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The American Psychiatric Association (APA) has issued practice guidelines for eating disorders - specifically anorexia nervosa and bulimia nervosa. These are the first practice guidelines on eating disorders to be approved by the APA. The guidelines define anorexia nervosa and bulimia nervosa and describe their complications, review the epidemiology of the disorders, discuss treatment principles and alternatives, include recommendations covering general principles of assessment and treatment and outline areas for future research. The following information has been excerpted from the guidelines, which were published in the February 1993 issue of the American Journal of Psychiatry.

Anorexia nervosa and bulimia nervosa affect large numbers of persons, with 90 to 95 percent of cases occurring in females. The prevalence appears to be increasing and may range from 1 to 4 percent among adolescent and young adult women in predominantly white upper-middle-class and middle-class student groups. Prevalence is much lower in other populations. With the obvious exception of concerns regarding menstrual function and female sexuality, issues of assessment and treatment for male patients generally parallel those for female patients. Some aspects of diagnosis and treatment may require special consideration for the very young.

The guidelines are based on the criteria outline in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders. Diagnostic criteria for anorexia nervosa include refusal to maintain a minimal normal body weight for age and height; intense fear of gaining weight or becoming fat, even though the person is underweight; disturbance in the way in which body weight, size or shape is experienced, and, in females, the absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea).

Diagnostic criteria for bulimia nervosa include recurrent episodes of binge eating (a minimum of two episodes a week for at least three months). The patient has a lack of control over eating behavior during the eating binges. Self-induced vomiting, laxatives or diuretics, strict diets or fasts or vigorous exercise are used to prevent weight gain, and the patient has a persistent over concern with body shape and weight. Although bulimia is more common than anorexia nervosa, many patients demonstrate anorectic and bulimic behaviors.

Comorbid major depression and/or dysthymia have been reported in 50 to 75 percent of patients with anorexia nervosa, while patients with bulimia have been found to have increased rates of bipolar disorder (12 percent), anxiety disorders (43 percent), chemical dependency disorders (49 percent) and personality disorders (50 to 75 percent).

Recommendations

The guidelines recommend that patients with eating disorders receive a comprehensive multidiscipline assessment. Clinicians should attempt to build trust, establish mutual respect and develop a therapeutic relationship with the patient that win serve as the basis for assessment and treatment of the problems associated with eating disorders. The assessment should include use of interview instruments or self-report questionnaires focused on eating disorders, a psychiatric history, a physical examination, a family assessment and a coordinated care plan. The coordinated care plan should include nutritional counseling, dental assessment, family involvement and behavioral programs.

For the treatment of anorexia nervosa, a trial of outpatient or partial hospitalization is recommended for highly motivated patients who have good support systems, are not losing weight rapidly, are metabolically stable, are not below 70 percent of their average weight for height and can be carefully monitored. However, many patients require hospital treatment, including those with rapidly falling weight or metabolic instability.

The goals of treatment should be to restore patients to a healthy weight; to restore healthy eating patterns; to treat or remediate physical complications; to address dysfunctional behavioral regulation; to improve associated psychologic difficulties; to enlist family support, and to prevent relapse. Many consultants believe that patients are less likely to relapse if they are hospitalized until they achieve a healthy weight. However, those patients who are fully cooperative with their treatment and who have good after-care available may be discharged from the hospital before full healthy weight is restored.

Nutritional assessment, education and ongoing support are essential. Families should usually be involved from the beginning of treatment and included in meetings and treatment planning sessions. Family therapy is most useful for younger patients.

Psychotherapy should be tailored to the level of cognitive development, style and complexity of the individual. Because of the enduring quality of the personality traits and disturbances that led to the development of anorexia nervosa, psychotherapy is frequently required for at least a year or more.

Eating disorders are a growing concern in the medical community, and researchers feel their prevalence is increasing in our society. Because eating disorders are closely associated with exercise patterns, instructors are becoming more educated and aware of these problems.

Anorexia-nervosa, bulimia and binge eating or compulsive overeating are considered eating disorders. The American Psychiatric Association (APA) defines anorexia as an intense fear of becoming fat with weight loss of 15% below ideal body weight, body image distortion and menstrual irregularities which result in the loss of three or more menstrual cycles. Bulimia is characterized by at least two binge eating episodes a week, followed by purging of food to prevent weight gain, in the form of vomiting, laxatives, diuretics, strict dieting or fasting or excessive exercise. Bulimics also suffer fear associated with loss of control over eating binges and persistent overconcern with body shape and weight. It is not uncommon for women to have symptoms of both anorexia and bulimia.

The APA has not yet established criteria for treating binge eating or compulsive overeating. Compulsive overeating is similar to bulimia in that the compulsive overeater is preoccupied with thoughts of food, engages in bulimic-type eating behavior and becomes distressed and overcome by guilt feelings after binge eating. But compulsive overeaters differ from bulimics in that compulsive overeaters do not purge after a binge.

Anorexics and bulimics also differ in many ways. Anorexics turn away from food to cope with life situations, while the bulimic will turn toward it for support. An anorexic tends to be introverted, avoiding intimacy and involvement with the opposite sex, while a bulimic is more extroverted, seeking intimacy and physical relationships. Anorexics have strict control over food; bulimics lack control. In many cases, the anorexic denies the illness; the bulimic will recognize it but keep it a secret. Following are warning signs of both disorders.

* Tired, dragged-out facial expression.

* Movements appear forced, lacking energy, frequent muscle soreness, cramps, many complaints about weakness, aches, pains, early fatigue and exhaustion during workouts.

* Decreased performance and coordination.

* Aimless physical activity, overtraining, excessive exercise and poor muscular development for the amount of exercise conducted.

* Preoccupied with thoughts and often asks questions about food, weight, fat, calories, dieting, etc.–often the same ones reworded.

* Inability to concentrate and indecisiveness, repeated comments about looking or feeling fat.

* Changes in sleep patterns.

* Nervousness in social situations with food.

* Depression and unhappiness due to a distorted body image.

* Fad diets, constant dieting and avoidance of food containing fat.

* Social isolation, withdrawal and mood swings.

* Complaints of bloating, stomach problems and not feeling well after eating.

* Dry skin and brittle and thinning hair.

* Always feels cold.

* Irregular or high heart rate during aerobic activity, dizziness and fainting.

* Lanugo (fine body hair).

Warning Signs of Bulimia

* Avoids social eating and/or disappears or goes to the bathroom after eating.

* Secretive eating, food/candy wrappers found in bedroom and hiding food.

* Intake of potassium pills.

* Binge eating and loss of control over food.

* Use of laxatives, diet pills, diuretics, substance abuse and steroids.

* Bloodshot eyes (from vomiting).

* Minor theft–food, exercise equipment.

Dieting, fear of fatness and binge eating are risk factors in the development of eating disorders. A 1992 study on fifth through 12th graders found 46% of nine-year-olds and 81% of 10-year-olds reported these behaviors. In another study, eating attitudes, dieting and body image were assessed in fourth to eighth grade children, and 18.2% of them had unhealthy scores as determined by an eating disorder diagnostic test. The Centers for Disease Control and Prevention surveyed over 10,000 high school students to measure the prevalence of health risk behaviors and found 43.6% of female students reported trying to lose weight. Another 27.4% considered themselves to be a healthy weight, yet they were still trying to lose weight.

Studies have shown female athletes have a higher incidence of eating disorders than non-athletes, especially in sports that emphasize thinness and appearance, such as diving, gymnastics, running, figure skating, swimming and professional dancing.

Eating disorders do not appear overnight. Feelings of ineffectiveness, depression, anxiety, low self esteem, the need to be accepted and having the perfect body may lead to eating disorders. Eating disorder behaviors can become a coping mechanism to avoid painful experiences in life.

They can be triggered by events or comments by people who are significant to them. Aerobics instructors and personal trainers are often role models. Students look to them for approval and favor. Comments about appearance, weight and body fat can have a great impact on students. To help individuals suffering, it is important instructors don’t overemphasize losing weight or burning off fat. Instructors should emphasize good nutrition, realistic weight loss, weight maintenance and exercising for cardiovascular fitness as well as fun.

The incidence of anorexia nervosa among men may be as low as 0.02 percent per year, and the prevalence of bulimia nervosa in men ranges from 0.1 to 0.5 percent. The incidence of these diseases is much higher among women. It has been suggested that this difference between the sexes may be attributed to biologic, sociocultural and psychodynamic factors. Olivardia and associates compared the characteristics of men and women with eating disorders.Of 25 men who responded to advertisements in college newspapers, 52 percent met criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for bulimia nervosa, 8 percent met criteria for anorexia nervosa and 24 percent met criteria for binge-eating disorder. There were no statistical differences in demographic characteristics. Mean age at onset of eating disorder was 14.7 years. The methods used by the men to prevent weight gain were self-induced vomiting, laxative abuse, fasting and excessive exercise. A group of 25 college men who did not have eating disorders and 33 women with bulimia nervosa served as comparison groups.

Both 58 percent of men who reported binge-eating behavior and 58 percent of women with bulimia described feeling very uncomfortable with their behavior. Of the 25 men with eating disorders, only four (16 percent) had sought treatment. Significantly more women with bulimia (52 percent) had received therapy. Men with eating disorders had a strikingly higher rate of current or past major mood disorders than men in the control group and somewhat higher rates of substance abuse and anxiety disorders.

Among men with eating disorders who had concurrent major depression, the onset of depression occurred at least one year before onset of the eating disorder in 40 percent, at least one year after onset of eating disorder in 47 percent and within the same year as onset of eating disorder in 40 percent. The rates of comorbid psychiatric disorders in men with eating disorders were similar to those in the women with bulimia. Of men in the study group, 36 percent reported at least one first-degree relative with major depression, compared with its percent of men in the control group.

Rates of homosexuality and bisexuality in the eating disorder group were not significantly greater than in the control group. Dissatisfaction with body image was similar for men with eating disorders and women with bulimia. For example, 28 percent of men with eating disorders and 15 percent of women with bulimia either agreed or agreed somewhat with the statement “I really like my body,” compared with 92 percent of men who did not have an eating disorder. A history of childhood physical and sexual abuse was reported slightly more often by men with eating disorders.

Research conducted and supported by the National Institute of Mental Health (NIMH) brings hope to millions of people who suffer from mental illness and to their families and friends. In many years of work with animals as well as human subjects, researchers have advanced our understanding of the brain and vastly expanded the capability of mental health professionals to diagnose, treat, and prevent mental and brain disorders.

Now, in the 1990s, which the President and Congress have declared the “Decade of the Brain,” we stand at the threshold of a new era in brain and behavioral sciences, Through research in animals and humans, we will learn even more about mental disorders such as depression, manic-depressive illness, schizophrenia, panic disorder, and obsessive-compulsive disorder. And we will be able to use this knowledge to develop new therapies that can help more people overcome mental illness.

The National Institute of Mental Health is part of the National Institutes of Health (NIH), the Federal Government’s primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.

Each year millions of people in the United States develop serious and sometimes life-threatening eating disorders. The vast majority - more than 90 percent - of those afflicted with eating disorders are adolescent and young adult women. One reason that women in this age group are particularly vulnerable to eating disorders is their tendency to go on strict diets to achieve an “ideal” figure. Researchers have found that such stringent dieting can play a key role in triggering eating disorders.

Approximately 1 percent of adolescent girls develop anorexia nervosa, a dangerous condition in which they can literally starve themselves to death. Another 2 to 3 percent of young women develop bulimia nervosa, a destructive pattern of excessive overeating followed by vomiting or other “purging” behaviors to control their weight. These eating disorders also occur in men and older women, but much less frequently.

The consequences of eating disorders can be severe, with 1 in 10 cases leading to death from starvation “cardiac arrest, or suicide. Fortunately, increasing awareness of the dangers of eating disorders - sparked by medical studies and extensive media coverage of the illness - has led many people to seek help. Nevertheless, some people with eating disorders refuse to admit that they have a problem and do not get treatment. Family members and friends can help recognize the problem and encourage the person to seek treatment.

This brochure provides valuable information to individuals suffering from eating disorders, as well as to family members and friends trying to help someone cope with the illness. The publication describes the symptoms of eating disorders, possible causes, treatment options, and how to take the first steps toward recovery.

Scientists funded by the National Institute of Mental Health (NIMH) are actively studying ways to treat and understand eating disorders. In NIMH-supported research, scientists have found that people with eating disorders who get early treatment have a better chance of full recovery than those who wait years before getting help.

Anorexia Nervosa

People who intentionally starve themselves suffer from an eating disorder called anorexia nervosa. The disorder, which usually begins in young people around the time of puberty, involves extreme weight loss - at least 15 percent below the individual’s normal body weight. Many people with the disorder look emaciated but are convinced they are overweight. Sometimes they must be hospitalized to prevent starvation.

Deborah developed anorexia nervosa when she was 16. A rather shy, studious teenager, she tried hard to please everyone. She had an attractive appearance, but was slightly overweight. Like many teenage girls, she was interested in boys but concerned that she wasn’t pretty enough to get their attention. When her father jokingly remarked that she would never get a date if she didn’t take off some weight, she took him seriously and began to diet relentlessly - never believing she was thin enough even when she became extremely underweight.

Soon after the pounds started dropping off, Deborah’s menstrual periods stopped. As anorexia tightened its grip, she became obsessed with dieting and food, and developed strange eating rituals. Every day she weighed all the food she would eat on a kitchen scale, cutting solids into minuscule pieces and precisely measuring liquids. She would then put her daily ration in small containers, lining them up in neat rows. She also exercised compulsively, even after she weakened and became faint. She never took an elevator if she could walk up steps.

No one was able to convince Deborah that she was in danger. Finally, her doctor insisted that she be hospitalized and carefully monitored for treatment of her illness. While in the hospital, she secretly continued her exercise regimen in the bathroom, doing strenuous routines of sit-ups and knee-bends. It took several hospitalizations and a good deal of individual and family outpatient therapy for Deborah to face and solve her problems.

Within the addictions treatment community, there has been a growing trend to describe all habits and compulsions, as well as certain psychiatric disorders, as additions. In this context, it is not surprising that alcohol dependence has been linked to the eating disorders anorexia nervosa (AN), the syndrome of self-starvation, and bulimia nervosa (BN), the bingepurge syndrome, one or both of which occur in approximately 5 percent of American women.

This is unfortunate, because many clinicians and other health care professionals have come to believe that eating disorders and alcohol and other drug abuse are associated because both illnesses are “addictive.” As has been too often the case in the development of psychiatry, theories have been proposed unencumbered by data. In this instance, similarities in symptomatology have led to rash speculations about the “addictive” etiology of eating disorders.

In fact, alcohol abuse and an eating disorder frequently do coexist–or covary–in the same individual, but whether this is due to a common “addictive etiology” is not necessarily suggested by the covariance. This article reviews the empirical data that led to the realization of covariance, examines the theoretical background, and explores some of the clinical issues involved in treating individuals with both eating disorders and alcoholism.

The first step in exploring the relationship between eating disorders and alcohol and other drug abuse was to establish that such a connection exists. The connection now may appear obvious, but this was not always the case. Tables 1 and 2 trace studies, excluding anecdotal reports, that have shown both that alcohol and other drug abuse occur commonly among patients with eating disorders (Table 1) and that eating disorders commonly occur among patients who abuse alcohol and other drugs (Table 2).

The studies in Table 1 all involved patients who entered into treatment with a primary diagnosis of either BN or AN. These individuals then were assessed for alcohol or other drug abuse. As shown in Table 1, each of the studies found high rates of alcohol abuse alone or alcohol and other drug abuse among patients with eating disorders. More important, in studies using control groups of persons without primary drug abuse diagnosis, the incidence of other drug abuse was shown to be higher among eating-disordered individuals.

The data in Table 1 suggest that alcohol and other drug abuse occur commonly in persons with eating disorders. Given these results, it is important to explore the clinically and etiologically significant corollary: Eating disorders would commonly occur in persons who abuse alcohol and other drugs. Table 2 summarizes studies that have been designed specifically to explore this relationship. As can be seen from this table, eating disorders have been found to occur frequently in individuals who abuse alcohol or other drugs. It should be noted, however, that other phenomenological surveys of alcohol abusers, reviewed by Schuckit (1986), have not routinely found increased covariance with either eating disorders or depression. This may mean that the association is somewhat weaker than suggested here, or that (as we believe) alcohol abusers need to be questioned more closely than they may have been. Without such questioning, an eating disorder diagnosis is apt to be overlooked.

The data in Tables 1 and 2 together suggest that eating disorders and alcohol and other drug abuse are linked meaningfully and coexist commonly. The data do not tell us why this is so. Nor is there evidence suggesting that one type of drug abuse is associated more commonly with eating disorders than another, although this is an area of ongoing investigation.

The phenomenological data serve as a reminder that clinicians should screen individuals with eating disorders for all forms of alcohol or other drug abuse, and that they should screen individuals who abuse alcohol and other drugs for the presence of eating disorders.

THEORETICAL BACKGROUND

Several theoretical explanations may account for the covariance of eating disorders and alcohol and other drug abuse. Perhaps the most provocative theory involves the role of the endogenous opioids in the modulation of all ingestive behaviors. It now is commonly recognized that opioid peptides appear to regulate appetite in mammals and may be involved in the etiology of AN and BN (Jonas and Gold 1988). Recently, evidence has emerged suggesting that opioid peptides also may modulate intake of alcohol and cocaine in mammals (see Reid in press, for a review of this area). Dysregulation of opioid peptides may produce abnormalities of ingestion, providing a possible explanation as to why eating disorders and alcohol and other drug abuse coexist.

Another possible explanation for the covariance of alcohol and other drug abuse and eating disorders is that individuals who develop addictive or compulsive attitudes toward a certain behavior or substance are more likely to do so in relation to another behavior or substance. This is a frequent clinical observation that leads to another question: Why are some individuals more prone to develop such behaviors than are others? The answer may lie in the neurochemical changes noted above.

With obesity on the rise, more research has been focused on racial differences. The prevalence of obesity is greater in black women than in white women and black women reputedly lose less weight with a range of treatment modalities. There remains considerable debate regarding the degree to which cultural, behavioral, physiological, and metabolic factors are responsible for racial differences in weight gain, response to weight loss treatment, and post-treatment recidivism.

Some research suggests that obese black women have a lower resting metabolic rate (RMR) than do obese white women, even after adjustment for variation in body composition. To test this hypothesis, a group of researchers compared total and regional lean (LBM) and fat mass patterns in white and black women in three weight states (overweight, normal weight, and at one-year follow-up) and assessed the degree to which regional lean tissue mass explains variance in RMR in different weight states.

Eighteen white and 22 black women, aged 20 to 46 years who had a baseline BMI of 27 to 30 (chosen to increase the likelihood that subjects could attain a normal weight in a reasonable time frame) and a family history of obesity (BMI > 27) in at least one first-degree relative were included in this study. Total and regional lean and fat masses were assessed by DXA at the three weight states. The Subjects also spent 23 hr in a whole-room respiration calorimetery for measurement of total energy expenditure and RMR. Weight loss to achieve normal weight (BMI < 25) was achieved by following a diet of approximately 800 kcal/day plus two frozen entrees. After the achievement of a normal-weight state, no intervention was provided and the subjects were contacted < 10 months later to schedule a follow-up evaluation.

In the overweight state, there were no significant differences between the white and black women in mean BMI, body weight, percentage body fat, or magnitude of weight loss. Whereas the races did not differ in trunk or limb fat mass, there were significant racial differences in the regional distribution of LBM. Trunk LBM was significantly lower in blacks than in whites and limb LBM was significantly greater in blacks than in whites. In both races, weight regain was associated with significant increases in limb LBM but not in trunk LBM. RMR, adjusted for total LBM and fat mass, was significantly higher in white women after weight loss and regain. However, no racial difference was found when RMR was adjusted for LBM distribution.

In both races, trunk LBM decreased with weight loss and remained lower, despite significant weight regain, which potentially reflected decreased organ mass. In addition, although racial differences were seen during weight loss and regain when RMR was adjusted for total LBM and fat mass, these differences were no longer evident after adjustment for regional LBM distribution. Consequently, these results show that, in comparing energy expenditure between races, adjustment for differences in distribution of LBM may have to be considered.

The prevalence of extreme obesity has increased three-fold over the past four decades, that is, having a body mass index (BMI;kg/[m.sup.2]) > 40. Obese persons with these BMI often have a long history of excess weight, of repeated failures with traditional weight-loss methods, or both, and gastric bypass surgery is one option as a useful treatment for achieving sustainable weight loss.

Relatively little is known about the long-term effects of weight loss induced by gastric bypass surgery on energy requirements or about the reasons observed for the substantial variability in weight loss between patients. One other question is whether it is possible to identify pre-surgical predictors of weight loss that could help identify those patients that are likely to obtain the maximum benefit from gastric bypass surgery. The potential predictors of weight loss are total energy expenditure (TEE), resting energy expenditure (REE) and leptin, which have been suggested to predict weight loss in several previous studies. Therefore, a group of researchers from Tufts University set out to determine changes in energy expenditure and body composition with weight loss induced by gastric bypass surgery and to examine the utility of several baseline variables, including TEE and REE, for predicting body weight and fat loss in these individuals.

Thirty extremely obese adults who underwent gastric bypass surgery at the Tufts-New England Medical Center Hospital participated in this study. All subjects were initially tested before gastric bypass surgery and then after weight loss and weight restabilization. TEE, REE, fasting leptin levels, body composition, and the thermic effect of food (TEF) were measured at baseline and follow-up. TEE was measured using the doubly labeled water methods and REE through indirect calorimetry. Body composition was evaluated by the Siri 3-compartment model at baseline and follow-up.

Subject characteristics at baseline are summarized in Table 1. The mean duration of weight loss after gastric bypass surgery was 14 + 2 months. Subjects lost 53.2 + 22.2 kg body weight and had significant decreases in REE and TEE. Gastric bypass surgery resulted in a substantial mean weight loss of 38% of initial weight. There were large and significant changes in all body-composition variables and, on an average, weight loss was 79% fat and 21% FFM. The changes in REE were predicted by changes in FFM and fat mass. Weight loss was predicted by baseline fat mass and BMI but not by any energy expenditure variable or leptin. Measured REE at follow-up was not significantly different from predicted REE. In addition, there were no significant changes in TEF, fasting RQ, or PPRQ.

This study showed that both TEE and REE decreased by 25% on an average after massive weight loss and weight restabilization after gastric bypass surgery. The results also indicated, in contrast with several previous reports, that the change in REE was explained by losses of both FFM and fat mass. In addition, the authors observed that mean REE after weight loss was not significantly different from REE predicted wit the use of standard equations developed for non-obese persons. Therefore, these results suggest no energetic adaptation of REE toward increased efficiency after massive weight loss induced by gastric bypass surgery. The data from this study are helpful but further research is needed to examine other potential explanations for the variability in weight loss between patients after gastric bypass surgery, including psychological or behavioral factors that may affect food intake.

Anorexia nervosa (AN) is the third-most common chronic disorder diagnosed in adolescent girls in the United States. Although improved nutrition intake and weight recovery remain the goal for all patients with AN, the effect on body composition, especially regional fat distribution, may make psychological and physical recovery more difficult in a population so focused on body image.

Studies of regional fat distribution in adults with AN have shown decreased extremity fat at baseline and increased trunk fat with weight recovery, resulting in truncal adiposity. There have been several studies on this topic in adults but very few have focused on adolescents. Therefore, a recent study in the American Journal of Clinical Nutrition sought to determine body composition and regional fat distribution in adolescents with AN and measured changes in these parameters during weight recovery.

Twenty-one adolescent girls with AN and 21 control subjects matched for age and pubertal stage were included in this study. All AN subjects were enrolled in integrated treatment programs for the duration of the study. Height, weight and body composition were measured at baseline through dual-energy X-ray absorptiometry (DXA), six month and 12 month visits. Four-day food records were analyzed to assess intakes of macronutrients and micronutrients at each visit. Weight recovery was defined as a >10% increase in body mass index (BMI).

At baseline, the girls with AN had a lower percentage of trunk fat than did the control subjects, whereas the percentage of extremity fat was not significantly different between the groups. There was no significant difference between the groups for total calories, protein or carbohydrates. However, girls with AN consumed significantly less fat and saturated fat than did the controls. BMI increased by a mean of 3.5 in the 13 anorexic subjects who met the criteria for weight recovery. At 12 months, in weight-recovered AN subjects, 55.6% of the weight gain was attributable to an increase in fat mass and 44.4% was attributable to an increase in lean body mass (LBM).

In contrast to studies on adults with AN, percentage extremity and trunk fat was not significantly different in adolescent AN subjects compared with controls. Thus, weight recovery resulted in a tendency toward normalization of body composition rather than the development of central adiposity. This concept is further supported by the finding that girls with the least trunk fat at baseline gained the most trunk fat over time. Regional fat distribution at baseline and changes with weight recovery are thus very different in adolescent than in adults with AN and may be related to the duration or severity of hypercortisolemia in adolescents compared with adults. These results are important in that they will allow healthcare providers to convey to adolescents with AN that weight recovery is not likely to lead to central adiposity.

If you have an eating disorder, you are very concerned about the way your body looks, and you use food to control your emotions. You want very much to be thin and are afraid of becoming fat.

Eating disorders result from a strong sense of emotional need or pain. If you have an eating disorder, you might think that you will be happy if you reach a certain weight. The most common eating disorders are anorexia nervosa and bulimia nervosa.

If you have anorexia nervosa, you are underweight but think you are overweight. You might try to lose weight by not eating much, eating only certain kinds of food, or exercising too much.

If you have bulimia nervosa, you might be normal weight or overweight but are not happy with your weight. If you have bulimia, you will eat a lot of food, then try to get rid of it by making yourself vomit or by taking water pills or laxatives. This is called binging and purging.

Why are eating disorders dangerous?

Eating disorders can cause serious medical problems, and they can even kill you. They can damage your heart, skin, muscles, teeth, and stomach. If you have an eating disorder, you might develop a condition called osteoporosis (say: oss-tee-oh-poor-oh-sis), where your bones weaken and break very easily. You might also develop a serious mental illness.

What are the symptoms of eating disorders?

If you have an eating disorder, you will probably spend a lot of time worrying about how you look. You might feel guilty when you eat or think you haven’t exercised enough. You might feel bad about yourself when you think you weigh too much. Other people might tell you that you have lost too much weight, even though you think you weigh too much.

You might feel tired. If you are a woman, you might stop having periods. Fine hair might start growing on your body. If you use water pills or laxatives to lose weight, you might get muscle cramps or have heart palpitations.

How will my doctor know if I have an eating disorder?

Your doctor will talk to you and your family. You will be asked questions about how you feel about yourself, what you eat, and how much you exercise. Your doctor will give you a physical exam and might order blood tests or other tests. If your doctor thinks you have an eating disorder, you might be referred to a specialist so you can get the treatment you need. Good nutrition and psychologic counseling can help you recover from an eating disorder.

Eating disorders are highly prevalent in the general population, certainly more so in women, appearing to peak during the childbearing years. While we tend not to see pregnant women with anorexia nervosa because they have secondary reproductive endocrine dysfunction, we do see those who have been successfully treated and are contemplating pregnancy or who are pregnant. Far more often, we see patients with bulimia or other binge-eating disorders on the less severe end of the spectrum.

There is very little information in the literature on the course of these disorders as women try to conceive or in pregnancy–and even less on the treatment of symptomatic women during pregnancy or the postpartum period.

The few data that are available include studies reported in the last several years suggesting that pregnancy is associated with improvements in eating disorders followed by postpartum exacerbation of symptoms. A limitation of these studies was that there were very few women included in the samples with active illness who were on medication.

The two drug classes used most frequently in patients with eating disorders are selective serotonin reuptake inhibitors (SSRIs), most commonly fluoxetine and sertraline, and antianxiety agents, typically lorazepam and clonazepam. In our experience, many women have a recurrence of symptoms of the eating disorder when they stop their medication while trying to conceive or while pregnant–consistent with what we see when women with mood and anxiety disorders stop their medications.

So what is the best way to manage patients? There are two avenues of treatment, group- and individual-based cognitive-behavioral therapy and pharmacologic interventions. We have found that patients who have been on pharmacologic therapy may be able to successfully switch from medication to cognitive-behavioral therapy in conjunction with state-of-the-art nutritional counseling while trying to conceive or during pregnancy.

Patients who do well using this approach are on the less severe ends of: the spectrum, for example those who engage in some binge-eating behaviors, followed by some restrictivelike behavior (calorie restriction), or who have intermittent bulimic symptoms when they experience anxiety. Cognitive-behavioral interventions can help these patients justify the need to consume calories and gain weight to sustain a healthy pregnancy

SSRI doses used to treat eating disorders are frequently higher than those used to treat depression, but the risk of adverse fetal effects, including fetal malformations, is not dose related. Patients who decide to stay on medication therefore should remain on the most effective dose, because reducing the dose increases the risk of relapse.

We frequently prescribe benzodiazepines during pregnancy and post partum in combination with antidepressants to modulate the anxiety symptoms that are frequently associated with eating disorders. A benzodiazepine can often break a cycle of behavior during pregnancy but is particularly effective during the postpartum period. A recent metaanalysis on prenatal exposure to benzodiazepines suggested that if these agents are linked to an increased risk for malformations, that risk is not for overall congenital anomalies, but only for cleft lip or palate. And this risk is less than 0.5% over the normal background risk. The risk of neonatal complications with exposure to benzodiazepines is extremely small.

Postpartum worsening of psychiatric disorders is the rule. In the postpartum period women may. demonstrate reemergence of rituals practiced before pregnancy, and comorbid depression and anxiety are common. While prophylaxis with medication is not necessarily indicated, these women should be considered at high risk for postpartum psychiatric disturbance.

Women who have been successfully treated with cognitive therapy and nutritional counseling during pregnancy may need to resume or start pharmacologic treatment. For example, it would not be unusual for a patient with mild to moderate symptoms before pregnancy, who managed well during pregnancy with cognitive interventions and nutritional counseling, to experience a reemergence of the eating disorder with major depression post partum. These patients can become ill relatively quickly so prompt reintroduction of a medication can be extremely important.

The incidence of treatment-emergent side effects in nursing babies whose mothers are taking a benzodiazepine or an SSRI is exceedingly low, and these drugs are not contraindicated during breast-feeding.