Enhancing motivation for change in treatment-resistant eating disorders

It is the position of the Academy for Eating Disorders (AED) that anorexia nervosa and bulimia nervosa, along with their variants, are biologically based, serious mental illnesses (BBMI) that warrant the same level and breadth of health care coverage as conditions currently categorized in this way (e.g., schizophrenia, bipolar disorder, depression, obsessive-compulsive disorder). As set forth below, we advocate this position unequivocally based on an emerging science that affirms with a reasonable degree of medical and scientific certainty that eating disorders are significantly heritable; influenced by alterations of brain function; significantly impair cognitive function, judgment, and emotional stability; and restrict the life activities of persons afflicted with these illnesses. Accordingly, the denial or restriction of equitable and sufficient treatment necessary to avert serious health consequences and risk of death is untenable and should be vigorously protested. Commentary

Academy for eating disorders position paper: eating disorders are serious mental illnesses.

Eating disorders in adolescents: position paper of the Society for Adolescent Medicine.

Background: Approximately 0.5% to 1% of collegeaged women have anorexia nervosa and most of them live in the community. However, few clinical data exist regarding community-dwelling women with anorexia nervosa. The objective of this study was to determine the prevalences of common medical findings for these women. Methods: Cross-sectional, community-based study of 214 women with anorexia nervosa as defined by the DiagnosticandStatisticalManualofMentalDisorders,Fourth Edition (DSM-IV). Participants were recruited through advertisements and community-based referrals to a study investigating skeletal health in outpatients with anorexia nervosa. Results: The prevalences of medical findings among the 214 participants were as follows: anemia, 38.6%; leukocytopenia, 34.4%; hyponatremia, 19.7%; hypokalemia, 19.7%; bradycardia, 41.3%; hypotension, 16.1%; hypothermia, 22.4%; elevation of alanine aminotransferase concentration, 12.2%; osteopenia, 51.7%; osteoporosis, 34.6%; and primary amenorrhea, 14.8%. Moreover, 30% of the women reported histories of bone fractures. Except for leukocytopenia (P=.01), bone loss (P=.04), and bradycardia (P=.01), the probability of specific medical findings could not be predicted by the degree of undernutrition. Conclusions: These results demonstrate a high prevalence of medical findings in community-dwelling women with anorexia nervosa. Therefore, women with anorexia nervosa should be carefully followed up with regular physical examinations and laboratory assessments. In addition, low weight, particularly in conjunction with the abnormalities reported, should prompt the consideration of a diagnosis of anorexia nervosa. Arch Intern Med. 2005;165:561-566

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Medical findings in outpatients with anorexia nervosa

Anorexia nervosa (AN) is a complex and heritable eating disorder characterized by dangerously low body weight. Neither candidate gene studies nor an initial genome-wide association study (GWAS) have yielded significant and replicated results. We performed a GWAS in 2907 cases with AN from 14 countries (15 sites) and 14 860 ancestrally matched controls as part of the Genetic Consortium for AN (GCAN) and the Wellcome Trust Case Control Consortium 3 (WTCCC3). Individual association analyses were conducted in each stratum and meta-analyzed across all 15 discovery data sets. Seventy-six (72 independent) single nucleotide polymorphisms were taken forward for in silico (two data sets) or de novo (13 data sets) replication genotyping in 2677 independent AN cases and 8629 European ancestry controls along with 458 AN cases and 421 controls from Japan. The final global meta-analysis across discovery and replication data sets comprised 5551 AN cases and 21 080 controls. AN subtype analyses (1606 AN restricting; 1445 AN binge–purge) were performed. No findings reached genome-wide significance. Two intronic variants were suggestively associated: rs9839776 (P=3.01 × 10−7) in SOX2OT and rs17030795 (P=5.84 × 10−6) in PPP3CA. Two additional signals were specific to Europeans: rs1523921 (P=5.76 × 10−6) between CUL3 and FAM124B and rs1886797 (P=8.05 × 10−6) near SPATA13. Comparing discovery with replication results, 76% of the effects were in the same direction, an observation highly unlikely to be due to chance (P=4 × 10−6), strongly suggesting that true findings exist but our sample, the largest yet reported, was underpowered for their detection. The accrual of large genotyped AN case-control samples should be an immediate priority for the field.

A genome-wide association study of anorexia nervosa

Anorexia nervosa is often characterized by progressive deterioration in many different organ systems. Most medical complications are the result of starvation and can be reversed with a well-planned refeeding program. While some of the complications of anorexia nervosa are predictable physiologic adaptations to the self-imposed starvation, many others are potentially life threatening. It is therefore incumbent upon all primary care physicians to become familiar with this disorder, because it is increasing in incidence and is commonly burdened by substantial chronicity and recidivism.

Medical complications of anorexia nervosa.

To the Editor: —The article by Pearson et al., which was published in the July 1998 issue of JGIM , looked at informal or “curbside” consultation. 1 The accompanying editorial by Borowsky discussed the advantages of curbside consultation. 2 Borowsky suggested that informal consults encourage a timely response by the consultant and provide an opportunity for direct interaction between the consultant and the referring physician. In health care systems with few direct responses by consultants, primary care providers may find these advantages especially attractive. Our institution is a public hospital system in a large metropolitan area that provides care to the medically indigent; it is the only safety net in our city. The system uses multiple community sites for providing primary care and one central hospital for specialty care. In our institution, a survey found that the direct response rate by specialists to primary care providers’ written requests for consultations was 17%. The results of the survey were discussed by the physician directors in our system, who in turn discussed them with members of their departments. After these discussions, the rate was remeasured at 18.8%. Primary care providers may refer up to 20% of their patients to subspecialists. 3 Given the apparently recalcitrant nature of communication in our public hospital system, we wonder whether more informal consultations would promote more quality interaction between the patient, general internists, and specialist.— M ARTINA S CHULTE , MD, and P HILIP S. M EHLER , MD, Denver Health Medical Center, Denver, Colo. REFERENCES

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Promoting primary care-subspecialist interaction through curbside consultations.

JGIM welcomes your letters and comments. Letters may contain brief commentaries on articles published in the Journal, illustrative case reports, general suggestions for improving the Journal, or other information of interest to readers. Letters to the Editor should not exceed 450 words in length and should be sent to the Editor via e-mail at ude.imhj@migj.

Care rendered by general internists, committed to the care of HIV-infected patients, compares favorably with that given by infectious disease physicians.

Martina Schulte

Papers

Medical complications of anorexia nervosa.

Promoting primary care-subspecialist interaction through curbside consultations.

Care rendered by general internists, committed to the care of HIV-infected patients, compares favorably with that given by infectious disease physicians.