such denial stems from misconceptions regarding the meaning of the diagnosis of an eating disorder. Some patients argue that they cannot have anorexia nervosa because they are not thin enough. Others fear that having the diagnosis means that they are crazy or that they will be hospitalized and force fed. More important than labeling the patient is the need to identify threats to health and to develop a treatment plan that addresses, monitors, and improves health

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status. It is necessary for the parents to understand the seriousness of the diagnosis because they may be confronted with the need for longterm treatment and hospitalization. Denial on the part of one or both parents can undermine all treatment interventions. To restore the patient with an established or moderate eating disorder to nutritional and physiologic health, it is usually necessary to provide structure to daily activities that ensures adequate caloric intake and limits expenditure of calories. This plan should take into consideration the present weight, the minimal goal weight for health, and the expected rate of weight gain. Behavioral contracts tend not to be as effective in outpatient management as they are in hospital settings because of difficulties with monitoring such plans. In general, the goal of outpatient treatment is to shift the burden of responsibility to the patient to eat adequately and attain health. For the young adult, this means self-monitoring. A contract also implies that both parties enter into the agreement freely, which is usually not the case for the patient. Negotiating a program or plan to assist the patient to attain and maintain health emphasizes the most important aspects of this intervention. Younger adolescents need closer parental involvement. The daily structure should include eating three meals a day. Breakfast is typically eliminated and lunch drastically reduced in eating disorders. Patients with anorexia nervosa tend to continue their restriction through dinner, whereas patients with bulimia nervosa tend to binge eat and purge after school or after dinner. Eating adequately at breakfast maximizes the likelihood of adequate daily caloric intake and should be emphasized by the physician and the dietitian. Eating an insufficient amount of food at meals can result in weight loss or subsequent binge eating. Parents of adolescents should be encouraged to ensure that healthy food is available and that mealtimes are planned into the day but not to assume responsibility for the patient’s eating. As long as parents believe it is their duty to force their adolescent to eat, eating becomes a battle that cannot be won. If the patient gives in and eats to please parents, purging often ensues. In addition to increasing caloric intake, it may be necessary to limit physical activity. Restricting activity, such as participating in sports or exercise classes, has numerous advantages. It helps maintain weight by decreasing energy expenditure and emphasizes the seriousness of the condition to the patient and parents. It can act as a motivator to eat properly to allow return to favorite activities. Parents and coaches often are relieved when the patient is restricted from excessive activity on medical grounds. It may be useful to explain the purpose of the restrictions to the coach or school nurse so that they can reinforce the importance of health. The patient often finds it reassuring that someone is assuming authority in a situation over which she has a decreasing sense of control. A potential disadvantage of limiting activity is the removal of positive influences because ballet, soccer, or cheerleading may be important for a patient’s ability to cope with stress. Parents of adolescents may

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worry that activity restriction may cause a retreat further into the eating disorder or cause the adolescent to give up. It should be emphasized that the restrictions are for medical, not disciplinary, purposes and are temporary limitations in response to the patient’s physical condition. For example, one could tell a patient and her parents: I am concerned about the physical symptoms and signs that your body is having as a result of your poor nutrition. Until you get healthier, I cannot give medical permission to run track. I know how much you want to run, but you need to be healthier to do that, and that means making some changes in your nutrition. A sports nutritionist who helps my patients with eating disorders plans what they will eat and drink in a way that will help them improve their sports performance and get healthy at the same time. Now this will mean gaining some weight, but you need to know that our plan will result in you gaining more lean weight than fat. How does that sound?

The goal is to ensure healthy participation, not to exclude from participation. It is unfair to expose the patient to potential injury or suboptimal performance because of malnutrition. Finally, a drive for weight control that overpowers all other desires is potentially life-threatening and must be taken seriously. If the patient responds, ”I won’t gain weight, even if it means I can’t run track,” she demonstrates that weight loss is more important than running and more likely that running is a means to the end of losing weight. Before one attempts to make such restrictions, however, it is important to make certain that the parents will support the decision not to have their daughter participate until she has reached some goal weight or other set of parameters. When the patient has no interest in exercise, there is little opportunity to conserve calories, and there may be few motivators for healthy eating. Going to the mall or on family outings may need to be restricted in these situations. More important is the need to identify rewarding activities when appropriate behavior does occur. Serious depression or severe anorexia nervosa should be considered when the adolescent or young adult has no interest other than losing weight. During follow-up visits, the patient and parents should receive ongoing medical, nutritional, and mental health counseling as dictated by individual circumstances. Frequently, consultation with or referral to specialists in the treatment of eating disorders is required at this stage of illness. The process by which the patient is referred for treatment can be crucial to the acceptance of complex and often difficult treatment recommendations. The trust in the primary care physician is not readily transferred to specialists merely because they are experts. In this respect, referral is often facilitated when the specialists are identified as consultants, rather than as independent agents. A statement such as, ”To provide you with the best overall care, I need the help of some professionals who specialize in treating eating disorders” emphasizes that the team approach has shown effectiveness, whereas continuity of care is made explicit. This approach can be especially important in referral for mental health treatment. “You need to see a psychiatrist” often elicits

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“But, I’m not crazy.” A more therapeutic message is as follows: ”You seem angry, sad, and a little hopeless about this whole situation. My patients find it helpful to talk to a professional about such feelings, so they can get on with their life. I’d like you to see Dr. Smith, who is a psychiatrist. She can help us with this aspect of your care.” To the patient’s mother the physician can say the following: ”It’s clear that this eating disorder is affecting your whole family. Even though Melissa is the one who’s losing weight, I think we need to include the rest of the family in coming up with solutions. Dr. Johnson is a therapist who often helps me in working with families in such situations. Here’s his phone number and address. I’ll call in the referral and will see you again in two weeks to see how the first meeting went and to check on Melissa’s health.” To reinforce the importance of the referral, the primary care physician should schedule a follow-up appointment after treatment by specialists has begun. It is common for a patient or parent to resist treatment, noting, “I don’t like talking about it,” ”She’s not helping,” ”It’s too expensive,” or ”It’s not that big of a deal.” To lessen the conflict related to the eating disorder, parents may decide to discontinue treatment prematurely, hoping that conflict will resolve spontaneously. Reinforcement is often needed: ”I know how difficult it is to deal with these problems, but it will be worth it. Keep up with treatment for at least another 2 months, then we can see how things are going. I think you’ll start to see some change soon if everybody works together.” The emphasis of the team approach helps the adolescent and parents realize that they are not alone in their struggle. Interdisciplinary Team Approach

The referral to a team of specialists implies that such a team is available to the physician; outside of metropolitan areas, this may not be the case. Because adolescent medicine is now a board-certified subspecialty, however, physicians capable of managing all but the most difficult cases of anorexia nervosa should be increasingly ac~essible.~ It is especially important for the patient and primary care provider to have contact with a physician who has experience in managing the medical aspects of eating disorders, including inpatient care. In less severe cases, this specialist may need only one or two visits with the patient to help establish the diagnosis and a treatment plan that the primary care provider can execute. In more severe or acute cases, this specialist may assume primary responsibility for coordinating care specifically related to the treatment of the anorexia nervosa, including hospitalization. Ideally the same specialty team offers outpatient and inpatient services because the transition between settings can be difficult. The therapeutic team should also include a dietitian and mental health care providers. In some situations, the involvement of a psychologist and a psychiatrist is indicated; the former may provide family

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therapy, whereas the latter provides individual therapy and, if needed, prescribes psychoactive medication, such as antidepressants, or oversees psychiatric hospitalization. Communication among members is crucial to the professionals functioning as a team. This communication can be facilitated by treatment of the adolescent and family in a dedicated eating disorder program. Commitment to providing optimal care is the most important credential, however, and an effective team can be assembled under the leadership of the primary care physician. Hospitalization Indications for hospitalization in eating disorders5 are outlined in the accompanying box. Some clinicians include falling below a preset minimum weight as an indication for hospitalization. Low weight is only one index of malnutrition; weight should never be used as the sole criterion for admission to the hospital. Most adolescents are sophisticated enough to realize that weight on a scale can be falsified. They may drink water or diet beverages or hide heavy objects in their underwear before weighing if weight alone determines hospital admission. This approach may result in acute hyponatremia or dangerous degrees of unrecognized weight loss.

Indications for Hospital Admission for Anorexia Nervosa Physiologic decompensation Temperature <36°C Pulse <45/min or orthostatic pulse differential >30/min Altered mental status, fainting, or other signs of significant malnutrition Rapid (>lo% in 2 months) or excessive (>15% overall) weight loss that cannot be curtailed as an outpatient Complications of weight-control habits (fluid or electrolyte imbalance or true loss of appetite) Inability to break the cyc/e of disordered eating as outpatient Inability to initiate effective outpatient psychotherapy I

Adequate preparation for inpatient treatment can prevent some negative perceptions regarding hospitalization. The patient may perceive admission to the hospital as a punishment: One mother said to her daughter, “If you don’t eat they’ll put you in the hospital and feed you through a tube in your nose! You don’t want that, do you?” Parents may fear that hospitalization indicates a serious deterioration in their daughter’s condition. One father asked, ”Will she ever get better?” By identifying hospitalization as a necessary component of treatment under specific conditions, the physician minimizes its use as a threat to achieve

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compliance with treatment and emphasizes the therapeutic purpose of inpatient care. Parents especially must be aware of the need to view hospitalization, if required, as an intensification of treatment that is best avoided through effective outpatient management but that is not something to be feared. Reinforcing the purpose of hospitalization as well as the specific goals and objectives of inpatient treatment (e.g., changes in metabolic and physiologic variables, planning and ingesting healthy meals, establishing improved communication skills, gaining insight into underlying conflicts, developing alternative coping strategies) directly with the patient and the parents can maximize the therapeutic impact of admission to the hospital. Outpatient follow-up should be planned before discharge so that continuity from inpatient to outpatient care is ensured. During hospitalization, dysfunctional habits of choosing, preparing, and eating food can be reversed. This reversal may require behavior modification, wherein patients learn how to eat with professional guidance. Patterns of interaction within the family that were previously dominated by arguments relating to the eating disorder can become focused on issues other than food, eating, and weight as the patient is restored to health. Equally important, however, is attention to the developmental issues that drive the eating disorder. Low self-esteem, lack of assertiveness, a sense of inadequacy and ineffectiveness, and underlying mood disturbance or other emotional problems should be addressed. The scope of hospital management is beyond the scope of this article, but the primary care provider needs to be aware of the issues related to successful treatment. PROGNOSIS Poor prognosis has been associated in the literature most consistently with long duration of illness, disturbed parent-child relationships, concomitant personality disorder, and the presence of vomiting (the latter two more common in bulimia). Degree of weight loss is not generally related to prognosis. Early age of onset has been proposed as a predictor of good outcome, but several studies have not found this to be the case. Regardless of the presence of good or poor prognostic indicators, the primary care provider’s role in the treatment of anorexia nervosa remains the early identification and initiation of effective interventions. Even with early treatment, the clinician should expect treatment to last 6 months to 2 years or more, and expectations for a quick fix need to be tempered. Anorexia nervosa, previously treated almost exclusively by mental health care professionals, has been considered a chronic condition with a variable but generally poor prognosis. Data from treatment programs based in adolescent medicine suggest that more favorable outcomes can be expected with early identification and definitive treatment of adolescents and their families. For example, applying standardized mea-

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sures to determine outcome, 71% to 86% of patients reported in the literature from adolescent medicine programs had a satisfactory outcome.5,16*21 An exception to this generalization may be the future development of osteoporosis. Adolescent girls and women with eating disorders have numerous risk factors for suboptimal bone accretion (low weight, poor calcium intake, hypoestrogenemia, and hypercortisolemia), placing them at risk for osteoporosis; evidence suggests that adolescents may be at even higher risk than adults.'l, 22 Studies are now underway to define those at greatest risk and treatment options to minimize the likelihood of fracture of the hip and spine. Despite these generally encouraging results, persistence or worsening of the illness over time, often with the development of personality or affective disturbances, occurs in 15% to 25% of patients in pediatric series. Mortality is less than 5% with treatment, however. The prognosis and outcome for patients with bulimia is less certain because it was identified as a separate condition in research studies only in the 1980s. Features that tend to be associated with poorer prognosis include the presence of significant depression, comorbidity with substance abuse, coexistent personality disorder, and a history of sexual abuse. MEDICAL CONCERNS IN EATING DISORDERS Myocardial Impairment

Bradycardia was recognized as a prominent feature of weight loss in the first case of anorexia nervosa described in the literature9 in 1874. Almost 50 years ago, young men underwent voluntary starvation under experimental conditions and were found by KeysI5 to have significant cardiovascular changes, including profound bradycardia (average resting pulse of 37 beats/min); decreases in amplitude of P, QRS, and T waves; decreased heart size in all dimensions; decreased systolic and diastolic blood pressure; decreased stroke volume; and reduction in all variables related to physical work done by the heart. The volunteers experienced fatigue, weakness, and acrocyanosis but no evidence of dyspnea or other symptoms suggestive of cardiovascular distress. During the period of nutritional rehabilitation after the studies of starvation were completed, there was a rapid return of heart size but a slower return of cardiac function, which eventually did return to normal in all subjects within 32 weeks of refeeding and weight restoration. There appeared to be less cardiac reserve during rehabilitation than during starvation, attributed to a more rapid return of metabolic demand than of cardiac output. During the phase of most rapid weight gain, subjects experienced a rapid increase in metabolic rate, tachycardia, venous pressure elevation, dyspnea, and refeeding edema. When given the opportunity to eat freely, one subject ate 10,000 calories a day and developed congestive heart failure. This event may have been due to a

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slowed response in up-regulation of muscle mass relative to the rapid increase in blood volume and afterload. An additional concern with refeeding is the precipitation of significant hypophosphatemia as energy is restored.21Applied to patients with eating disorders, these data indicate that the rehabilitation phase may be more dangerous than the starvation phase. Clinically, it is useful to categorize myocardial abnormalities in eating disorders into physiologic adaptations, such as sinus bradycardia, sinus arrhythmia, low blood pressure, or myocardial abn0rma1ities.I~ The former occur gradually, are not life-threatening, yet still meet the needs of decreasing demands of tissue perfusion. Prolonged corrected QT interval, ventricular dysrhythmias, and abnormal contractility are evidence of a myocardial abnormality, occur more quickly, and can be lethal.13Patients who have prolonged corrected QT should be monitored for hypokalemia or hypomagnesemia, especially if they vomit or take laxatives. The most serious cardiac dysfunction affecting patients with eating disorders is ventricular tachyarrhythmia.26This condition is more common in patients who have been chronically starved. There have not been consistent findings regarding abnormal contractility in the literature. Mitral valve prolapse has been associated with significant weight loss, but this is a functional abnormality caused by a decrease in chamber size relative to the fixed size of the mitral valve and does not require any treatment other than weight gain. Orthostatic blood pressure and pulse measurements form the foundation of cardiovascular monitoring in patients with eating disorders. A baseline electrocardiogram is indicated if there are any concerns based on the history or physical examination but is not routinely repeated unless abnormal. Studies have indicated that increases in orthostatic pulse from supine or sitting to standing indicate the degree of autonomic balance. In anorexia nervosa, a pulse differential of greater than 30 beats/ min, especially if there is resting bradycardia, suggests excess vagotonia that is counterbalanced by excess sympathetic tone on standing.Is In normal-weight patients with bulimia, this pulse differential more likely indicates hypovolemia resulting from excessive purging. Regardless of the cause, this abnormality improves with fluid and nutritional rehabilitation and weight gain. Osteoporosis

Hypoestrogenemic osteoporosis is commonly seen in the amenorrheic athlete and young woman with anorexia nervosa.H,22, 25 Although sex hormone replacement therapy is clearly beneficial to postmenopausal women with respect to reducing bone loss, there are few data regarding such treatment for adolescent girls with anorexia nervosa.20Existing studies are equivocal, many lacking adequate power, time, or both to detect treatment effect.IO, Because the data are inconclusive and because the mechanism for starvation-induced amenorrhea differs from that for

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postmenopausal amenorrhea, patients may be offered the alternative of sex steroids with the understanding that they may or may not help preserve bone mineral density. Risks and benefits of treatment with hormones need to be weighed carefully and individually with the patient and parents. Many older adolescents are capable of making the decision for themselves based on the objective benefits and disadvantages of therapy. Patients who choose hormones should be aware that they may experience withdrawal bleeding but will not be menstruating; the medications are working at the level of the endometrium, not the hypothalamus.*' The use of transdermal patches, especially those containing combined estrogen and progesterone, may provide an alternative means of delivering hormones without many of these negative effects. Amenorrhea

The absence of menses, a hallmark feature of anorexia nervosa in postmenarcheal girls, is due to hypothalamic dysfunction associated with starvation and weight Patients who are moderately low weight because of cystic fibrosis or inflammatory bowel disease are more likely to maintain menstruation than patients with eating disorders at similar degrees of thinness. This difference may be due to the fact that at least 75% of patients with anorexia nervosa also exercise compulsively and may have cortical suppression of menses because of the stress associated with an eating disorder. A study suggested that menstrual suppression is related more to dysfunctional eating habits than weight per se. Amenorrhea occurs in only about one third of patients with bulimia who maintain a normal weight. Shomento and Kreipe2*have conducted long-term follow-up studies of patients who recovered from anorexia nervosa and found that more than 90% of them were menstruating regularly. Using a standard formula for average body weight (ABW) for height (100 lb for 5 ft of height plus 5 lb for each inch over 5 ft tall), the ABW at which patients regained or established their menses was 92% k 7.4%. That is, a 64-inch patient (whose ABW is 120 lb) was, on average, 110 lb when she began menstruating. The authors used this formula rather than formal weight charts to facilitate rapid calculation of the menstrual weight in the office in response to the frequently asked question, "How much weight do I need to gain to get my periods back?" For patients with eating disorders who are having unprotected sexual intercourse, amenorrhea does not preclude the possibility of conception. Bonne et a12 reported two cases of amenorrheic women with eating disorders who had unexpected, unplanned, and unintended pregnancy, with significant negative results on their emotional health. This risk is greatest in normal-weight women, who are more likely to be sexually active than extremely emaciated individuals because cachexia also tends to be associated with loss of libido, regardless of the cause of weight loss. In addition to being more likely to have a normal weight,

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patients with bulimia are more likely than those with anorexia nervosa to have a history of sexual abuse as well as engage in promiscuous sexual activity. Normal-weight amenorrheic patients with this profile deserve special attention to prevent pregnancy. The history of amenorrhea did not necessarily have significant longterm effects on fertility, if patients were eventually able to achieve and maintain weight in the target range. It appears as if patients may need to gain more weight to begin to ovulate than they do to menstruate. That is, some patients reported regaining menses at around 90% of ABW but having difficulty conceiving. When they gained to around 100% of ABW, they were able to conceive. Data from the authors’ program suggest that a history of anorexia nervosa does not in itself increase the risk of infertility as long as the patient is able to gain weight to within a normal range and maintain relatively normal eating and weightcontrol habits. For young adults with an eating disorder who are seeking advice regarding fertility, the authors recommend that they focus on eating and exercising healthfully and attend to mental health issues that may be underlying body image distortion, rather than to focus on weight. If they normalize their eating and activity habits, the weight normalizes on its own. The fear of gaining excess weight may be quite strong, so a gradual weight gain is recommended. Gaining weight by eating large meals is contraindicated because it may trigger binge eating. Eating three balanced meals and at least one snack daily minimizes the likelihood of patients with anorexia nervosa developing bulimia. If the patient regains menses but still has difficulty becoming pregnant, the best advice is to gain a small amount of more weight. The addition of only 2 or 3 lb appears to be sufficient to result in ovulation. The use of ovulation induction with clomiphene should be considered only if the patient is maintaining a normal weight and appears to have recovered from her eating di~order.~ In the authors’ follow-up, they learned that a patient with an active eating disorder and weighing only about 80% of ABW was given clomiphene, resulting in a pregnancy with triplets. She was neither physically nor psychologically prepared for this and has had experienced significant ongoing problems that might have been avoided had she recovered from her eating disorder before attempting to become pregnant. CONCLUSION Eating disorders are relatively common and frequently result in medical signs and symptoms. Armed with an appreciation of the protean manifestations of these complex health problems as well as an appreciation of the biopsychosocial approach needed to help the adolescent or young adult woman recover, the primary care physician is in an excellent position to have a therapeutic role in the recovery from these chronic conditions. By recognizing the medical aspects of eating disorders, the

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oversimplified viewpoint of considering them as purely psychiatric disorders can be avoided. Open and consistent communication with patients, with a focus on health rather than dysfunction and mental illness, facilitates the acceptance of a comprehensive approach in which the internist, dietitian, and mental health provider all have a role. References la. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994 1. Becker AE, Grinspoon SK, Klibanski A, et al: Eating disorders. N Engl J Med 340:10921098, 1999 2. Bonne OB, Rubinoff B, Berry EM: Delayed detection of pregnancy in patients with anorexia nervosa: Two case reports. Int J Eat Disord 20:423-425, 1996 3. Bulik CM, Sullivan PF, Fear JL, et al: Fertility and reproduction in women with anorexia nervosa: A controlled study. J Clin Psychiatry 60:130-135, 1999 4. Comerci GD: Eating disorders in adolescents. Pediatr Rev 1O:l-18, 1988 5. Fisher M, Golden NH, Katzman DK, et al: Eating disorders in adolescents: A background paper. J Adolesc Health 16:420437, 1995 6. Frank JB, Weihs K, Minerva E, et al: Women’s mental health in primary care: Depression, anxiety, somatization, eating disorders, and substance abuse. Med Clin North Am 82:359-389, 1998 7. Garfinkel F, Garner D: Anorexia Nervosa: A Multidimensional Perspective. New York, Brunner / Mazel, 1982 8. Garner DM, Rosen LW, Barry D: Eating disorders among athletes: Research and recommendations. Child Adolesc Psychiatr Clin North Am 7839-857, 1998 9. Gull WW: Anorexia nervosa. Transactions of the Clinical Society of London 722-28, 1874 10. Hergenroeder AC: Bone mineralization, hypothalamic amenorrhea, and sex steroid therapy in female adolescents and young adults. J Pediatr 126:683489, 1995 11. Hergenroeder AC, Smith EO, Shypailo R, et al: Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone, or placebo over 12 months. Am J Obstet Gynecol 176:1017-1025, 1997 12. Herzog DB, Nussbaum KM, Marmor AK: Comorbidity and outcome in eating disorders. Psychiatr Clin North Am 19:843-859, 1996 13. Isner JM, Roberts WC, Heymsfield SB, et al: Anorexia nervosa and sudden death. Ann Intern Med 102:49-52, 1985 14. Kann L, Kinchen SA, Williams BI, et al: Youth risk behavior surveillance-United States, 1997. Morb Mortal Wkly Rep CDC Surveil1Summ 47(SS-3):1-89, 1998 15. Keys A: Cardiovascular effects of malnutrition and starvation. Modem Concepts of Cardiovascular Disease 2721, 1948 16. Kreipe RE, Dukarm CP: Outcome of anorexia nervosa related to treatment utilizing an adolescent medicine approach. J Youth Adolescence 25:483-497, 1996 17. Kreipe RE, Dukarm CP: Outcome of eating disorders among children and adolescents. Pediatr Rev 16, 1999 18. Kreipe RE, Goldstein BH, De King DE, et al: Heart rate power spectrum analysis of autonomic dysfunction in adolescents with anorexia nervosa. Int J Eat Disord 16:159-165, 1994 19. Kreipe RE, Harris JP: Myocardial impairment resulting from eating disorders. Pediatr Ann 21~760-768, 1992 20. Kreipe RE, Hicks DG, Rosier RN, et al: Preliminary findings on the effects of sex hormones on bone metabolism in anorexia nervosa. J Adolesc Health 14:319-324, 1993 21. Kreipe RE, Uphoff M: Treatment and outcome of adolescents with anorexia nervosa. Adolesc Med State Art Rev 3:519-540, 1992 22. Laughlin GA, Dominguez CE, Yen SS: Nutritional and endocrine-metabolic aberrations

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in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 83:2532, 1998 Morgan JF: Eating disorders and gynecology: Knowledge and attitudes among clinicians. Acta Obstet Gynecol Scand 78:233-239, 1999 Palla 8, Litt IF: Medical complications of eating disorders in adolescents. Pediatrics 81:613423, 1988 Putukian M: The female athlete triad. Clin Sports Med 17675-696, 1998 Schocken DD, Holloway D, Powers PS: Weight loss and the heart: Effects of anorexia nervosa and starvation. Arch Intern Med 1492377-881, 1989 Selzer R, Caust J, Hibbert M, et al: The association between secondary amenorrhea and common eating disordered weight control practices in an adolescent population. J Adolesc Health 19:56-61, 1996 Shomento SH, Kreipe RE: Menstruation and fertility following anorexia nervosa. Adolesc Pediatr Gynecol 7142-146, 1994 Wiederman MW, Pryor T Substance use among women with eating disorders. Int J Eat Disord 20:163-168, 1996 Wonderlich SA, Mitchell JE: Eating disorders and comorbidity: Empirical, conceptual, and clinical implications. Psychopharmacol Bull 33:381-390, 1997 Yager J (ed): Eating Disorders. Psychiatr Clin North Am 19:639-882 1996 Ziedonis D, Brady K Dual diagnosis in primary care: Detecting and treating both the addiction and mental illness. Med Clin North Am 81:1017-1036, 1997 Address reprint requests to Richard E. Kreipe, MD Division of Adolescent Medicine Department of Pediatrics, Box 690 601 Elmwood Avenue University of Rochester Rochester, NY 14642 e-mail: [email protected]