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Am Fam Physician. 1999;60(6):1814-1816

Eating disorders affect a significant number of Americans, an estimated 5 million every year. These disorders include anorexia nervosa, bulimia nervosa, binge-eating disorders and several other variants. Although these disorders are more common in adolescent girls or young women, 5 to 15 percent of cases of anorexia nervosa and bulimia nervosa and 40 percent of cases of binge-eating disorders occur in boys or men. In addition, eating disorders may occur in young children and persons over 40 years of age. Becker and colleagues reviewed the various treatment options for patients affected by eating disorders and addressed the evidence for medical and psychiatric therapies.

The primary goal of management should include stabilization of the patient's medical and nutritional status. This step involves attempts to resolve the psychosocial precipitants of the problem and to re-establish healthy eating patterns. These goals can usually be achieved with outpatient treatment. Indications for hospital-based day treatment or inpatient care include: extremely low weight (75 percent or less of expected body weight), rapid weight loss, electrolyte imbalances, cardiac disorders, other acute medical disorders, severe or intractable purging, psychosis, high risk for suicide or symptoms that are refractory to outpatient treatment.

Medical treatment of eating disorders should focus on correcting and preventing complications of abnormal weight and purging. Routine treatment should include close monitoring of weight, vital signs and electrolyte levels. Weight gain, the primary goal of treating anorexia nervosa, requires active education about limitations on exercise, as well as on caloric and nutrition intake, combined with behavior modification. The treating physician should consider collaboration with a nutritionist. Enteral or parenteral therapy is indicated for use only in patients with severe weight loss who are refractory to the methods just mentioned. In addition, electrocardiography is imperative not only in determining hypokalemia or palpitations but also for assessing the safety of any planned psychopharmacologic management.

Amenorrhea is a primary symptom in women with anorexia nervosa. Therapy for this problem is focused on improving the patient's nutritional status. Estrogen replacement is rarely indicated and has no established benefit on bone density. In addition, periodic use of progesterone is not helpful because of decreased serum estrogen levels and endometrial atrophy. However, daily supplementation with a multivitamin that contains at least 400 IU of vitamin D and 1,000 to 1,500 mg of calcium is recommended.

A variety of beneficial psychiatric treatments for eating disorders includes individual, family and group therapy. Anorexia nervosa may respond best to family therapy, but cognitive deficits because of weight loss may limit the benefit of psychotherapy in the early stages of the disorder until weight gain is established. In patients with bulimia nervosa, cognitive-behavior therapy and interpersonal, time-limited psychotherapy are equally effective in the treatment of binge-eating disorders.

Psychopharmacologic therapies are of limited benefit in patients with anorexia nervosa. However, fluoxetine therapy may stabilize a patient who has achieved 85 percent of expected body weight. Other antidepressants, along with zinc, cyproheptadine and neuroleptic drugs, have not proved effective in controlled trials. In adults with bulimia nervosa, psychopharmacotherapy is moderately effective. Fluoxetine has been widely studied; it is the most easily tolerated and currently the only drug that is labeled by the U.S. Food and Drug Administration for this indication (usual dosage is 60 mg per day). Other antidepressant agents that may be efficacious include desipramine, imipramine hydrochloride and trazodone. For binge-eating, pharmacologic therapy has not been well studied, but desipramine and fluvoxamine appear to exhibit some level of efficacy.

The general approach in patients who have been diagnosed with an eating disorder should initially include the evaluation and the treatment of medical complications. Patients should be referred for psychotherapy and nutritional counseling. As noted, pharmacologic therapy is of limited benefit and is best employed as an adjunct to psychotherapy in patients with bulimia nervosa and, perhaps, binge-eating disorder.

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