Eating disorders in adolescents and young adults.

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 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.

Eating disorders in adolescents and young adults.

Eating disorders are relatively common and frequently result in gynecologic abnormalities. The gynecologist must appreciate the various manifestations of these complex health problems as well as the biopsychosocial approach needed to help the adolescent or young adult woman recover from these chronic conditions. By recognizing both the medical and gynecologic aspects of eating disorders, the oversimplified viewpoint of considering these conditions 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 involving the gynecologist, dietitian, and mental health provider.

Reduction mammaplasty in patients with bulimia nervosa.

Women with eating disorders have been disqualified as candidates for plastic surgery. We present a group of 6 young women with bulimia nervosa who presented with clinically symptomatic evidence of macromastia. All patients reported that dysfunctional eating habits, at least in part, where due to breast enlargement. Five patients underwent bilateral reduction mammaplasty. Patients were interviewed postoperatively and reported relief of physical symptoms and improvement in psychological well-being. Symptoms of eating disorders were completely eliminated or greatly reduced. This series has supported the contention that macromastia can produce a distortion of body image and become a secondary cause of eating disorders. Surgical correction of large breasts has improved body image, leads to the amelioration of associated eating disorders, and may in part represent a surgical treatment for a psychological abnormality. The presence of an eating disorder should not, therefore, automatically exclude a patient from surgical consideration. Routine preoperative evaluation of young women seeking plastic surgery should include a set of standard questions regarding eating behaviors.

Outcome for patients with bulimia and breast hypertrophy after reduction mammaplasty.

OBJECTIVES: To determine the outcome of patients with bulimia nervosa and symptomatic breast hypertrophy (macromastia) who had reduction mammaplasty and to identify factors that were associated with positive outcomes. DESIGN: Case series with semistructured, retrospective, personal interviews performed an average of 4 years after the procedure. SETTING: University hospital-based adolescent eating disorder program. PATIENTS: Five adolescent and young adult females who had been treated for bulimia nervosa and underwent reduction mammaplasty. OUTCOME MEASURES: Presurgical and postsurgical report of physical symptoms, body image and weight control habits, ability to exercise, psychosocial functioning and self-esteem. RESULTS: All patients experienced improvement in physical symptoms (pain and inframammary dermatitis), in their posture, and in their ability to find clothes that fit properly, to exercise, and to avoid embarrassment in social situations. Preoperative eating disorder habits were a dysfunctional attempt to achieve more "normal" body proportions; postoperatively, symptoms of an eating disorder were completely eliminated or greatly reduced. Factors related to favorable outcome included professional validation of patient's symptoms, realistic patient expectations from the surgical procedure, supportive family dynamics, and ongoing treatment for the eating disorder. CONCLUSION: This series of patients with bulimia nervosa and macromastia experienced significant improvement in symptoms related to their eating disorder and their breast hypertrophy following reduction mammaplasty.

Eating disorders among children and adolescents.

Anorexia nervosa and bulimia nervosa represent extreme manifestations of weight control patterns in adolescents. When they occur in children, they often are associated with more severe psychiatric or family dysfunction. However, rather than framing these conditions as purely psychiatric problems, it is more useful to approach them in terms of development. Then, the pediatrician can be positioned to address the various biologic, psychological, and social issues presenting in the individual. Furthermore, the pediatrician already is familiar with the principles of managing chronic illnesses, and eating disorders frequently require months to years of treatment. Finally, for each patient in a pediatrician's practice who has an eating disorder, several other patients will develop unhealthy habits with respect to eating, food choices, and weight control. By being familiar with the larger issues associated with weight loss, rather than the more narrow topic of eating disorders, the pediatrician will be able to help all patients remain healthy in a culture of thinness, regardless of their diagnosis.

Bone mineral density in adolescents.

Bone densitometry is becoming more widely available and is no longer limited to studying the elderly. Rapid, safe, and accurate methods of measuring BMD now allow serial determination of this important factor in fracture risk and will undoubtedly become even more accessible in the future. Likewise, our knowledge about the mechanisms and genetics of bone resorption and bone formation is rapidly expanding. Therefore, efforts to prevent osteoporosis in later life by maximizing peak BMD during adolescence and young adulthood must be directed at identifying young people who are at risk because of low body weight, inactivity, inadequate calcium intake, sex hormone deficiency, or because of disease or treatments associated with reduction of BMD. If BMD is found to be low, efforts to enhance bone formation (eg, weight gain, weightbearing exercise, increased calcium intake, and effective treatment of the underlying illness) should be encouraged. Antiresorptive agents, such as sex hormones, should be used cautiously, since they can have significant side effects and may not produce the expected results. Pediatricians must keep in mind the axiom: osteoporosis ... the only cure is prevention.

Heart rate power spectrum analysis of autonomic dysfunction in adolescents with anorexia nervosa.

We studied autonomic modulation of heart rate in 8 females with anorexia nervosa (AN) using power spectral analysis (PSA) of heart rate variability in the supine and standing positions at baseline and after 2 weeks of intensive nutritional rehabilitation, and compared findings with healthy female control subjects. The results indicate that there is a decrease in sympathetic modulation of heart rate, evident by a deficit of low frequency (0.01-0.15 Hz) heart rate power in the supine position in AN compared with control subjects. In addition, parasympathetic modulation of heart rate failed to decrease with standing. A trend toward improvement in autonomic control of heart rate in adolescents with AN occurs in the supine position relatively early in weight rehabilitation. PSA is a sensitive, quantitative, and noninvasive means of determining autonomic control of heart rate and could be a useful tool in monitoring the health of patients with AN.

The paradoxical effect of diet commercials on reinhibition of dietary restraint.

Although many studies have explored the mechanism by which dietary restraint becomes disinhibited, few have examined how restraint is restored or "reinhibited." Using a taste test with preload design, we showed a sad movie clip interrupted by diet-related commercials, neutral commercials, or no commercials to women with high and low restraint scores. We predicted that images of successful dieting would foster reinhibition. Results, however, revealed the opposite: high restrained eaters who viewed the diet-oriented commercials ate more than other subjects. We interpret these data as suggesting that diet-related images act as additional disinhibitors and view our results in light of research linking ego threat to dietary disinhibition (Heatherton, Herman, & Polivy, 1991).

QT prolongation by isoproterenol in anorexia nervosa.

A 17-year-old male with anorexia nervosa developed atypical prolongation of his corrected QT interval (QTc) when placed on isoproterenol for profound sinus bradycardia. His QTc normalized after the infusion was discontinued. Autonomic imbalance may explain the observed QTc lengthening. Because bradycardia associated with weight loss in anorexia is usually a physiologic adaptation and rarely symptomatic, aggressive chronotropic therapy may be not only unwarranted, but potentially deleterious.

Preliminary findings on the effects of sex hormones on bone metabolism in anorexia nervosa.

We performed tetracycline double-labeled bone biopsies and serial bone densitometry on four patients with anorexia nervosa to determine the effects of various conditions of sex hormone replacement and body weight status. We found negligible bone mineral apposition rate in two patients with anorexia nervosa who were taking estrogen and progestin pills while weighing only 79% of normal. However, bone mineral apposition rate was normal in two patients with anorexia nervosa who took no sex hormones and remained amenorrheic while weighing 87% of normal. Histomorphometric analysis revealed a decrease in intracortical trabecular area by 57% and an increase in active osteoblastic surface area by 300%, comparing the subjects who were taking hormone replacement to those who were not. There was no direct evidence of increased resorption in any subject. Six months after biopsy, the two subjects taking sex hormones decreased lumbar bone mineral density by 1.9%, while the two taking no sex hormones remained amenorrheic, but increased bone mineral density by 1.3%. Therefore, we propose that sex hormone therapy in the presence of persistently low body weight might be of limited benefit for bone mineral apposition and density.

Long-term outcome of adolescents with anorexia nervosa.

The long-term outcome of 49 adolescent girls hospitalized for the treatment of anorexia nervosa on a pediatric service was determined by personal interview an average of 80 +/- 21 months after admission to the hospital. The mean age at follow-up was 22.7 years. Between admission to the hospital and follow-up, body weight increased, on average, from 72.1% to 96.1% of ideal. Amenorrhea occurred in all subjects, but menstruation began or resumed in 80% of patients after hospitalization, at a mean body weight 90.3% +/- 6.5% of ideal. A total of 15 pregnancies resulted in 2 elective abortions, 3 ongoing pregnancies, and 10 healthy newborns. No subject who desired to become pregnant was unable to conceive. Almost half of the subjects (22 of 45) acquired binge eating patterns after hospitalization. Overall, 86% had a satisfactory outcome. These data indicated that adolescents with anorexia nervosa can be successfully treated with a developmentally oriented, multidisciplinary approach that includes inpatient and outpatient management based in pediatrics.

Menstrual cycle abnormalities and subclinical eating disorders: a preliminary report.

Menstrual dysfunction is a common concomitant of anorexia nervosa and bulimia. Initial investigations emphasized the role of weight loss and lean/fat ratio in amenorrhea. Subsequent studies suggest a more complex interaction between eating disorders and menstrual status. However, in past investigations, menstrual abnormalities have been confounded with low weight. We conducted two studies to ascertain the prevalence of menstrual abnormalities in a group of women with subclinical eating pathology versus an age-, education-, and weight-matched group of normal controls. In Study I, 93.4% of the subclinical subjects reported a history of menstrual abnormality as compared to 11.7% of the normal controls. In Study II, 100% of the subclinical subjects, versus 15.0% of the controls, reported an abnormal menstrual history. These data suggest that menstrual dysfunction often occurs in women with abnormal eating attitudes but without weight loss or diagnosable eating pathology. Several hypotheses for this finding are proposed.

Communicating with adolescents who have behavior problems.

Any clinician providing health care to adolescents needs to be able to communicate with them about behavior problems. For reasons relating both to adolescents and to health care providers, such communication is often challenging and sometimes frustrating. Nevertheless, one can develop a method of communicating with adolescents about their problems that will provide information that can be used therapeutically and will make the practice of adolescent medicine more rewarding for the professional. Numerous skills and techniques have been presented that enable the practitioner to initiate, facilitate, and encourage effective communication. These include both verbal and nonverbal methods. Methods for maintaining communication also have been discussed, since there are numerous ways in which communication with adolescents can go awry once it is established. Many health care providers already have developed other individualized skills and techniques; they are encouraged to consider adding those presented in this article. However, communication skills and techniques are useless unless they are based on an interest in the patient. As Peabody wrote almost 6 decades ago: "The secret of the care of the patient is in caring for the patient."