Statistics on Bodies, Weight, and Culture
One out of three women and one out of four men are on a diet at any given time.
35% of occasional dieters progress into pathological dieting.
Two out of five women and one out of five men would trade three to five years of their life to achieve their weight goals.
Diet and diet related products are a 33 billion dollar a year industry.
In 1970 the average age a girl started dieting was 14; by 1990 the average age dropped to 8.
One half of 4th grade girls are on a diet.
81% of ten-year-old girls are afraid of being fat.
51% of nine and ten-year-old girls stated they felt better about themselves when they were adhering to a diet.
While only one out of ten high school girls are overweight, nine out of ten high school juniors and seniors diet.
79% of teenage girls who vomit and 73% of teenage girls who use diet pills are frequent readers of women&rsquos health and fitness magazines. This is in contrast to less than 43% of teenage girls who do not participate in these purging methods.
Following the introduction of Western television in Fiji, there was a surge in the rate of eating disorders.
One out of every four television commercials sends out some sort of message about attractiveness.
80% of women who answered a People magazine survey responded that images of women on television and in the movies make them feel insecure.
Actresses Julia Roberts and Cameron Diaz and singer Diana Ross all meet the Body Mass Index physical criteria for Anorexia.
Model/Actress Elizabeth Hurley stated in Allure Magazine, "I've always thought Marilyn Monroe looked fabulous, but I'd kill myself if I was that fat."
Pamela Anderson is 5'7" and weights 120 pounds. She is supposed to be the voluptuous ideal yet she is 11% below ideal body weight.
In contrast, a generation ago Marilyn Monroe set the beauty standard at 5'5" and weighed 135 pounds.
In one study, three out of four women stated that they were overweight although only one out of four actually were.
Four out of five U.S. Women are dissatisfied with their appearance.
A study found that adolescent girls were more fearful of gaining weight than getting cancer, nuclear war or losing their parents.
Over one half of normal weight white adolescent girls consider themselves fat.
Following viewing images of female fashion models, seven out of ten women felt more depressed and angrier than prior to viewing the images.
When preschoolers were offered dolls identical in every respect except weight, they preferred the thin doll nine out of ten times.
A study asked children to assign attractiveness values to pictures of children with various disabilities. The participants rated the obese child less attractive than a child in a wheelchair, a child with a facial deformity, and a child with a missing limb.
A study found that women overestimate the size of their hips by 16% and their waists by 25%, yet the same women were able to correctly estimate the width of a box.
In a Glamour survey, 61% of respondents said they were ashamed of their hips, 64% were ashamed of their stomachs and 72% were ashamed of their thighs.
30% of women chose an ideal body shape that is 20% underweight and an additional 44% chose an ideal body shape 10% underweight.
50% of women wear size 14 or larger, but most standard clothing outlets cater to sizes 14 or smaller.
In 1950 mannequins closely resembled the average measurements or women. The average hip measurement of mannequins and women were 34 inches. By 1990 the average hip measurement was 37 inches, while the average mannequins hip measured only 31 inches.
If today's mannequins were actual human women, based on their theoretical body-fat percentages they would have probably ceased to menstruate.
The average U.S. woman is 5'4" and weighs 140 pounds. In contrast, the average U.S. model is 5'11" and weighs 117 pounds.
Over the last three decades fashion models, Miss America contestants, and Playboy centerfolds have grown steadily thinner, while the average woman's weight has actually risen.
Some of the pictures of the models in magazines do not really exist. The pictures are computer-modified compilations of different body parts.
A study found that 25% of Playboy centerfolds met the weight criteria for Anorexia.
Twenty years ago the average fashion model weighed 8% less than the average woman. Today she weighs 23% less.
Kate Moss is 5'7" and weights 95 pounds. That is 30% below ideal body weight.
Supermodels Niki Taylor and Elle Macpherson also meet the Body Mass Index physical criteria for Anorexia.
Gisele Bundchen was Vogue's model of the year, in part the magazine states, because she strays from the rail-thin image. Gisele is 5'11" and weighs only 115, that is 25% below her ideal body weight.
Taken from Pro-Ana Nation.
First mention about anorexia nervoza by William GullOne out of three women and one out of four men are on a diet at any given time.
35% of occasional dieters progress into pathological dieting.
Two out of five women and one out of five men would trade three to five years of their life to achieve their weight goals.
Diet and diet related products are a 33 billion dollar a year industry.
In 1970 the average age a girl started dieting was 14; by 1990 the average age dropped to 8.
One half of 4th grade girls are on a diet.
81% of ten-year-old girls are afraid of being fat.
51% of nine and ten-year-old girls stated they felt better about themselves when they were adhering to a diet.
While only one out of ten high school girls are overweight, nine out of ten high school juniors and seniors diet.
79% of teenage girls who vomit and 73% of teenage girls who use diet pills are frequent readers of women&rsquos health and fitness magazines. This is in contrast to less than 43% of teenage girls who do not participate in these purging methods.
Following the introduction of Western television in Fiji, there was a surge in the rate of eating disorders.
One out of every four television commercials sends out some sort of message about attractiveness.
80% of women who answered a People magazine survey responded that images of women on television and in the movies make them feel insecure.
Actresses Julia Roberts and Cameron Diaz and singer Diana Ross all meet the Body Mass Index physical criteria for Anorexia.
Model/Actress Elizabeth Hurley stated in Allure Magazine, "I've always thought Marilyn Monroe looked fabulous, but I'd kill myself if I was that fat."
Pamela Anderson is 5'7" and weights 120 pounds. She is supposed to be the voluptuous ideal yet she is 11% below ideal body weight.
In contrast, a generation ago Marilyn Monroe set the beauty standard at 5'5" and weighed 135 pounds.
In one study, three out of four women stated that they were overweight although only one out of four actually were.
Four out of five U.S. Women are dissatisfied with their appearance.
A study found that adolescent girls were more fearful of gaining weight than getting cancer, nuclear war or losing their parents.
Over one half of normal weight white adolescent girls consider themselves fat.
Following viewing images of female fashion models, seven out of ten women felt more depressed and angrier than prior to viewing the images.
When preschoolers were offered dolls identical in every respect except weight, they preferred the thin doll nine out of ten times.
A study asked children to assign attractiveness values to pictures of children with various disabilities. The participants rated the obese child less attractive than a child in a wheelchair, a child with a facial deformity, and a child with a missing limb.
A study found that women overestimate the size of their hips by 16% and their waists by 25%, yet the same women were able to correctly estimate the width of a box.
In a Glamour survey, 61% of respondents said they were ashamed of their hips, 64% were ashamed of their stomachs and 72% were ashamed of their thighs.
30% of women chose an ideal body shape that is 20% underweight and an additional 44% chose an ideal body shape 10% underweight.
50% of women wear size 14 or larger, but most standard clothing outlets cater to sizes 14 or smaller.
In 1950 mannequins closely resembled the average measurements or women. The average hip measurement of mannequins and women were 34 inches. By 1990 the average hip measurement was 37 inches, while the average mannequins hip measured only 31 inches.
If today's mannequins were actual human women, based on their theoretical body-fat percentages they would have probably ceased to menstruate.
The average U.S. woman is 5'4" and weighs 140 pounds. In contrast, the average U.S. model is 5'11" and weighs 117 pounds.
Over the last three decades fashion models, Miss America contestants, and Playboy centerfolds have grown steadily thinner, while the average woman's weight has actually risen.
Some of the pictures of the models in magazines do not really exist. The pictures are computer-modified compilations of different body parts.
A study found that 25% of Playboy centerfolds met the weight criteria for Anorexia.
Twenty years ago the average fashion model weighed 8% less than the average woman. Today she weighs 23% less.
Kate Moss is 5'7" and weights 95 pounds. That is 30% below ideal body weight.
Supermodels Niki Taylor and Elle Macpherson also meet the Body Mass Index physical criteria for Anorexia.
Gisele Bundchen was Vogue's model of the year, in part the magazine states, because she strays from the rail-thin image. Gisele is 5'11" and weighs only 115, that is 25% below her ideal body weight.
Taken from Pro-Ana Nation.
Sir William Withey Gull, 1st Baronet of Brook Street (31 December 1816 – 29 January 1890) was a prominent 19th century English physician and Governor of Guy's Hospital, London, who served as one of the Physicians-in-Ordinary to HM Queen Victoria. He is remembered for a number of significant contributions to medical science, including advancing the understanding of myxoedema, Bright's disease, paraplegia and anorexia nervosa(for which he first established the name).
Since the 1970s, he has been named in a number of notable works of fiction and non-fiction linking him to the Jack the Ripper case, several of which depict him as the actual perpetrator of the murders. None of these theories has been established as historical truth.
Anorexia nervosa
Miss A, pictured in 1866 aged 17 (No. 1) and in 1870 aged 21 (No. 2). From the published medical papers of Gull
In 1868, he had delivered an address to the British Medical Association at Oxford in which he referred to a peculiar form of disease occurring mostly in young women, and characterised by extreme emaciation. Gull observed that the cause of the condition could not be determined, but that cases seemed mainly to occur in young women between the ages of sixteen and twenty-three. In this address, Gull referred to the condition as Apepsia hysterica, but subsequently amended this to Anorexia hysterica and then to Anorexia nervosa.
Five years later, in 1873, Gull published his seminal work “Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica)", in which he describes the three cases of Miss A, Miss B, and a third unnamed case. In 1887, he also recorded the case of Miss K, in what was to be the last of his medical papers to be published.
Miss A was referred to Sir William Gull by her doctor, a Mr Kelson Wright, of Clapham, London on 17th January 1866. She was aged 17 and was greatly emaciated, having lost 33 pounds. Her weight at this time was 5 stones 12 pounds (82 pounds); her height was 5 ft 5 inches. Gull records that she had suffered from amenorrhoea for nearly a year, but that otherwise her physical condition was mostly normal, with healthy respiration and heart sounds and pulse; no vomiting nor diarrhoea; clean tongue and normal urine. The pulse was slightly low at between 56 and 60. The condition was that of simple starvation, with total refusal of animal food and almost total refusal of everything else.
Gull prescribed various remedies (including preparations of cinchona, biochloride of mercury, syrup of iodide of iron, syrup of phosphate of iron, citrate of quinine) and variations in diet without noticeable success. He noted occasional voracious appetite for very brief periods, but states that these were very rare and exceptional. He also records that she was frequently restless and active and notes that this was a "striking expression of the nervous state, for it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable".
In Gull's published medical papers, images of Miss A are shown that depict her appearance before and after treatment. Gull notes her aged appearance at age 17:
It will be noticeable that as she recovered she had a much younger look, corresponding indeed to her age, twenty-one; whilst the photographs, taken when she was seventeen, give her the appearance of being nearer thirty.
Miss A remained under Gull's observation from January 1866 to March 1868, by which time she seemed to have made a full recovery, having gained in weight from 82 to 128 pounds.
Miss B, pictured around 1868 aged 18 (No. 1) and 1872 (No. 2). From the published medical papers of Gull
Miss B was the second case described in detail by Gull in his Anorexia nervosa paper. She was referred to Gull on 8th October 1868, aged 18, by her family who suspected tuberculosis and wished to take her to the south of Europe for the coming winter.
Gull noted that her emaciated appearance was more extreme than normally occurs in tubercular cases. His physical examination of her chest and abdomen discovered nothing abnormal, other than a low pulse of 50, but he recorded a "peculiar restlessness" that was difficult to control. The mother advised that "She is never tired". Gull was struck by the similarity of the case to that of Miss A, even to the detail of the pulse and respiration observations.
Miss B was treated by Gull until 1872, by which time a noticeable recovery was underway and eventually complete. Gull admits in his medical papers that the medical treatment probably did not contribute much to the recovery, consisting, as in the former case, of various tonics and a nourishing diet.
Miss K was brought to Gull's attention by a Dr. Leachman, of Petersfield, in 1887. He notes the details in the last of his medical papers to be published. Miss K was aged 14 years in 1887. She was the third child in a family of six, one of whom died in infancy. Her father had died, aged 68, of pneumonic phthisis. Her mother was living and in good health; she had a sister who displayed various nervous symptoms and an eplieptic nephew. With these exceptions, no other neurotic cases were recorded in the family. Miss K, who was described as a plump, healthy girl until the beginning of 1887, began to refuse all food except half cups of tea or coffee in February that year. She was referred to Gull and began to visit him of 20 April 1887; in his notes, he remarks that she persisted in walking through the streets to his house despite being an object of attention to passers-by. He records that she displayed no sign of organic disease; her respiration was 12 to 14; her pulse was 46; and her temperature was 97º. Her urine was normal. Her weight was 4 stone 7 pounds (63 pounds) and her height was 5 feet 4 inches. Miss K expressed herself to Gull as "quite well". Gull arranged for a nurse from Guy's to supervise her diet, ordering light food every few hours. After six weeks, Dr. Leachman reported good progress and by 27 July her mother reported that her recovery was almost complete, with the nurse by this time no longer being needed.
Photographs of Miss K appear in Gull's published papers. The first is dated 21 April 1887 and shows the subject in a state of extreme emaciation. The unclothed torso and head is displayed with the ribcage and clavicle clearly visible. The second photograph is dated 14 June 1887 in a similar attitude and shows a clear recovery.
Although the cases of Miss A, Miss B and Miss K resulted in recovery, Gull states that he observed at least one fatality as a result of anorexia nervosa. He states that the post mortem revealed no physical abnormalities other than thrombosis of the femoral veins. Death appeared to have resulted from starvation alone.
Gull observed that slow pulse and respiration seemed to be common factors in all the cases he had observed. He also observed that this resulted in below-normal body temperature and proposed the application of external heat as a possible treatment. This proposal is still debated by scientists today.
Gull also recommended that food should be administered at intervals varying inversely with the periods of exhaustion and emaciation. He believed that the inclination of the patient should in no way be consulted; and that the tendency of the medical attendant indulge the patient ("Let her do as she likes. Don't force food"), particularly in the early stages of the condition, was dangerous and should be discouraged. Gull states that he formed this opinion after experience of dealing with cases of anoerexia nervosa, having previously himself been inclined to indulge patients' wishes.
Wikipedia
Anorexia Nervosa Statistics (US)
According to the first nationally representative study of eating disorders in the United States, which appeared in the February 2007 edition of Biological Psychiatry, 0.9 percent of women and 0.3 percent of men reported suffering from anorexia in their lifetime.
On average, the illness lasted 1.7 years.
Here are some anorexia nervosa statistics from various other US organisations, which were all obtained from their corresponding websites:
National Institute of Mental Health (NIMH):
Somewhere between 0.5 and 3.7 percent of females suffer from anorexia nervosa in their lifetime.
Somewhere between 0.5 and 3.7 percent of females suffer from anorexia nervosa in their lifetime.
Approximately 0.56 percent of anorexia sufferers will die each year, while 5.6 percent will die each decade.
The mortality rate among people with anorexia is 12 times higher than the mortality rate for all causes of death among females aged 15-24.
An estimated 5 to 15 percent of anorexia and bulimia sufferers are male.
Academy for Eating Disorders:
Nearly 50 percent of anorexia sufferers recover, while 33 percent show some improvement and 20 percent continue to be severely ill.
Nearly 50 percent of anorexia sufferers recover, while 33 percent show some improvement and 20 percent continue to be severely ill.
National Eating Disorders Association:
Of all the mental illnesses, anorexia has the highest mortality rate.
Of all the mental illnesses, anorexia has the highest mortality rate.
2 in 5 new cases of anorexia are in girls aged between 15 and 19 years.
The number of cases of anorexia increased significantly between 1935 and 1989, particularly in women aged 15-24.
Only one-third of people with anorexia in the community receive mental health care.
The Renfrew Center Foundation:
1 in 5 anorexia sufferers will suffer related complications such as suicide attempts and heart problems that lead to premature death.
1 in 5 anorexia sufferers will suffer related complications such as suicide attempts and heart problems that lead to premature death.
An average woman gains 25 lbs during pregnancy, while restricting anorexics gain an average of 15.8 lbs during pregnancy.
The average birth weight of babies born to purging anorexics is 4.9 lbs.
96% of professionals who deal with eating disorders believe their anorexic patients lives are put at risk because their health insurance policies authorise early release.
Source: www.disordered-eating.co.uk
Effects of Anorexia Nervosa on Clinical, Hematologic, Biochemical, and
Bone Density Parameters in Community-Dwelling Adolescent Girls
Madhusmita Misra, MD*‡; Avichal Aggarwal, MD*; Karen K. Miller, MD*; Cecilia Almazan, BS*;
Megan Worley, BA*; Leslie A. Soyka, MD§; David B. Herzog, MD; and Anne Klibanski, MD*
ABSTRACT. Objective. Anorexia nervosa (AN) is an
eating disorder that leads to a number of medical sequelae
in adult women and has a mortality rate of 5.6%
per decade; known complications include effects on hematologic,
biochemical, bone density, and body composition
parameters. Few data regarding medical and developmental
consequences of AN are available for
adolescents, in particular for an outpatient communitydwelling
population of girls who have this disorder. The
prevalence of AN is increasing in adolescents, and it is
the third most common chronic disease in adolescent
girls. Therefore, it is important to determine the medical
effects of this disorder in this young population.
Methods. We examined clinical characteristics and
performed hematologic, biochemical, hormonal, and
bone density evaluations in 60 adolescent girls with AN
(mean age: 15.8 1.6 years) and 58 healthy adolescent
girls (mean age: 15.2 1.8 years) of comparable maturity.
Nutritional and pubertal status; vital signs; a complete
blood count; potassium levels; hormonal profiles; bone
density at the lumbar and lateral spine; total body, hip,
and femoral neck (by dual-energy x-ray absorptiometry)
and body composition (by dual-energy x-ray absorptiometry)
were determined.
Results. All measures of nutritional status such as
weight, percentage of ideal body weight, body mass index,
lean body mass, fat mass, and percentage of fat mass
were significantly lower in girls with AN than in control
subjects. Girls with AN had significantly lower heart
rates, lower systolic blood pressure, and lower body temperature
compared with control subjects. Total red cell
and white cell counts were lower in AN than in control
subjects. Among girls with AN, 22% were anemic and
22% were leukopenic. None were hypokalemic. Mean
age at menarche did not differ between the groups. However,
the proportion of girls who had AN and were premenarchal
was significantly higher compared with
healthy control subjects who were premenarchal, despite
comparable maturity as determined by bone age. Ninetyfour
percent of premenarchal girls with AN versus 28%
of premenarchal control subjects were above the mean
age at menarche for white girls, and 35% of premenarchal
AN girls versus 0% of healthy adolescents were delayed
>2 SD above the mean. The ratio of bone age to chronological
age, a measure of delayed maturity, was significantly
lower in girls with AN versus control subjects and
correlated positively with duration of illness and markers
of nutritional status. Serum estradiol values were
lower in girls with AN than in control subjects, and
luteinizing hormone values trended lower in AN. Levels
of insulin-like growth factor-I were also significantly
lower in girls with AN. Estradiol values correlated positively
with insulin-like growth factor-I, a measure of
nutritional status essential for growth (r 0.28). All
measures of bone mineral density (z scores) were lower
in girls with AN than in control subjects, with lean body
mass, body mass index, and age at menarche emerging as
the most important predictors of bone density. Bone density
z scores of <1 at any one site were noted in 41% of
girls with AN, and an additional 11% had bone density z
scores of <2.
Conclusions. A high prevalence of hemodynamic, hematologic,
endocrine, and bone density abnormalities are
reported in this large group of community-dwelling adolescent
girls with AN. Although a number of these
consequences of AN are known to occur in hospitalized
adolescents, the occurrence of these findings, including
significant bradycardia, low blood pressure, and pubertal
delay, in girls who are treated for AN on an outpatient
basis is of concern and suggests the need for vigilant
clinical monitoring, including that of endocrine and bone
density parameters. Pediatrics 2004;114:1574–1583; adolescent
health, anorexia nervosa, blood, bone mineral density,
cardiovascular.
ABBREVIATIONS. AN, anorexia nervosa; GH, growth hormone;
LH, luteinizing hormone; BMI, body mass index; UFC, urinary
free cortisol; CBC, complete blood count; IGF-I, insulin-like
growth factor-I; DXA, dual-energy x-ray absorptiometry; BMAD,
bone mineral apparent density; BA/CA, ratio of bone age to
chronological age; MCV, mean corpuscular volume; RBC, red
blood cell; WBC, white blood cell; SA, surface area; LBMD, lumbar
spine bone mineral density; LBMAD, lumbar spine bone mineral
apparent density.
Anorexia nervosa (AN) is a potentially lifethreatening
eating disorder characterized by
an intense fear of gaining weight, a distorted
body image, and amenorrhea. It affects 0.2% to 4%
of all adolescent girls in the United States,1,2 and its
incidence has increased at an alarming rate over the
past few decades.3 AN represents the third most
common chronic illness among adolescent girls,1 and
the true prevalence may be even higher because it
goes undiagnosed in up to 50% of cases. The onset is
most frequent during the adolescent years 4 a
period during which the majority of physical and
psychosocial growth occurs. Critical hormonal and
growth-related changes (both statural and organ related)
occur during this period, and deprivation of
substrates that are essential for growth and development
can hinder these physiologic processes.
AN is associated with a mortality rate of 5.6% per
decade in adults,5 the highest among all psychiatric
illnesses.6 Suicide and cardiovascular events are important
causes of death in this disorder. Some deaths
are of unclear cause and may be attributable to other
medical complications.5,7 In addition to these serious
complications of AN contributing to the mortality
associated with this disorder, other significant
changes have been reported in hemodynamic, hematologic,
and bone metabolism parameters in adults
with AN.8–14 Although not life-threatening, these
complications can be disabling and contribute to the
morbidity of this disorder. Many of these complications
result from physiologic adaptation to self-imposed
starvation and malnourishment, and a large
number are reversible with refeeding, at least in
adults.15,16
Several groups have examined and reviewed medical
complications of AN in adults.8–14 However,
data derived from adults cannot be extrapolated to
adolescents with this disorder, adolescence being a
time when critical changes are occurring in the hormonal
milieu and in growth, very different from
adult life, when pubertal development and growth
are complete. The data that are currently available
regarding the prevalence of medical complications in
adolescent girls who have AN are primarily from
hospitalized patients with this disorder17,18 and from
retrospective chart reviews.19–21 Warren and Vande
Wiele22 examined 42 hospitalized girls and young
women with AN and reported a 26% prevalence of
bradycardia, 86% prevalence of hypotension, 64%
prevalence of hypothermia, 38% prevalence of leukopenia,
and 7% prevalence of anemia in a 1973
study without matched healthy control subjects.
Shamim et al20 recently reported normalization of
orthostatic pulse changes after nutritional rehabilitation
in hospitalized adolescents with AN. All medical
consequences of AN may not be completely reversible
in adolescents, especially changes that
pertain to growth, pubertal development, and attainment
of peak bone mass.23–25
Because AN is increasing in prevalence in adolescents
and because many of these patients are now
being followed as outpatients, it is important to investigate
the prevalence of medical complications in
community-dwelling adolescents with AN and to
determine the predictors of these medical complications.
This will allow effective and timely intervention
and help to reduce the morbidity associated
with this eating disorder. The most comprehensive
data on medical complications in ambulatory AN
adolescents are from a 1988 chart review by Palla and
Litt,19 which did not include a healthy control population.
The authors reported a high prevalence of
bradycardia (94%), hypotension (70%), hypothermia
(100%), anemia (32%), and neutropenia (38%) in girls
with AN. In a small study of 10 girls, Lambert et al26
reported lower leukocyte and platelet counts in girls
with AN than in control subjects. There has been a
growing awareness of the prevalence of AN in adolescence
over the past decade, and monitoring of this
condition is usually intensive. It is important to determine
whether increased monitoring of adolescents
who have this eating disorder has resulted in a decrease
in the prevalence of these complications. In
this cross-sectional study, we investigated the prevalence
of medical complications in a large community-
dwelling group of adolescent girls who had AN
and were receiving multidisciplinary outpatient care
at the time of the study as compared with healthy
adolescents of comparable maturity, and we also
determined demographic and body composition predictors
of these complications in the subjects studied.
METHODS
Subject Selection and Enrollment
We studied 118 adolescent girls, 60 with AN diagnosed by
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
criteria and 58 healthy control subjects, at Massachusetts General
Hospital. A subset of data regarding bone metabolism and hormonal
parameters were reported earlier for 18 AN and 15 healthy
subjects in the study by Soyka et al27 and for another 19 AN and
20 healthy subjects in the study by Misra et al.28 Primary endpoints
for the 2 studies were, respectively, bone density and
growth hormone (GH) secretory dynamics in AN compared with
healthy adolescents and hemodynamic, hematologic, and biochemical
parameters were secondary endpoints. Clinical data collected
at the baseline visit of subjects from both studies were
examined to determine the prevalence of medical complications in
this population. We also reviewed unpublished data from 23 girls
with AN and 23 healthy control subjects. Girls with AN were
recruited consecutively at Massachusetts General Hospital
through referrals from primary care providers, nutritionists, psychiatrists,
and therapists and also from day-treatment eating disorder
programs in and around Boston. A diverse referral group
better represents community-dwelling girls with AN and precludes
selection bias that may occur if all subjects are enrolled
from a single center.
All subjects were white and were in the age range of 12.0 to 18.8
years. The duration of amenorrhea in girls with AN ranged from
3 to 36 months, and the time since diagnosis ranged from 1 to 48
months. None of the girls were on any hormonal medications.
There was no past or present history of eating disorders in the
healthy control subjects. All girls with AN were receiving integrated
multidisciplinary outpatient therapy at the time of the
study. No subject had been hospitalized within 3 months of study
initiation. Given the labile nature of this disorder with frequent
hospitalizations in sicker patients, a period of 3 months or more
without hospitalization was considered a sufficient period to define
a community-dwelling population. Our Institutional Review
Board approved all studies, and written informed assent and
consent were obtained from all subjects and their parents.
Study Procedures
Eligibility for participation in the study was determined during
an initial screening visit at Massachusetts General Hospital, which
included a history, physical examination, and screening laboratory
tests. Blood was drawn for thyroid-stimulating hormone in
all subjects. Follicle-stimulating hormone, luteinizing hormone
(LH), hematocrit, potassium, and glucose were recorded in subjects
who participated in the study by Misra et al,28 but these data
have not been previously reported. When the values of the above
tests were within the normal accepted range and the subjects
fulfilled diagnostic criteria for AN (Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition) and had not received any
medications affecting bone metabolism within 3 months of the
study, they were considered eligible for this study. A few girls
with AN and a body mass index (BMI) 17.5 k/m2 were included
ARTICLES 1575
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in the study because they were tall with heights greater than the
95th percentile for age and weights at approximately the 50th
percentile (with percentage of ideal body weight for height
85%). They fit other criteria for AN, including having the body
image issues and amenorrhea for 3 months or greater. Hormonal,
nutritional, and bone metabolism parameters were assessed.
Eligible subjects were evaluated at the General Clinical Research
Center of Massachusetts General Hospital. Height and
weight were measured. BMI was calculated, and BMI percentiles
were determined from published charts.29 Hemodynamic parameters,
including heart rate, blood pressure, and temperature, were
measured. A 24-hour urine sample was collected for urinary free
cortisol (UFC), calcium, and creatinine. A complete blood count
(CBC) and a fasting blood sample for insulin-like growth factor-I
(IGF-I) and estradiol were obtained. Not all subjects had every
endpoint measured. Bone density, bone age, and body composition
were assessed in 44 girls with AN and 48 healthy adolescents.
Anthropometric Measurements
Weight was measured on an electronic scale with the patient
wearing a hospital gown, and a single stadiometer was used to
measure height. Height was measured in triplicate, and an average
of three readings was used. Tanner breast and pubic hair
staging was conducted in all subjects. However, breast staging
may be unreliable to assess pubertal stage in girls with AN as
excessive weight loss and low estrogen levels can result in breast
atrophy. Therefore, bone age was obtained from an radiograph of
the left hand and wrist using the methods of Greulich and Pyle.30
Subjects were classified as immature when bone age (BA) was 15
years and mature when BA was 15 years. BMI [weight in kg/
(height in m)2] percentiles were calculated using published
charts.29
Hematologic Parameters and Biochemical Assessment
CBC was determined by the hospital laboratory. Measurements
of serum ionized calcium, phosphorus, thyroid-stimulating hormone,
LH, follicle-stimulating hormone, potassium, prolactin and
glucose, and urine creatinine were performed through the hospital
laboratory using published methods.31
UFC was measured by the Gammacoat I125 radioimmunoassay
(Diasorin Inc, Stillwater, MN; detection limit: 1 g/dl; coefficient
of variation: 7.0%) using the extraction method. The concentration
of free cortisol in the 24-hour urine sample was multiplied by the
total volume over 24 hours to obtain the value for UFC in g/day.
Radioimmunoassay was used to measure estradiol (Diagnostic
Systems Laboratories, Inc, Webster, TX; limit of detection: 2.2
pg/ml; coefficient of variation: 6.5%–8.9%). An IRMA (Nichols
Institute Diagnostics, San Juan Capistrano, CA) with a detection
limit of 30 g/L and a coefficient of variation of 3.1% to 4.6% was
used to measure serum IGF-1.
Bone Density and Body Composition
Total body and anteroposterior lumbar spine (L1–L4) bone
densities were measured by dual-energy x-ray absorptiometry
(DXA; QDR-4500; Hologic Inc, Waltham, MA). The SD for bone
density measurement is 0.01 g/cm2 and does not vary with bone
density. Bone density at the hip was also measured for 24 healthy
control subjects and 25 girls with AN using a QDR-4500. An
estimate of volumetric bone density, ie, bone mineral apparent
density (BMAD), was calculated using formulas described by
Katzman et al,32 as BMAD is a better measure of bone density in
a group that is not matched for height. A whole-body DXA scan
was performed to determine the body composition comprising
validated measures of fat mass and lean body mass.33–36 Percentage
of body fat was also determined using bioimpedance analysis.
37
Statistical Analysis
The JMP program (JMP Statistical Data Software; SAS Institute,
Inc, Cary, NC) was used for statistical analysis. Anthropometric,
bone density, body composition, and biochemical data were analyzed
using the t test. The significance was set at P .05 for all
comparisons. Univariate regression analysis was used to determine
the correlations between variables being tested. Stepwise
regression analysis was used to determine significant predictors of
bone density. All results are expressed as mean SD.
RESULTS
Clinical and Anthropometric Characteristics
Clinical and anthropometric data are shown in
Table 1. Mean duration since diagnosis of AN was
10.5 10.4 months, and the duration of amenorrhea
was 10.8 9.8 months. Chronological age, bone age,
and Tanner stage did not differ between the groups.
However, the ratio of bone age and chronological age
was significantly lower in girls with AN than in
healthy adolescents, suggestive of a delay in pubertal
maturation. Girls with AN were taller than healthy
control subjects in this particular group. Midparental
height did not differ between the 2 groups.
BMI and weight were lower in girls with AN than
in control subjects, as expected. In the AN group,
total fat mass measured by DXA was significantly
lower (50%) than in healthy control subjects, and
lean mass was also lower. Percentage of body fat
(measured by DXA) was substantially reduced in
girls with AN. Percentage of trunk fat was significantly
lower in girls with AN (32.4 5.1% vs 37.9
5.1%; P .0001), whereas percentage of extremity fat
was comparable in the 2 groups. Ratio of trunk to
extremity fat was lower in AN than in healthy adolescents
(0.57 0.13 vs 0.67 0.14; P .0008). The
duration of illness was found to correlate inversely
with BMI (r0.40, P .0001), lean body mass (r
0.30, P .004), total fat mass (r0.40, P .0001),
and 8% body fat (r 0.38, P .0002).
Sixty-four percent of girls with AN had been hospitalized
for treatment of eating disorders 3 months
or more before study entry. Thirty-two percent of
girls with AN and 26% of control subjects had sustained
fractures during childhood or adolescence. No
specific type of fracture was prevalent in either
group.
Medication use is shown in Table 2. Sixty-two
percent of patients with AN reported use of at least
1 psychiatric medication, and 14% reported use of 2
or more psychiatric medications at the time of the
visit. Fifty-two percent reported taking antidepressants,
4% were on anxiolytics, and 6% of patients
reported use of antipsychotics. Forty percent of the
girls with AN were regularly taking multivitamins as
compared with 4% of control subjects, and 20% of
girls with AN reported taking regular calcium supplements
compared with 2% of healthy control
subjects. In addition, 12% of girls with AN were
taking antireflux, gastrointestinal motility, or stoolsoftening
medications.
Menstrual Function
The mean duration since the last menstrual period
was 11 months (Table 1), with a range of 3 to 36
months. The duration of amenorrhea correlated with
the duration of illness (r 0.51, P .001). Mean age
at menarche did not differ between the groups (Table
1). However, 28% of girls with AN were premenarchal
as opposed to 11% of control subjects (P .02).
All premenarchal controls were 13.2 years of age.
Of the girls who had AN and had not attained menarche,
94% were above the mean age at menarche
(12.8 years) for white girls in the United States,38 and
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35% were delayed 2 SD (ie, 15.3 years). Conversely,
only 28% of premenarchal healthy subjects
were older than 12.8 years, and none was older than
15.3 years. Of girls who had AN and had attained
menarche, 32% had menarche at an age greater than
the mean age of menarche. Primary amenorrhea was
noted in 3 girls with AN. The ratio of bone age to
chronological age (BA/CA) correlated inversely with
duration of illness and positively with markers of
nutritional status (BMI, lean and fat mass, percent
body fat; Table 3).
Hemodynamic Status
Vital signs are detailed in Table 4. Mean heart rate
in girls with AN was significantly lower than in
control subjects. There was a wide range of heart rate
(40–88 bpm) in girls with AN, with 27% having a
heart rate 56 bpm (ie, mean 2 SD for control
subjects). Patients with bradycardia (n 12) did not
differ from patients whose heart rate was at least 56
bpm (n 33) when BMI and duration of illness were
compared but did have significantly lower percentage
of body fat (13.3 3.8% vs 20.0 4.5%; P .002)
and total fat mass (5.8 2.2 vs 9.6 3.1 kg; P .009).
Overall, heart rate correlated positively with BMI, fat
mass, and percentage of body fat and inversely with
duration of illness (Table 3). Nine percent of girls
with AN had a heart rate of 46 bpm (ie, mean 3
SD for control subjects).
Mean systolic pressure was lower and diastolic
blood pressure trended lower in girls with AN. Diastolic
blood pressure was as low as 46 mm Hg in
this group, and mean pulse pressure trended lower.
Systolic pressure correlated inversely with duration
of illness, and both systolic and diastolic pressures
TABLE 1. Clinical and Anthropometric Data in Girls With AN and Control Subjects
Controls
(n 58)
AN
(n 60)
P Value
Chronological age, y 15.2 1.8 15.8 1.6 NS
Bone age, y 15.7 1.7 15.7 1.5 NS
Weight, kg 56.5 11.1 46.4 5.9 .0001
Height, cm 161.1 7.6 163.9 6.2 .03
BMI, kg/m2 21.8 3.6 16.6 1.4 .0001
Fat mass, kg 18.5 5.9 8.8 3.0 .0001
% body fat 31.2 6.0 18.5 5.1 .0001
Lean body mass, kg 38.0 5.9 35.8 4.4 .05
Maturity, bone age 15 y 70.8% 71.7% NS
BA/CA 1.03 0.05 0.98 0.06 .0001
Tanner stage, pubic hair 4.1 0.8 4.1 0.7 NS
Tanner stage, breasts 4.3 0.9 4.1 0.9 NS
Age at menarche, y 12.2 1.0 12.4 1.4 NS
Premenarchal 10.6% 28.3% .02
Duration of illness, mo N/A 10.5 10.4
Duration of amenorrhea, mo* N/A 10.8 9.8
History of fractures 25.5% 31.5% NS
Body composition data were available for 46 healthy control subjects and 45 girls with AN. NS
indicates not significant.
* Of the 60 girls with AN, 43 were postmenarchal and had secondary amenorrhea at the time of the
study.
TABLE 2. Medication Use in 48 Subjects With AN
Medication % of Patients
Psychiatric medications 62.0
Antidepressants 52.0
Anxiolytics 4.0
Antipsychotics 6.0
Two or more psychiatric medications 14.0
Multivitamins 40.0
Calcium supplements 20.0
Antireflux/gastrointestinal
motility/stool softeners
12.0
TABLE 3. Correlation Coefficient (r) Between Duration of Illness and Markers of Nutritional Status Versus Maturity, Hemodynamic,
Hematologic, and Biochemical Endpoints
Duration of Illness BMI Lean Body Mass Fat Mass % Body Fat
BA/CA 0.25* 0.37§ 0.25† 0.44§ 0.39‡
Heart rate 0.29* 0.21† NS 0.30* 0.35*
Systolic blood pressure 0.23† 0.47§ 0.33* 0.55§ 0.44‡
Diastolic blood pressure NS 0.32* NS 0.48§ 0.39*
Pulse pressure NS 0.26* NS 0.24† NS
Total RBC NS 0.24† NS NS NS
MCV NS 0.26† NS NS NS
MCH NS 0.34* NS NS NS
Total WBC 0.41‡ NS NS NS NS
Platelet count 0.26† NS NS NS NS
UFC/cr.SA 0.25† 0.24† NS 0.22† 0.29*
Estradiol NS 0.29* NS 0.25† 0.23†
IGF-I 0.48§ 0.47§ NS 0.47§ 0.50§
NS indicates not significant; MCH, mean corpuscular hemoglobin.
* P .01; † P .05; ‡ P .001; § P .0001.
correlated positively with markers of nutritional status
(Table 3). Pulse pressure was predicted by BMI
and fat mass. On stepwise regression analysis when
BMI, duration of illness, fat mass, and lean mass
were entered into the model, fat mass emerged as the
single significant predictor of heart rate, systolic and
diastolic blood pressures, and pulse pressure, contributing
to 15%, 33%, 22%, and 10% of the variability,
respectively. Girls with AN had a lower mean
oral temperature than healthy control subjects. An
inverse correlation was noted between temperature
and mean corpuscular volume (MCV; r0.38, P
.006).
Hematologic Status
Table 5 shows the mean values of different hematologic
parameters in girls with AN and control subjects.
Twenty-two percent of girls with AN had anemia
(hematocrit 37%). When subjects who had AN
and anemia (n 8) were compared with those without
anemia (n 28), BMI (17.2 1.8 vs 17.0 1.1
kg/m2; not significant) did not differ between the
groups. Duration of illness, fat mass, and lean mass
also did not differ. No correlations were observed
between hematocrit and measures of nutritional status
or duration of illness. Total red blood cell (RBC)
count, however, was significantly lower in girls with
AN than in control subjects and was predicted by
BMI (Table 3). Thirty-one percent of girls with AN
had total RBC counts below normal. MCV was normal
in all subjects but was significantly higher in
girls with AN when compared with control subjects.
An inverse correlation was observed between MCV
and BMI. Mean corpuscular hemoglobin was also
higher in girls with AN than in control subjects and
correlated inversely with BMI. Forty percent of the
girls were on multivitamins with variable amounts
of iron in the preparations being taken. However,
none of the girls were on iron-only pills.
White blood cell (WBC) count in girls with AN
was lower than in control subjects. Twenty-two percent
of girls with AN had leukocyte counts below
normal (normal range: 4.5–13 th/mm3). BMI did not
differ in girls who had AN and leukopenia (n 8)
versus those with WBC count in the normal range
(n 28; 16.6 1.4 vs 17.2 1.3 kg/m2; not significant).
However, there was an inverse correlation between
WBC count and duration of illness. Platelet
counts did not differ but were predicted by the duration
of illness.
Biochemical Data
Biochemical data are shown in Table 6. Mean serum
potassium was slightly higher in the group with
AN, possibly because of dehydration (3.8 0.3 vs 3.6
0.2 mmol/L). No subject was hypokalemic (potassium
3.0 mmol/L), which may be attributed to the
fact that only 2 girls with AN reported a history of
regular purging. Levels of ionized calcium and phosphorus
were not different in the 2 groups. Calcium
excretion in the 24-hour urine sample was found to
be normal in all but 2 subjects. Of these 2 subjects, 1
was on a calcium supplement.
UFC standardized for creatinine and for surface
area (SA) and creatinine39 was significantly higher in
girls with AN than in control subjects. Of girls with
AN, 12.5% (5 of 40) had mildly elevated UFC (range:
72–115 g/day). Five girls with AN had values of
UFC/cr.SA that were elevated above 0.07 g/mg
creatinine per m2 (mean 2 SD for control subjects).
UFC/cr.SA correlated positively with duration of
illness and duration of amenorrhea and inversely
with BMI, fat mass, and lean body mass (Table 3). A
strong positive correlation was observed between
24-hour creatinine levels and total lean mass (r
0.53, P .0001).
Serum estradiol concentrations were significantly
lower in girls with AN compared with control subjects,
whereas LH values trended lower in this group
All subjects were sampled in the early follicular
phase of menstrual cycle to avoid variation in estradiol
levels across a menstrual cycle. Serum estradiol
correlated positively with BMI, fat mass, and per-
TABLE 4. Vital Signs in Girls With AN and Healthy Adolescents
Controls
(n 47)
AN
(n 44)
P Value
Heart rate, bpm 76 10 66 14 .0004
Blood pressure, mm Hg
Systolic 105 11 99 9 .005
Diastolic 66 8 63 9 .07
Pulse pressure, mm Hg 38 8 35 8 .09
Temperature, °F 98.1 0.7 97.7 0.5 .01
TABLE 5. Hematologic Parameters in Girls With AN and
Control Subjects
Controls
(n 33)
AN
(n 36)
P Value
Hematocrit, % 38.2 2.5 37.4 2.4 NS
RBC, 106/mm3 4.5 0.3 4.3 0.3 .001
MCV, fl 84.7 4.6 88.2 3.5 .0007
MCH, pg/rbc 29.1 1.7 30.6 1.4 .0003
MCHC, g/dl 34.4 1.0 34.7 1.0 NS
WBC, 103/mm3 7.4 1.9 5.4 1.1 .0001
Platelet count, 103/ mm3 262 66 244 47 NS
MCHC indicates mean corpuscular hemoglobin concentration.
TABLE 6. Biochemical Data in Girls With AN and Control
Subjects
Controls
(n 45)
AN
(n 39)
P Value
TSH, U/ml 1.7 0.8 1.8 0.9 NS
UFC, g/day 40.6 24.6 39.2 24.3 NS
Creatinine-24 h, mg 968 386 680 291 .0002
UFC/cr, g/mg cr 0.05 0.03 0.06 0.04 .04
UFC/cr.SA, g/mg
cr per m2
0.03 0.02 0.04 0.03 .007
Estradiol, pg/ml 20.1 6.9 16.4 6.2 .01
FSH, U/L* 4.7 2.1 5.3 2.1 NS
LH, U/L* 6.6 7.0 3.8 3.8 .07
Prolactin, ng/ml* 9.0 4.2 7.7 5.0 NS
IGF-1, ng/ml 505 128 315 127 .0001
cr indicates creatinine; TSH, thyroid-stimulating hormone; FSH,
follicle-stimulating hormone.
* Performed in a subset of 32 healthy control subjects and 27 girls
with AN.
centage of body fat (Table 3) and predicted BA/CA (r
0.25, P .03).
Mean serum IGF-1 levels were significantly lower
in girls with AN than in control subjects and were
reduced by 38% in girls with AN. An inverse correlation
was observed between IGF-I and duration of
illness, and a positive correlation was observed with
BMI, fat mass, and percentage of body fat (Table 3).
A positive correlation also existed between IGF-I and
estradiol (r 0.28, P .02) and between IGF-I and
the ratio of BA/CA (r 0.38, P .001). On stepwise
regression including BMI, fat mass, and duration of
illness, the most significant predictors of IGF-I levels
were fat mass and duration of illness, contributing to
32% and 8% of the variability, respectively.
Bone Density
Figure 1 exhibits bone density z scores in girls with
AN versus control subjects. Table 7 shows the proportion
of girls with AN and control subjects who
had z scores 1 or 2 at the different sites examined.
Our results clearly demonstrate significant
bone loss in a large number of girls with AN, primarily
at the lumbar spine. Lumbar spine bone mineral
density (LBMD) z scores and lumbar spine
BMAD (LBMAD) z scores were significantly lower in
girls with AN than in control subjects. Forty-one
percent of girls with AN had z scores of 1, and 9%
had z scores of 2 at the lumbar spine. When
LBMAD z scores were examined, 39% of girls with
AN had z scores of less than 1, and 54% had z
scores of 2. Bone density at the lateral spine was
significantly lower in girls with AN than in control
subjects (0.71 0.10 vs 0.78 0.09; P .0009). Hip
and femoral neck BMD z scores were also significantly
lower in girls with AN. Z scores of 1 at the
hip and at the femoral neck were noted in 30% and
20% of girls with AN. Z scores of between 1 and 2
at any site were noted in 41% of girls with AN and in
23% of control subjects, whereas z scores of 2
were noted in 11% of girls with AN and in 2% of
control subjects (P .03).
Weight, lean body mass, and fat mass correlated
positively with BMD at all skeletal sites in our subjects,
whereas an inverse correlation was noted between
age at menarche and BMD (Table 8). In addition,
BMI correlated positively with LBMD (r 0.49,
P .0001), LBMAD (r 0.48, P .0001), lateral BMD
(r 0.52, P .0001), hip BMD (r 0.45, P .002),
femoral neck BMD (r 0.50, P .0007), and total
body BMD (r 0.39, P .0001). On multiple regression
analysis when BMI, total fat mass, lean body
mass, duration of illness, and age at menarche were
entered into the model, lean body mass was the
single most significant predictor of BMD at most
sites, contributing to 28%, 34%, 43%, and 23% of the
variability at the lumbar spine, hip, femoral neck,
and total body BMD, respectively. BMI was the most
significant predictor of BMD at lateral spine, contributing
to 24% of the variability. Age at menarche
contributed to an additional 7%, 10%, and 5% of the
variability of BMD at the lateral spine, hip, and total
body, respectively. Similarly, lean body mass contributed
to 22%, 29%, 31%, and 19% of the variability
of the z scores at the lumbar spine, hip, femoral neck,
and total body, respectively, whereas age at menarche
contributed another 8% and 10% to the variability
of LBMD and total body BMD z scores. Another
7% of the variability of LBMD z scores was
attributable to the duration of illness.
DISCUSSION
AN is a potentially fatal disorder that commonly
affects adolescent girls, and its incidence is increasing.
We previously reported abnormalities in bone
metabolism25,27 and GH alterations in adolescent
girls with AN.28 Here we evaluate the overall prevalence
of hematologic, hemodynamic, endocrine,
and skeletal abnormalities in a large group of community-
dwelling subjects.
Twenty-seven percent of our patients had bradycardia,
with heart rate as low as 40 bpm, and the
severity of bradycardia was predicted by the duration
of illness and nutritional status. In addition, both
systolic and diastolic blood pressures were found to
be significantly lower in girls with AN than in
healthy control subjects and were also predicted by
length of illness and nutritional status. Fat mass was
the most significant predictor of all hemodynamic
parameters. In a previous study, we reported that fat
Fig 1. Z scores for lumbar spine, hip, and femoral neck BMD in
girls with AN (■) and healthy control subjects (). Girls with AN
had significantly lower z scores at each site than healthy adolescents.
*P .01; **P .001.
TABLE 7. Prevalence of Low Bone Density at Different Sites
in Girls With AN and Healthy Control Subjects
Controls
(%; n 51)
AN
(%; n 45)
P Value
LBMD .01
Normal 79.2 50.0
Z score 1 18.8 40.9
Z score 2 2.0 9.1
Hip BMD* NS
Normal 91.3 70.0
Z score 1 8.7 20.0
Z score 2 0 10.0
Femoral neck BMD* NS
Normal 86.0 79.6
Z score 1 14.0 13.6
Z score 2 0 6.8
* Hip and femoral neck BMD were examined in a subset of 23
healthy control subjects and 20 girls with AN.
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intake in diet is a strong predictor of body fat mass.40
Changes in heart rate and blood pressure thus may
be attributable to an adaptive response to weight loss
and reduced energy intake. Although bradycardia,
postural hypotension, and abnormalities in cardiac
function are known to occur in inpatients and in girls
with more severe AN,18,20,41 the occurrence of significant
bradycardia and low blood pressure in ambulatory
girls with AN is of concern. However, the
prevalence of bradycardia in this study was much
lower than that reported almost 16 years ago by Palla
and Litt19 (27% vs 94%), which suggests that intensive
monitoring of this condition in adolescent girls
is resulting in an overall improvement in hemodynamic
status.
Increased cardiac vagal hyperactivity is thought to
cause the bradycardia of adolescent girls with AN.42
Nudel et al43 found abnormal cardiovascular and
sympathetic responses to experimental physical exercise
in adolescent girls with AN, and QT prolongation
has also been reported in adults with
AN.9,10,19 Decreased myocardial contractility and impaired
left ventricular function have been reported in
adult women with AN,11,15 but no differences were
found in myocardial contractility in adolescent girls
with AN compared with control subjects.44 However,
because cardiovascular events, especially arrhythmias,
are a common cause of death in AN,45 the
high prevalence of bradycardia that we found in
outpatient adolescent girls who have this eating disorder,
although lower than in the 1988 study by Palla
and Litt,19 is disturbing. Monitoring hemodynamic
status is necessary not only in adolescents who have
AN and are hospitalized but also in communitydwelling
adolescents with this eating disorder, and
girls with a longer duration of illness seem to be
particularly at risk. Because nutritional status, especially
fat mass, predicts heart rate and blood pressure,
it is extremely important to emphasize weight
recovery in girls who have AN and are noted to have
bradycardia or low systolic or diastolic blood pressure.
This is supported by a recent report by Shamim
et al20 demonstrating normalization of orthostatic
pulse changes in girls with AN after nutritional rehabilitation.
Data regarding hematologic complications in ambulatory
adolescents with AN are few. It has been
reported that hematologic changes in young women
with AN are selectively related to total body fat mass
and amount of weight loss in AN.26 Bone marrow
hypoplasia has been reported in adults with AN,46
resulting in low RBC, WBC, and platelet counts.
Previous studies have reported a prevalence of anemia
in 30% of hospitalized adults with AN.12,13 We
report a 22% prevalence of anemia in our adolescent
subjects with AN. However, this is likely an underestimate
because mild degrees of dehydration are
common in AN and may result in spuriously elevated
hematocrit values. Palla and Litt19 reported
32% of anemia in their retrospective study of an
adolescent AN population. Bone marrow suppression
and hypoplasia are a likely explanation for anemia,
26 but dietary deficiencies of serum folate, vitamin
B12, and iron may be contributory. Changes in
red cell morphology (acanthocytosis, anisocytosis,
and poikilocytosis) have been reported in some previous
studies.47 We found significantly higher MCV
and mean corpuscular hemoglobin values in girls
with AN than in healthy control subjects predicted
by the degree of undernutrition, suggestive of possible
relative deficiencies in vitamin B12 or folate
intake, although both hematologic parameters were
still within the accepted laboratory range. This has
not been previously reported.
Twenty-two percent of our girls with AN had low
WBC counts. Conversely, adult studies have reported
leukopenia in as many as 36% of hospitalized
AN patients,12 and Palla and Litt reported a 38%
prevalence of neutropenia in their adolescent girls
with AN.19 A positive correlation between BMI and
total WBC count in girls with AN suggests that lower
BMI in these girls predisposes to lower WBC count in
AN. Similarly, Lambert et al26 reported that fat mass
predicted WBC counts. Although Bowers and Eckert48
found no increase in infection rates despite the
low WBC counts, Devuyst et al12 did report a higher
incidence of infectious complications in patients who
had AN and neutropenia. No serious infection was
noted in any subject in our cross-sectional study.
Previous reports suggest that the prevalence of anemia
was either lower than or the same as leukopenia.
13,19,49 We report a similar prevalence of anemia
and leukopenia in this group of community-dwelling
subjects. Although our subjects had a lower incidence
of leukopenia than those reported in adult,
sicker patients with AN and in older adolescent studies,
19,22 the report of increased infections in women
with lower WBC counts12 is of concern and suggests
that regular monitoring of CBC may be necessary
even on an outpatient basis in adolescent girls who
have this eating disorder, especially in girls with a
longer duration of illness. In addition, it may be
TABLE 8. Relationship Between Bone Density and Clinical Parameters
Chronological
Age
Age at
Menarche
Duration of
Illness
Duration of
Amenorrhea Weight Height Total Fat
Lean Body
Mass
r P r P r P r P r P r P r P r P
LBMD 0.29 .005 0.27 .02 0.30 .005 0.49 .008 0.58 .0001 0.31 .003 0.43 .0001 0.58 .0001
LBMAD 0.19 .07 0.20 .09 0.28 .007 0.28 NS 0.43 .0001 0.05 NS 0.41 .0001 0.27 .01
Lat BMD 0.00 NS 0.38 .001 0.37 .0004 0.30 NS 0.54 .0001 0.15 .09 0.43 .0001 0.46 .0001
Hip BMD 0.33 .03 0.51 .002 0.21 NS 0.10 NS 0.61 .0001 0.40 .002 0.43 .005 0.64 .0001
FN BMD 0.33 .03 0.41 .02 0.24 NS 0.22 NS 0.68 .0001 0.45 .002 0.49 .001 0.69 .0001
TBMD 0.37 .0003 0.26 .03 0.17 NS 0.28 NS 0.49 .0001 0.29 .005 0.33 .002 0.52 .0001
FN BMD indicates femoral neck bone mineral density; TBMD, total body bone mineral density/
1580 ANOREXIA NERVOSA IN COMMUNITY-DWELLING ADOLESCENT GIRLS
Provided by Swets Blackwe
necessary and serum levels of micronutrients,
including iron, vitamin B12, and folate,
and to advise dietary supplements as necessary to
treat anemia.
Contrary to the earlier reports showing hypokalemia19,50
in patients with AN, all girls with AN in our
study had normal serum potassium levels. This may
be attributed to the fact that only 2 of our 48 girls
with AN reported regular purging behavior. These
findings are in accordance with the work of Greenfeld
et al,51 who reported that adult patients with
purely restricting AN are not at risk for hypokalemia
even when their weight is very low. Similar data
were reported by Palla and Litt.19 However, Powers
et al52 reported that even with normal serum potassium
levels, these patients may be at risk for cardiac
arrhythmias and other physiologic abnormalities because
total body potassium may be low. Hence, monitoring
for cardiac abnormalities is advisable even
when serum potassium is in the normal range.
This study confirmed our previous findings of normal
levels of calcium and phosphorus in ambulatory
adolescents with AN,25,27,28 in contrast to reports of
hypocalcemia and hypophosphatemia in an older
adolescent AN study.19 It is likely that AN is now
being diagnosed earlier than in the past and that
earlier intervention is resulting in fewer and less
severe disturbances in calcium metabolism.
This study also confirms findings from our previous,
smaller studies demonstrating that osteopenia
and osteoporosis are highly prevalent in adolescent
girls with AN at the lumbar spine.25,27 In this study,
we demonstrate that BMD z scores at all sites are
significantly lower in a large number of girls with
AN compared with control subjects. Comparison of
the prevalence of osteopenia and osteoporosis at different
sites, however, suggests that the lumbar spine
is the site most affected in girls with AN. BMI, lean
body mass, and age at menarche were the most
significant predictors of BMD, confirming our findings
in a smaller number of subjects25,27 and concordant
with findings in other studies.14,53,54 Bone density
was also lower in girls with a longer duration of
illness. Adolescence is a critical time for accrual of
bone mass, and 90% of peak bone mass is accrued by
the end of the second decade of life.55 Low bone
density at this time of life thus is of concern because
enough time may not be available for catch-up even
if weight recovery does occur,25 especially because
many girls who do recover weight will relapse. Inadequate
bone mass accrual in adolescence results in
increased fracture risk, which may persist despite
weight recovery.
A large proportion of girls with AN were premenarchal
compared with control subjects, and one
third of the girls who had AN and were premenarchal
had delayed menarche (menarche not achieved
by 15 years). This is also reflected in the lower estradiol
levels in adolescents with AN than in healthy
control subjects. Moreover, this study underestimates
the degree of difference in these levels between
healthy control subjects and girls with AN
because the healthy girls were studied in the early
follicular phase of their cycles, whereas estradiol levels
are highest around midcycle. Hypothalamic hypogonadism
is a well-recognized feature of AN with
low LH levels and attenuation of episodic release of
the hormone.22,56 As amenorrhea precedes significant
weight loss in a number of patients,57,58 weight
loss by itself does not completely explain the relationship
between nutritional deprivation and menstrual
dysfunction, and studies suggest that energy
deprivation and emotional stress may also contribute
to the hypogonadism seen in AN.
Delayed menarche was a predictor of low bone
density in this study, suggesting that hypogonadism
may contribute to impaired bone metabolism in AN.
Estrogen has important effects in adolescence. In
early adolescence, the gradually rising estrogen levels
are followed closely by increases in levels of GH
and IGF-I, both of which are anabolic to bone. In
addition, adult levels of estrogen in late adolescence
result in a decrease in bone resorption. Estradiol
levels in this study were predicted by nutritional
status. An improvement in nutritional status therefore
should result in increasing levels of estradiol
and thus an increase in bone density. However, administration
of oral estrogen did not improve bone
density in adult women or in adolescents with
AN.59,60 This study demonstrates very low levels of
IGF-I in girls with AN, another possible cause of the
low bone density seen in girls with this disorder.
Hypercortisolemia in AN may be a consequence of
persistent stress related to this illness and can also
contribute to decreased bone density. UFC levels
were not different between the 2 groups in this
study. This is in contrast to the higher UFC values
reported in adult women with AN as compared with
healthy control subjects.61 However, Legro et al39
demonstrated that UFC levels increase with increasing
age through the pubertal years, and standardizing
urinary cortisol for creatinine and SA provides a
fairly constant value for children in the age range of
12 to 17 years, suggesting that this standardization
may be necessary when comparing values in groups
that differ in creatinine excretion and SA. When we
standardized UFC values for creatinine and SA, values
were significantly higher in girls with AN than in
control subjects, suggesting that there is hyperactivity
of the hypothalamic-pituitary-adrenal axis in AN
in adolescence as has been demonstrated previously
in adults.62,63 Licinio et al63 reported that hypercorticalism
in adults with AN was associated with increased
corticotrophin-releasing hormone levels and
normal circulating levels of adrenocorticotropic hormone.
Failure of cortisol to respond to the dexamethasone
suppression test has also been reported.64
Refeeding causes reversal of these findings, suggesting
that malnutrition may be responsible for this
hypercortisolemia.
Girls with AN were taller than control subjects,
although midparental height was not different between
the 2 groups, as opposed to other reported
studies, in which girls with AN did not achieve
genetic potential for height.23 Our subjects had a
mean bone age of 15 years, and 99% of adult height
is achieved by a bone age of 15 years. It thus is likely
that the majority of our girls with AN had attained
most of their adult height potential before developing
this disorder and as a result were not stunted for
height. Our findings may also be related to a small
sample size, and a larger sample may be necessary to
sort out differences in adult stature in AN versus
control subjects.
We report an increased prevalence of hematologic,
metabolic, hemodynamic, and skeletal abnormalities
in community-dwelling outpatient girls with AN
when compared with healthy subjects, suggesting a
need for continued medical monitoring of these parameters
in this population. Most of these medical
complications relate to the duration of illness and
nutritional status of the individual, and in particular
fat mass. Girls who have had AN for a prolonged
duration are specifically at risk for these complications,
as expected, and should be monitored more
intensively. In addition, BMI predicts leukopenia; fat
mass is an important predictor of hemodynamic
complications, and lean body mass predicts bone
density; thus, monitoring BMI and body composition
is important in girls with AN as a means of predicting
the risk for these complications. It is reassuring to
note, however, that the prevalence of medical complications
in an ambulatory adolescent AN population,
although still high, has decreased compared
with older published studies. Intervention in this
younger population is often earlier than in adults
with AN and thus may be more successful.
Downloaded from www.pediatrics.org. Provided by Swets Blackwell 61620793 on May 10, 2010
They are the forgotten ones. The parents and siblings of thousands of teenage girls with the debilitating eating disorder anorexia nervosa, where sufferers refuse to eat, purge or exercise relentlessly to lose weight.
Anorexia, which affects up to one in 10 girls, can have a devastating impact on young bodies, but now researchers at the University of Western Sydney have spent four years studying how families cope with an illness which can last up to seven years.
"We found that many fathers had given up work or reduced their hours because all of the mother's time was invested in looking after a chronically ill girl and many siblings had rebelled or become withdrawn," one of the study's authors, Christine Halse, said yesterday. "It takes an enormous toll on everyone."
The study, which has been published as a book calledInside Anorexia, followed 24 girls and their families in two Sydney clinics.
It features Hannah, who would peel and steam one frozen carrot at a time, weigh it, have three mouthfuls, turn the plate 45 degrees and have another three mouthfuls. When the carrot was gone, she would repeat the same routine with the next carrot from the freezer.
"It nearly drive us bonkers," her mother said. "It would take her up to 2½ hours each night to eat … 200 calories. It was mind-blowingly annoying. And we'd have to have the exact products in the right part of the fridge or she'd throw a hysterical screaming fit."
Such behaviour was extraordinarily difficult for families to understand, Professor Halse said.
One parent told of tempting her daughter, Angela, with a trip overseas if she managed to gain some weight but found the holiday "demanding and difficult".
"She couldn't eat this or wouldn't have that. It meant that I had to … find soup places because she wouldn't have a sandwich. It meant that we missed certain things because we had to search for the right place where Angela would have something to eat."
Another mother said: "You cope but you're constantly anxious. I've developed irritable bowel syndrome. And you don't sleep."
Obsessive compulsive disorder is often apparent in anorexics, with one mother telling how her daughter, Kate, obsessed with vacuuming and sweeping, caused the family dog to lose four kilograms by continually yelling at it for dropping hair on the floor. Kate had blocked doorways with furniture to stop the stressed dog moving about the house.
Source: www.theage.com.au
American Psychiatric Association's (APA) Obesity Rejected as Psychiatric Diagnosis in DSM-5.
Neither obesity nor simple overeating will be included in the DSM-5, the forthcoming revision to the Diagnostic and Statistical Manual of Mental Diseases, but binge eating is on track to become a formal psychiatric diagnosis, it was reported here. The addition of binge eating is one of several changes within the eating disorders category in the DSM, according to B. Timothy Walsh, MD, of Columbia University in New York City, head of the DSM-5 work group in this clinical area. But, said Walsh in a report here at the APA annual meeting, he and his colleagues did not believe there was enough hard evidence to support creating a psychiatric diagnosis for obesity or overeating. "We don't have the data to merit anything beyond binge eating," he said. "We have to follow the field, not lead it." But he held out the possibility that some kind of overeating syndrome, distinct from binge eating, might be added in the future. "I would not dismiss the theoretical basis" for considering overeating a psychiatric condition, he said. Darrel Regier, MD, MPH, the APA's research director, commented that a number of studies have suggested that people who eat excessively have biological similarities, in terms of neural firing patterns, to those with substance addictions.Trimming EDNOS: Walsh told attendees that the eating disorders category had cried out for an overhaul. The current edition of the DSM lists just three types for adults: anorexia, bulimia, and eating disorders not otherwise specified (EDNOS). Studies reviewed by the work group suggested that up to 45% of all patients treated for eating disorders receive a diagnosis of EDNOS, an indication that the current classifications are inadequate. Three additional diagnoses were initially proposed to take patients out of EDNOS, Walsh said. In addition to binge eating disorder, these were purging disorder and night eating syndrome.
Purging disorder would have covered patients with bulimia symptoms but without any abnormal eating habits. Night eating syndrome was intended for patients who get up in the night to eat an extra meal, but who wouldn't qualify as binge eaters.
In the end, according to Walsh, the work group decided that these would be premature. They may be included in an appendix to the DSM-5, a sort of holding tank for symptom bundles that need more study before acceptance as officially recognized disorders. Indeed, binge eating is in the appendix of the current DSM.
Defining Binge Eating: The primary definition is that patients eat amounts at one sitting that are "definitely larger than most people would eat in a similar period of time under similar circumstances," and the patient must also perceive a lack of control over the amount eaten. Binges must occur at least once a week for three months, and patients must express "marked distress" over them. In addition, patients must have at least three of the following associated behaviors or symptoms:
* Eating much more rapidly than normal
* Eating until feeling uncomfortably full
* Eating large amounts of food when not feeling physically hungry
* Eating alone because of being embarrassed by how much one is eating
* Feeling disgusted with oneself, depressed, or very guilty after overeating
Walsh said there was ample evidence in the literature that binge eating is distinct from bulimia and is clearly not just an extreme of normal behavior. He acknowledged that distinguishing a binge from a large meal is somewhat subjective. "It is not a sharp line in the sand," he said. On the other hand, he said, patients who meet the proposed criteria show definite abnormalities in laboratory testing -- i.e., they eat more at a sitting than people who don't meet the criteria.
Anorexia and Bulimia: Also in the offing are some changes to the diagnostic criteria for anorexia and bulimia. The current definition had been criticized in part because it included an example of "85% of recommended body weight" as an indicator that a person was too thin. Walsh said the work group agreed that this figure, though not a hard and fast criterion for diagnosis, was arbitrarily restrictive. In the revision, the first criterion has been reworded to say "restriction of energy intake [leading to] markedly low weight." Other criteria have undergone minor wording changes as well, and amenorrhea has been dropped entirely from the list of symptoms that may be associated with anorexia. For bulimia, a diagnosis will be easier than before because of a change in the required frequency of binge-purge episodes. Whereas the current DSM specifies that episodes must occur twice a week for the previous three months, the new criteria allow a diagnosis when the frequency is once a week. The new binge eating category and the anorexia and bulimia revisions should greatly cut down on EDNOS diagnoses, Walsh said. Analysis of 247 calls to an eating disorder clinic indicated that only 15% would receive an EDNOS diagnosis under the new criteria, compared with 39% using the existing system, he said.
Childhood Eating Disorders: Walsh said the infant and childhood eating disorders category would undergo little change. Pica and rumination disorder criteria will remain largely intact. Children now classed as having "feeding disorder of infancy and early childhood" -- reflecting a lack of interest in food for no medically apparent reason -- may receive a new diagnosis, avoidant-restrictive food intake disorder. But he said the scientific evidence on the relevant symptoms is scant. "We know they exist but there is almost no literature," he said, adding that the main basis for creating a diagnosis is simply that parents come to child psychiatrists seeking help.
By John Gever, Senior Editor, MedPage Today May 29, 2010. Primary source: American Psychiatric Association. Source reference: Walsh B, "Approaches to the diagnosis and classification of eating disorders in DSM-V" APA 2010; p. 106.
Source: Christine A. Hartline, M.A., Executive Director
Eating Disorder Referral and Information Center
www.EDReferral.com
Eating Disorder Referral and Information Center
www.EDReferral.com
