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A Review of Anorexia Nervosa in Primary Care



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Am Fam Physician. 2002 Feb 1;65(3):476-478.

Patients with anorexia nervosa, characterized by abnormal eating habits that cause weight loss, can present with symptoms that range from mild and nonspecific weakness to substantial weight loss and lack of energy. They are frequently unconcerned about their weight loss, and family members often bring them to the physician because of observed weight loss or amenorrhea. The criteria for diagnosing anorexia nervosa are defined in Table 1. Two subtypes include “restricting,” in which food intake is voluntarily limited, and “purging,” in which patients engage in purging behaviors. Mehler reviews the diagnosis and care of these patients.

The most common presentation is an adolescent or young woman with profound cachexia. Other anorexia-associated characteristics include higher socioeconomic class, participation in modeling and athletics, and type 1 diabetes. Proposed psychologic risk factors include perfectionism and overprotective parenting. Although both bulimic and anorectic patients have abnormal eating habits and often exercise excessively, bulimia can be determined by the habit of binge eating and purging (Table 2). Symptoms and signs of purging habits include reflux esophagitis, abdominal cramping, diarrhea, and rectal bleeding. Electrolyte abnormalities and metabolic alkalosis signal extreme purging habits in a bulimic patient. Patients with anorexia generally have laboratory test results within normal limits until the very late stage of the condition.

TABLE 1
Criteria for Anorexia Nervosa

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The initial course of treatment for patients with anorexia nervosa involves determining the level of treatment: outpatient, acute inpatient, or acute psychiatric. Patients with mild cases who are within 10 percent of ideal body weight and have a relatively normal body image actually have a not-otherwise-specified eating disorder rather than anorexia nervosa. These patients, and those with weight 25 to 30 percent below ideal body weight who are relatively asymptomatic and functional, can be treated as outpatients. Inpatient care becomes more appropriate in patients with greater weight loss, marked symptoms of hypotension or dizziness, or arrhythmias. Involvement of an experienced mental health professional is useful in helping patients alter the thought processes that result in abnormal behaviors. The primary care physician should monitor physical status and weight, and discourage athletic activity until relative normalization of weight is achieved.

TABLE 2
Criteria for Bulimia Nervosa

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Caloric need is calculated by identifying the target weight and adjusting the diet to gain lb (0.45 kg) per week in outpatients and to 3 lb (0.9 to 1.35 kg) per week in inpatients. After starting a low-calorie diet of 800 to1,000 kcal per day, gradual increments of 200 to 300 kcal every three to four days as tolerated are indicated until 3,000 to 3,500 kcal per day is reached. Refeeding syndrome, in which cardiovascular collapse occurs after early high caloric intake, results in phosphate depletion and is a potential complication that can be avoided by monitoring serum electrolyte levels during the early phase of treatment. Cardiac monitoring is appropriate when the heart rate falls below 40 beats per minute, but some bradycardia and hypotension are normal, energy-saving mechanisms and simply require observation. A prolonged QT interval is a marker for sudden-death risk.

Metoclopramide may relieve bloating caused by increased dietary intake. Secondary amenorrhea results from low levels of follicle-stimulating hormone and luteinizing hormone in the presence of low estrogen levels. Therapy requires nutritional improvement and weight gain. Withdrawal bleeding cannot be stimulated because of low estrogen. Menstruation will usually resume when the patient approaches 90 percent of ideal body weight. Patients can become pregnant despite amenorrhea. Osteopenia, resulting in osteoporosis, is caused by low turnover with increased bone resorption and cannot be reversed with estrogen. Calcium and vitamin D supplementation are appropriate. The utility of bisphosphonates and calcitonin is uncertain, and these agents should be reserved for use in the patient with ongoing, deteriorating bone density.

The author concludes that anorexia nervosa is a common and serious condition requiring a multidisciplinary approach to treatment. The treatment goal is to prevent continued weight loss and physical deterioration. Long-term therapy may include cognitive behavioral psychotherapy, family counseling, and judicious use of psychopharmacology.

Mehler PS. Diagnosis and care of patients with anorexia nervosa in the primary care setting. Ann Intern Med. June 5, 2001;134:1048–59.

editor's note: Determining when patients with anorexia nervosa need hospitalization is a difficult task. Pressure from third-party payers discourages hospitalization and prolonged inpatient care. In addition, the long-term benefits of inpatient care in the absence of serious metabolic or cardiac disorders is unclear. Hospital admission can be a traumatizing event for patients and subjects them to the inevitable treatment errors that occur in this setting. When patients do receive inpatient care, poor prognostic indicators such as longer duration of illness, amenorrhea for more than 2.5 years, and a body mass index of 75 percent or less than normal indicate the need to consider continuation of inpatient care to avoid relapse and a longer course of treatment. Full recovery in patients with bulimia is much higher than it is in those with anorexia nervosa. Relapse rates are approximately one third in patients with both disorders, so the caring physician must continue observation for early evidence of eating disorder relapse.—r.s.

 


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