Anorexia Overview

Anorexia nervosa is an eating disorder that makes people lose more weight than is considered healthy for their age and height. Persons with this disorder may have an intense fear of weight gain, even when they are underweight. They may diet or exercise too much, or use other methods to lose weight. Reference from A.D.A.M.
ALTERNATIVE NAMES

Eating disorder - anorexia

CAUSES

The exact causes of anorexia nervosa are unknown. Many factors probably are involved. Genes and hormones may play a role. Social attitudes promoting very thin body types may also be involved. Family conflicts are no longer thought to contribute to this or other eating disorders. Risk factors for anorexia include:
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Trying to be perfect or overly focused on rules Being more worried about, or paying more attention to, weight and shape Having eating problems during infancy or early childhood Certain social or cultural ideas about health and beauty Having a negative self-image Having an anxiety disorder as a child Anorexia usually begins during the teen years or young adulthood. It is more common in females, but may also be seen in males. The disorder is seen mainly in white women who are high academic achievers and who have a goal-oriented family or personality.
SYMPTOMS

To be diagnosed with anorexia, a person must:

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Have an intense fear of gaining weight or becoming fat, even when she is underweight Refuse to keep weight at what is considered normal for her age and height (15% or more below the normal weight) Have a body image that is very distorted, be very focused on body weight or shape, and refuse to admit the seriousness of weight loss Have not had a period for three or more cycles (in women) People with anorexia may severely limit the amount of food they eat, or eat and then make themselves throw up. Other behaviors include:

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Cutting food into small pieces or moving them around the plate instead of eating Exercising all the time, even when the weather is bad, they are hurt, or their schedule is busy Going to the bathroom right after meals

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Refusing to eat around other people Using pills to make themselves urinate (water pills or diuretics), have a bowel movement (enemas and laxatives), or to decrease their appetite (diet pills) Other symptoms of anorexia may include:

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Blotchy or yellow skin that is dry and covered with fine hair Confused or slow thinking, along with poor memory or judgment Depression Dry mouth Extreme sensitivity to cold (wearing several layers of clothing to stay warm) Loss of bone strength Wasting away of muscle and loss of body fat
EXAMS AND TESTS

Other causes of weight loss or muscle wasting must be ruled out with medical testing. Examples of other conditions that can cause these symptoms include:
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Addison's disease Celiac disease Inflammatory bowel disease Tests should be done to help find the cause of weight loss, or see what damage the weight loss has caused. Many of these tests will be repeated over time to monitor the patient. These tests may include:

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Albumin Bone density test to check for thin bones (osteoporosis) CBC Electrocardiogram (ECG or EKG) Electrolytes Kidney function tests Liver function tests Total protein Thyroid function tests Urinalysis
TREATMENT

The biggest challenge in treating anorexia nervosa is making the person recognize that they have an illness. Most persons with anorexia nervosa deny that they have an eating disorder. People often enter treatment only once their condition is serious. The goals of treatment are to restore normal body weight and eating habits. A weight gain of 1 - 3 pounds per week is considered a safe goal. A number of different programs have been designed to treat anorexia. Sometimes the person can gain weight by:
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Increasing social activity

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Reducing physical activity Using schedules for eating Many patients start with a short hospital stay and continue to follow-up with a day treatment program. A longer hospital stay may be needed if:

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The person has lost a lot of weight (being below 70% of their ideal body weight for their age and height). For severe and life-threatening malnutrition, the person may need to be fed through a vein or stomach tube. Weight loss continues even with treatment Medical complications, such as heart problems, confusion, or low potassium levels develop The person has severe depression or thinks about committing suicide Care providers who are usually involved in these programs include:

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Nurse practitioners Physicians Nutritionists or dietitians Mental health care providers Treatment is often very difficult, and patients and their families must work hard. Many therapies may be tried until the patient overcomes this disorder. Patients may drop out of programs if they have unrealistic hopes of being "cured" with therapy alone. Different kinds of talk therapy are used to treat people with anorexia:

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Individual cognitive behavioral therapy, group therapy, and family therapy have all been successful. The goal of therapy is to change a patient's thoughts or behavior to encourage them to eat in a healthier way. This kind of therapy is more useful for treating younger patients who have not had anorexia for a long time. If the patient is young, therapy may involve the whole family. The family is seen as a part of the solution, instead of the cause of the eating disorder. Support groups may also be a part of treatment. In support groups, patients and families meet and share what they've been through. Medications such as antidepressants, antipsychotics, and mood stabilizers may help some anorexic patients when given as part of a complete treatment program. Examples include:

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Antidepressants Olanzapine (Zyprexa, Zydis) Selective serotonin reuptake inhibitors (SSRIs) These medicines can help treat depression or anxiety. Although these drugs may help, no medication has been proven to decrease the desire to lose weight.

SUPPORT GROUPS

See: Eating disorders - support group

OUTLOOK (PROGNOSIS)

Anorexia nervosa is a serious condition that can be deadly. By some estimates, it leads to death in 10% of cases. Experienced treatment programs can help people with the condition return to a normal weight, but it is common for the disease to return. Women who develop this eating disorder at an early age have a better chance of recovering completely. However, most people with anorexia will continue to prefer a lower body weight and be very focused on food and calories. Weight management may be hard. Long-term treatment may be needed to stay at a healthy weight.
POSSIBLE COMPLICATIONS

Complications can be severe. A hospital stay may be needed. Complications may include:
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Bloating or swelling Bone weakening Electrolyte imbalance (such as low potassium) Dangerous heart rhythms Decrease in white blood cells, which leads to increased risk of infection Severe dehydration Severe malnutrition Seizures due to fluid loss from repeated diarrhea or vomiting Thyroid gland problems, which can lead to cold intolerance and constipation Tooth decay
WHEN TO CONTACT A MEDICAL PROFESSIONAL

Talk to your doctor if a loved one is:

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Too focused on weight Over-exercising Limiting his or her food intake Very underweight Getting medical help right away can make an eating disorder less severe.
PREVENTION

In some cases, prevention may not be possible. Encouraging healthy, realistic attitudes toward weight and diet may be helpful. Sometimes, talk therapy can help.

REFERENCES

Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet. 2010; 375(7914):583-593. Attia E, Walsh BT. Behavioral management for anorexia nervosa. N Engl J Med . 2009;360:500506. Gowers SG. Management of eating disorders in children and adolescents. Arch Dis Child . 2008;93:331-334. American Psychiatric Association. Treatment of patients with eating disorders, third edition. American Psychiatric Association. Am J Psychiatry . 2006;163(7 Suppl):4-54. le Grange D, Lock J, Loeb K, Nicholls D. Academy for eating disorders position paper: The role of the family in eating disorders. Int J Eat Disord . 2009;43:1-5. Fisher Ca, Hetrick SE, Rushford N. Family therapy for anorexia nervosa. Cochrane Database Syst Rev . 2010 Apr 14; (4):CD004780.
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January 2, 2012

Protocol to Treat Anorexia Is Faulted

By RONI CARYN RABIN

When a malnourished teenager with anorexia nervosa is admitted to the hospital, weight gain is a top priority and food is medicine. But doctors mete out meals with caution, providing fewer calories than needed at first because the patients may be so frail that major swings in diet can be life-threatening. The strategy, called start low, advance slow, often results in further weight or fluid loss during the first day or two of hospitalization. Now some researchers and health providers, both in the United States and abroad, are challenging the start-low approach, suggesting that many patients could be fed more aggressively as long as they are closely monitored for medical complications. Scientific evidence in support of the start-low method has been scarce. In a study published online in The Journal of Adolescent Health in August,

researchers at the University of California, San Francisco, sought to evaluate it more closely, examining weight gain in hospitalized teenagers on a recommended refeeding protocol, in what they believe is the first study of its kind. The study, which involved 35 young people, found that 83 percent on the startlow regimen, who were fed 1,200 calories a day with increases of 200 calories every other day, lost weight. Over all, patients did not regain the newly lost weight until the sixth day in the hospital, on average. Its very upsetting to parents, said Andrea K. Garber, an associate professor of pediatrics at University of California, San Francisco and the lead author of the study. The irony is that the goal of hospitalization is to get the kids renourished, and were spending the first eight days without any weight gain. While it is not unusual for a patient with anorexia to lose weight after hospitalization, most practitioners attribute it to fluid loss, mostly water. There is a body of evidence that our older, more cautious feeding strategies are older and more cautious than they need to be, said Dr. David S. Rosen, a professor of pediatrics, internal medicine and psychiatry at the University of Michigan Medical School, who leads the American Academy of Pediatrics Committee on Adolescence. Still, he and other doctors are urging caution before making any radical changes in treatment, saying more research needs to be done. Twenty percent of the patients in the U.C.S.F. study had low blood phosphorus levels, indicating an electrolyte imbalance and a high risk of developing a potentially lethal condition called refeeding syndrome, Dr. Rosen noted. Weve proven that with the regular approach, we dont make as much progress as wed like, he said. But do we know that feeding people more aggressively is a safe thing to do? The answer is, not really. Though medical practices are far from uniform and treatment is individualized depending on the patients circumstances, a typical regimen starts young patients with meals and snacks totaling around 1,200 calories a day.

Newer regimens being evaluated and already introduced in some inpatient programs start patients with 1,900 calories a day. Within a week and a half, a patient may be consuming 3,000 or more calories a day. The danger is that these patients may experience refeeding syndrome, which can lead to numerous complications including cardiac arrhythmia and death, when trying to return to normal diets too quickly. These patients also may have developed digestive disorders like constipation, diarrhea and reflux disease. They may vomit involuntarily because the stomach and digestive capacity is diminished. And there are the psychological concerns. Starvation affects cognitive ability, experts say, and often counseling cannot be effective until weight is restored. Until then, patients with eating disorders are prone to continuing aversions to food. Think about the psychological trauma of being in a hospital and having to eat all this food, said Marjorie Nolan, a registered dietitian in Manhattan who specializes in eating disorders and a spokeswoman for the Academy of Nutrition and Dietetics. These adolescents are so young they cant process the information, and here theyve gained five pounds in a week and their biggest fear is happening: Theyre getting fat. Which we know isnt true, but thats how they see it. Ms. Nolan said one of her patients, who is now 18, was fed aggressively at age 15, and it set her recovery back in the long term. They got the weight back on her, which medically stabilized her to a degree, which was necessary, but it was so aggressive that now, several years later, shes still traumatized by it, Ms. Nolan said. One 27-year-old woman from the New York City area who was hospitalized twice, at age 18 and again at 20, said aggressive refeeding can be psychologically overwhelming and even physically painful. Your stomach shrinks when you dont eat, so it feels like Thanksgiving, every day, when you are in the hospital getting large quantities of food, said the woman, who asked that her name be withheld to maintain her privacy. Its physically difficult to walk around afterward, and its hard to keep it all down.

After having consumed so little for so long, she said, you eat a carrot, and you feel it. She said she regained a lot of weight during her first hospitalization but was so upset by the rapid gain that she promptly lost the weight as soon as she was discharged. Two years later, she was hospitalized again but remained in the hospital for a longer stay of six weeks. Current guidelines from the American Academy of Pediatrics recommend slow refeeding of malnourished children and teenagers to prevent refeeding syndrome; the Society for Adolescent Health and Medicine also recommends gradual increase of calorie intake. Yet in an editorial accompanying the new study from U.C.S.F., Dr. Debra Katzman, head of the division of adolescent medicine at the Hospital for Sick Children in Toronto, said that overzealous application of the conservative refeeding guidelines had resulted in death in some cases. In the United States, pressure to keep hospital stays short has made rapid weight gain even more urgent, because the goal is to restore as much weight as possible before discharge, she said in an interview. Experts agree that much more research is needed to develop clear, evidencebased guidelines for treatment. We dont know the best way to treat these kids, even when they wind up in the hospital, Dr. Rosen said. Its a balancing act. What you want to do is find the sweet spot between feeding people as aggressively as you can but not causing refeeding syndrome, which is a lethal, scary, dangerous disease.