Cardiovascular complications of eating disorders.

Eating disorders (anorexia nervosa and bulimia) are associated with the highest mortality rate of any psychiatric disorder. Much of this mortality and morbidity stem from cardiovascular complications such as arrhythmia related to a prolonged QTc interval and/or electrolyte disorders, hypotension, and bradycardia. Structurally, the heart in patients with eating disorders is atrophic, which may relate to longstanding hypovolemia. These patients have low cardiac output and demonstrate increased peripheral vascular resistance despite the presence of hypotension. The treatment of eating disorders is incremental caloric feeding, which can have its own intrinsic cardiovascular risk (refeeding syndrome) manifested by arrhythmia, tachycardia, congestive heart failure, and sudden cardiac death. Patients will require close monitoring and slower refeedings to minimize the risk of these complications.

Twelve-year course and outcome predictors of anorexia nervosa.

OBJECTIVE: The current study presents the long-term course of anorexia nervosa (AN) over 12 years in a large sample of 103 patients diagnosed according to criteria in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). METHOD: Assessments were made at the beginning of therapy, at the end of therapy, at the 2-year follow-up, at the 6-year follow-up, and at the 12-year follow-up. Self-rating and an expert-rating interview data were obtained. RESULTS: The participation rate at the 12-year follow-up was 88% of those alive. There was substantial improvement during therapy, a moderate (in many instances nonsignificant) decline during the first 2 years posttreatment, and further improvement from 3 to 12 years posttreatment. Based on a global 12-year outcome score, 27.5% had a good outcome, 25.3% an intermediate outcome, 39.6% had a poor outcome, and 7 (7.7%) were deceased. At the 12-year follow-up 19.0% had AN, 9.5% had bulimia nervosa-purging type (BN-P), 19.0% were classified as eating disorder not otherwise specified (EDNOS). A total of 52.4% showed no major DSM-IV eating disorder and 0% had binge eating disorder (BED). Systematic-strictly empirically based-model building resulted in a parsimonious model including four predictors of unfavorable 12-year outcome explaining 45% of the variance, that is, sexual problems, impulsivity, long duration of inpatient treatment, and long duration of an eating disorder. CONCLUSION: Mortality was high and symptomatic recovery protracted. Impulsivity, symptom severity, and chronicity were the important factors for predicting the 12-year outcome.

[Eating disorders in childhood and adolescence. Anorexia nervosa, bulimia nervosa, binge eating disorder]. / Essstörungen im Kindes- und Jugendalter. Anorexia nervosa, bulimia nervosa, binge eating disorder.

The most important eating disorders are anorexia and bulimia, which most frequently occur for the first time during adolescence and continue into adulthood. Medical complications and accompanying psychological disturbances cause a significant mortality rate of up to 6% in anorexia and up to 3% in bulimia. The pathogenesis of eating disorders is still unclear. Current etiological concepts are multidimensional including biological, individual, familial, and sociocultural factors. In spite of a great variety of therapeutic possibilities, the prognosis for eating disorders is quite poor. In the long term, only about 50% of the persons affected overcome their illness. Preventive measures are therefore indispensable.

Abordaje de los trastornos de la conducta alimentaria / Approaches to eating disorders

Los trastornos de la conducta alimentaria forman un grupo de enfermedades donde se mezcla el deterioro físico y el malestar psíquico. Partiendo de esta premisa, el contexto de atención de estos trastornos debe realizarse en un espacio multidisciplinario. La atención del deterioro físico requiere una aproximación médica tanto de los problemas nutricionales como de las complicaciones físicas del síntoma. Según nuestro criterio, la especialidad de endocrinología y nutrición es la más capacitada para dar dicha respuesta. Existe una gran variabilidad en el abordaje terapéutico de los trastornos de la conducta alimentaria. No existe unanimidad sobre su génesis y, por tanto, de cómo se debe tratar estos trastornos, y existen diferentes aproximaciones terapéuticas. La orientación teórica del psicoterapeuta encargado del tratamiento es un factor muy importante. Otra diferencia sería la indicación del ingreso hospitalario; algunos grupos consideran el ingreso hospitalario como una parte del proceso terapéutico y otros (como el nuestro) optan por el seguimiento ambulatorio fundamentalmente y restringen los ingresos a los casos en que el deterioro físico lo haga imprescindible. Y por último, la forma de constituirse los equipos multidisciplinarios está sujeta a una gran variabilidad. Los datos de morbimortalidad de los diferentes estudios presentan una gran diversidad, que puede ser un reflejo de la gran variabilidad existente en el abordaje de los trastornos de la conducta alimentaria. Como conclusión habría que señalar que existen todavía muchas incógnitas en la patología de los trastornos de la conducta alimentaria y que cualquier abordaje terapéutico aplicado debe estar sometido a un continuo juicio crítico (AU)

Current challenges in recognizing and treating eating disorders.

Anorexia nervosa and bulimia nervosa are serious, life-threatening illnesses that often require several years of treatment. Although classified as mental health diagnoses, they are associated with significant medical consequences and have the highest rate of premature death of any mental health diagnosis. They also are associated with the highest rate of short- and long-term physiological complications. Eating disorders disproportionately affect young women. With early intervention and aggressive treatment, affected adolescents and young adults can recover and be free of the disorder. This article reviews the difficulties in recognizing that a patient has an eating disorder and the signs and symptoms providers should look for. It also discusses our current understanding of the causes of eating disorders as well as current treatment methods, which involve a multidisciplinary approach.

Predictors of mortality in eating disorders.

BACKGROUND: Anorexia nervosa, but not bulimia nervosa, has one of the highest mortality rates among psychiatric disorders. However, potential predictors of mortality, such as comorbid psychiatric illnesses, remain unclear. We sought to determine mortality ratios and predictors of fatal outcome in women diagnosed as having anorexia or bulimia nervosa. METHODS: Women (N = 246) diagnosed as having either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) between January 1, 1987, and December 31, 1991, participated in a prospective longitudinal study. Vital status was determined by ongoing contact and a National Death Index search as of December 1998 (overall ascertainment, 99.8%) and telephone contact as of October 2000 (ascertainment, 95.0%). RESULTS: Eleven women died. Standardized mortality ratios were elevated for all causes of mortality (11.6; 95% confidence interval, 5.5-21.3) and suicide (56.9; 95% confidence interval, 15.3-145.7) in anorexia nervosa but not for death (1.3; 95% confidence interval, 0.0-7.2) in bulimia nervosa. Predictors of mortality in anorexia nervosa included severity of alcohol use disorder during follow-up (P<.001). Hospitalization for an affective disorder before baseline assessment seemed to protect women from a fatal outcome (P<.001). CONCLUSIONS: Physicians treating patients with anorexia nervosa should carefully assess patterns of alcohol use during the course of care because one third of women who had alcoholism and died had no history of alcohol use disorder at intake.

The course and outcome of bulimia nervosa.

We reviewed the literature on the course and outcome of bulimia nervosa. Longer-term outcome is associated with a considerable degree of relapse and chronification. Diagnostic crossover to anorexia nervosa and binge eating disorder is low. Mortality in bulimia nervosa is considerably lower than in anorexia nervosa. Social adjustment and sexuality apparently normalizes in quite a few bulimic women over the course of time. A large group of bulimic patients, however, chronifies and suffers from severe bulimic symptoms and social and sexual impairment. Assessments using more systematic categories and standardized reporting procedures are required in order to make the results of studies comparable and to allow generalized conclusions.

Mortality in eating disorders: a descriptive study.

OBJECTIVE: We report rates and causes of death for a cohort of 246 eating-disordered women and provide descriptive information on their eating disorder and comorbid diagnoses. METHOD: Data on mortality were collected as part of a longitudinal study of anorexia nervosa and bulimia nervosa, now in its 11th year. Other data sources included death certificates, autopsy reports, relative interviews, and a National Death Index search. RESULTS: Seven deaths have occurred during the study, all among anorexic subjects with a history of binging and purging and with comorbid Axis I disorders. The crude mortality rate was 5.1%. The standardized mortality ratios for death (9.6) and suicide (58.1) were significantly elevated (p <. 001). CONCLUSIONS: Anorexia nervosa is associated with a substantial risk of death and suicide. Features correlated with fatal outcome are longer duration of illness, binging and purging, comorbid substance abuse, and comorbid affective disorders.

Hospital admission and mortality rates in anorexia nervosa: experience from an integrated medical-psychiatric outpatient treatment.

OBJECTIVES: To evaluate the effectiveness of an integrated medical-psychiatric treatment of major eating disorders. DESIGN: Historical cohort study. SETTING: Outpatient Unit for Protein Energy Malnutrition of the Department of Clinical and Experimental Medicine, "Federico II" University of Naples, time of study: January 1994 to December 1997 PARTICIPANTS: 147 female patients with restrictive or bulimic anorexia nervosa (mean age 19.8 +/- 13.7, BMI 14.7 +/- 2.1 Kg/m2) consecutively attending the outpatient unit between January 1994 and December 1997. MAIN OUTCOME MEASURES: Hospitalization and mortality rates were evaluated up to Jan 1999 with a minimum follow-up of 18 months. RESULTS: There were 23 admissions to the Clinical Nutrition ward for 19 patients (i.e. 12.9%) mostly due to severe protein energy malnutrition, and 2 deaths, only 1 strictly related to anorexia (mortality rate 0.7%). CONCLUSIONS: Integrated outpatient medical-psychiatric treatment for major eating disorders is an effective and inexpensive procedure that reduces mortality and admissions due to medical complications in the medium term.

"A body to die for": eating disorders and body-image distortion in women.

This article presents an overview of anorexia nervosa, bulimia, and eating disorders not otherwise specified (including binge eating disorder) and their psychological and medical complications. Also included are strategies that enhance the communication process with patients who may be in denial or reluctant to share fears and concerns. Some of the most important points for readers to keep in mind are their own hidden prejudices about size, weight and shape. The eating disorders of anorexia nervosa and bulimia have reached epidemic proportions in our population today, especially among adolescent and adult women. Often, these disorders go undiagnosed (and thus untreated) because patients rarely disclose their symptoms to their physician, therapist or dietitian.

Outcome in bulimia nervosa.

OBJECTIVE: The authors sought to synthesize existing data on outcome for individuals diagnosed with bulimia nervosa in order to better understand long-term outcome and prognostic factors. METHOD: They reviewed 88 studies that conducted follow-up assessments with bulimic subjects at least 6 months after presentation. Findings are summarized for the areas of mortality, recovery, relapse, crossover, and prognostic variables. RESULTS: The crude mortality rate due to all causes of death for subjects with bulimia nervosa in these studies was 0.3% (seven deaths among 2,194 subjects); however, ascertainment rates and follow-up periods were small and likely to produce underestimation. Five to 10 years following presentation, approximately 50% of women initially diagnosed with bulimia nervosa had fully recovered from their disorder, while nearly 20% continued to meet full criteria for bulimia nervosa. Approximately 30% of women experienced relapse into bulimic symptoms, and risk of relapse appeared to decline 4 years after presentation. Few prognostic factors have been consistently identified, but personality traits, such as impulsivity, may contribute to poorer outcome. In addition, participation in a treatment outcome study was associated with improved outcome for follow-up periods less than 5 years. CONCLUSIONS: Treatment interventions may speed eventual recovery but do not appear to alter outcome more than 5 years following presentation. Long-term outcome for women diagnosed with bulimia nervosa remains unclear. However, this disorder may be chronic for at least a subset of women.

Future directions in obesity and eating disorders.

The purpose of this article is to explore future directions in the treatment of obesity and eating disorders. After briefly reviewing the costs of eating disorders, in terms of morbidity, mortality, and economics, we provide suggestions for future research and treatment. We first focus on changes that should be considered to improve etiological and outcome research, with the idea that a better understanding of etiological factors will lead to better interventions. We then examine promising treatment approaches, public health initiatives, and the importance of focusing on health and self-acceptance as valid treatment outcomes.

Body weight in acute anorexia nervosa and at follow-up assessed with percentiles for the body mass index: implications of a low body weight at referral.

OBJECTIVE: A systematic epidemiological comparison of body weights of patients with anorexia nervosa can be enhanced by the use of age percentiles for the body mass index. METHOD: To demonstrate the feasibility of this approach, body mass indices of 81 female adolescents with anorexia nervosa were calculated from anthropometric data upon admission for inpatient treatment and at follow-up and set into relationship to the age-dependent distribution of the body mass index in a large and representative sample of the German population. The percentiles were used to visualize the weight increase over time of each former patient by aligning the body mass index at referral with the respective body mass index at follow-up. RESULTS: Upon admission most adolescents had body mass indices below the third age centile. The distribution of body mass indices at outcome suggests a continuum between death of complications related to starvation, chronic anorexia, residual anorexia, and a low body weight Patients with very low body weights at referral had a poor prognosis, because their body weights tended to remain below the minimal normal weight for height. These conditions were statistically best described by categorical analysis, because they were nonlinear to a certain extent. DISCUSSION: The results indicate that the body mass index at referral influences the amount of weight that an individual patient gains in the future.

Ten-year follow-up of anorexia nervosa: clinical course and outcome.

The clinical course and outcome of anorexia nervosa are presented in a 10-year follow-up study of 76 severely ill females with anorexia nervosa who met specific diagnostic criteria and had participated in a well-documented hospital treatment study. Information was obtained on 100% of the subjects. A comprehensive assessment was made in 93% of the living subjects in specific categories of weight, eating and weight control behaviours, menstrual function, anorexic attitudes, and psychological, sexual, social and vocational adjustment. Five subjects had died, which gives a crude mortality rate of 6.6%. Standardized mortality rates demonstrated an almost 13-fold increase in mortality in the anorexia nervosa subjects. Only eighteen (23.7%) were fully recovered. Sixty-four per cent developed binge-eating at some time during their illness, 57% at least weekly. Twenty-nine (41%) were still bulimic at follow-up. The high frequency and chronicity of the bulimic symptoms plus the high rate of weight relapse (42% during the first year after hospital treatment) suggest that intensive intervention is needed to help anorexics restore and maintain their weight within a normal range and to decrease abnormal eating and weight control behaviours.

[Severe complications and mortality in mental eating disorders in adolescence. On 99 hospitalized patients]. / Complications graves et mortalité au cours des dysorexies mentales à l'adolescence. A partir de 99 patients hospitalisés.

BACKGROUND: Subclinical medical complications frequently occur during the follow-up of anorexia nervosa and bulimia. This paper describes some of these. POPULATION AND METHODS: Charts of 99 adolescent patients (89 girls and 10 boys), aged 11.8 to 22 years (mean: 16.6 +/- 2.1 years), admitted for anorexia nervosa (N:92) or bulimia (N:7), were analyzed retrospectively. All severe or potentially severe, clinical and non-clinical, findings at admission were included in the study. RESULTS: Anorexic patients had a mean weight loss of 31.5% (22 of them were also vomiters or laxative abusers). Initial nasogastric tube feeding was necessary in 19 patients and parenteral nutrition in 2. Bradycardia and hypotension were common. A variety of ECG abnormalities were seen in 86% of the patients. Mitral valve prolapse was present in 14 of the 43 patients examined by echocardiography. Electrolyte imbalance was also common: hyponatremia in 7 patients, hypokalemia in 21, hypochloremia in 10 of the 12 vomiters, hypophosphatemia in 7, hyperazotemia in 24 and hypoglycemia in 22. Bone marrow hypoplasia was frequent, with leukopenia in 29 patients, anemia in 21 and thrombocytopenia in 5. No patient developed infectious complications. One patient presented with an acute gastric dilatation and another with spontaneous pneumomediastinum. One patient, 14 year-old, died 3 years after the onset of anorexia from acute water intoxication. CONCLUSION: These well-known complications are more common in anorexic than in bulimic patients. Their prevention requires rigorous and continuous medical supervision.