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Dental erosion

To determine the influence of oral hygiene practices and additional fluoride on erosive tooth wear in eating disorders. The proportional dietary intake of carbohydrates, fats, and proteins was also investigated.

Tooth wear was measured with the use of the tooth wear index (TWI).

Oral hygiene practices between subjects with and without severe erosion were not significantly different. Only 8 bulimics spent more time brushing after vomiting than at other times. The pH of vomitus from 6 subjects ranged between 2.9 and 5.0, with a mean of 3.8, well below the critical pH for enamel demineralization to occur. Of the 20 follow-up subjects, 12 (60%) exhibited worsening tooth wear.

The contribution by toothbrush abrasion to the overall wear in the eroded dentition of bulimics is not significant. Therefore, immediate post-vomiting oral hygiene practices can be recommended. The proportional nutritional intake values of carbohydrates, fats, and proteins in this group of bulimics are acceptable.

Milosevic A et al., Dental erosion, oral hygiene, and nutrition in eating disorders. Int J Eat Disord, 1997 Mar, 21:2, 195-9.


Diaphragmatic function

The effects of malnutrition and refeeding on nutritional indices, pulmonary function, and diaphragmatic contractile properties were studied in severely malnourished patients with anorexia nervosa. Diaphragmatic function is severely impaired in malnuorished patients.

"Diaphragmatic function in severely malnourished patients with anorexia nervosa. Effects of renutrition." Murciano-D; Rigaud-D; Pingleton-S; Armengaud-MH; Melchior-JC; Aubier-M. Am-J-Respir-Crit-Care-Med. 1994 Dec; 150(6 Pt 1): 1569-74.


A case of anorexia nervosa (AN) is reported where heart failure occurred secondary to severe hypophosphatemia despite oral phosphate supplementation. We recommend starting patients with AN on oral phosphate when refeeding is begun, monitoring serum phosphate every 1 to 2 days for at least the first week of refeeding, and discontinuation of refeeding during phosphate supplementation should severe hypophosphatemia develop.

Birmingham CL et al., Anorexia nervosa: refeeding and hypophosphatemia. Int J Eat Disord, 1996 Sep, 20:2, 211-3.

Diet Pills

Users of widely prescribed diet pills may suffer irreversible loss of brain serotonin nerve terminals, possibly resulting in symptoms of anxiety, depression, and cognitive and sleep problems, suggests the first author of a recently published report on fenfluramine side effects. Una McCann, MD, Chief of Anxiety Disorders Research in the National Institute of Mental Health, Biological Psychiatry Branch (Bethesda, Md.) and colleagues, reported on their review of 90 animal studies on serotonin neurotoxicity and primary pulmonary hypertension from fenfluramine and its chemical cousin dexfenfluramine in the August 27, 1997, issue of the Journal of the American Medical Association.

An estimated 50 million people have taken the drugs, often in combination with phentermine (hence "fen/phen"), an amphetamine-like diet drug that counteracts the fenfluramines' tendency to induce drowsiness. The study cautions that if the animal findings apply to humans, the brain damage "would be expected to occur in almost everyone taking a dose sufficient to achieve weight loss."

"I think there is cause for concern that people who take fenfluramines are at risk for a host of problems," says McCann. "A dose comparable to that prescribed to reduce weight in humans causes neurotoxicity in monkeys . . . Many people who try diet pills quickly regain their weight after they stop taking the drugs, so they might be tempted to continue taking them. We won't know the long-term risks of these drugs until controlled studies are completed in humans."

In one study reviewed, monkeys' brains continued to show signs of damage 17 months after taking a course of the drug. Much like the branches of a tree, neurons contain extensions called axons that transport messenger chemicals like serotonin and form synapses--connections with other neurons. Fenfluramines damage serotonin-secreting neurons by pruning these axons, which do not grow back in monkeys, although studies show that they do in rodents. And since human brains are more like those of monkeys, any such damage in humans would also likely be permanent, according to McCann.

"However, the neurotoxic potential of fenfluramines in humans has not been systematically evaluated . . . the functional consequences of brain serotonin neurotoxicity are largely unknown [even though the neurotransmitter is thought to be important] in a variety of brain functions, including cognition and memory and the regulation of mood, anxiety, impulsivity, aggression, sleep and neuroendocrine function," write the researchers.

McCann cites case reports that some users have experienced psychiatric disorders, which, she points out, tend to be underdiagnosed in clinical practice. Studies also document that fenfluramines increase the risk for developing primary pulmonary hypertension, a rare but incurable and life-threatening illness.

The researchers advise doctors to be vigilant about identifying both behavioral and cardiopulmonary side effects, and they recommend that patients be apprised of the risks and benefits of fenfluramines for weight loss.

Anonymous: Psychiatric Symptoms May Signal Brain Damage From Diet Pills. Drug Benefit Trends 1997,9(10):40.


To explore the role of life events and difficulties in the onset of anorexia nervosa and bulimia nervosa and to find out whether events and difficulties with a specific meaning, i.e. those of a certain sexual nature, are important in the onset of anorexia nervosa.

Anorexic patients, bulimic patients and community controls did not differ in proportion of patients with at least one severe event; however, significantly more AN and BN patients than community controls had experienced a major difficulty. Sixty-seven per cent of anorexics and 76% of bulimia nervosa patients had either a severe event or a marked difficulty during the year before onset.

In AN and BN the most common serious life stresses before onset concerned close relationships with family and friends with BN patients being significantly more often than AN patients directly involved in the problem (interpersonal events). Patients with anorexia nervosa had significantly more pudicity events before onset than BN patients or community controls.

While serious life stresses commonly precede the onset of anorexia nervosa and bulimia nervosa, problems with sexuality seem to be specific in triggering the onset of anorexia nervosa.

Schmidt U et al., Is there a specific trauma precipitating anorexia nervosa? Psychol Med, 27(3):523-30 1997 May.


Past research has shown that women with eating disorders commonly display clinical elevations on several scales of the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1983), so the MMPI may be useful for the differentiation of women with Anorexia Nervosa from those with Bulimia Nervosa.

In this study, 116 women diagnosed with either Bulimia Nervosa or Anorexia Nervosa completed the Minnesota Multiphasic Personality Inventory-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989).

Multivariate analyses failed to reveal any differences among the diagnostic subtypes. Consideration of profile code types was suggestive of possible group differences that mirror those discussed in previous literature on the personality features of women with eating disorders.

Pryor T & Wiederman MW: Use of the MMPI-2 in the outpatient assessment of women with Anorexia Nervosa or Bulimia Nervosa. J Pers Assess, 66(2):363-73 1996 Apr.

Food preferences

To determine whether eating disordered patients and controls differ in 100-mm visual analog scale (VAS) ratings of liking and desire to eat 50 common foods and whether ratings differ according to caloric or macronutrient content of the foods.

All patient groups rated their desire to eat high-calorie foods significantly lower than their desire to eat low-calorie foods whereas controls rated their desire to eat high- and low-calorie foods equally. Patients also differed from controls more in ratings of desire to eat than in liking when foods were classified according to macronutrient content.

Differences in the way patients and controls perceive foods should be borne in mind during the treatment process. Furthermore, since patients had not completely normalized by discharge, treatment strategies should emphasize acceptance of foods varying in macronutrient and caloric content, as intake of a varied diet is of key importance in regaining and maintaining good health.

Stoner SA et al., Food preferences and desire to eat in anorexia and bulimia nervosa. Int J Eat Disord, 1996 Jan, 19:1, 13-22.

Food selection

The food selection and nutrient intake were investigated in women with anorexia nervosa, bulimia nervosa and controls.

Dietary data was obtained by 24-hour recall, and 7-day recording among eating disordered patients, and by 3-day registration among controls.

The intake of energy and nutrients differed from controls, as expected, while there were no differences between anorectics and bulimics in this respect, except for iron. There were only minor differences among the three groups studied with respect to nutrient density. Energy percentages of protein, fat, and carbohydrates, were similar in all groups, but a subdivision of the macronutrients into respective sources showed that bulimics had a lower relative and absolute intake of carbohydrates from bread and cereals than anorectics and controls.

Eating disorder patients, despite their marginal food intake, still met the minimum requirement for most nutrients according to the Nordic Nutrient recommendations.

van der Ster Wallin G et al., Food selection in anorectics and bulimics: food items, nutrient content and nutrient density. J Am Coll Nutr, 1995 Jun, 14:3, 271-7.


The effect of starvation-related malnutrition on muscle performance and on the energy cost of exercise remains unknown, as does the timing of improvement by refeeding. Indeed, in most diseases that induce malnutrition, muscle dysfunction is worsened by an inflammatory process.

Thus, physical performance and the energy cost of exercise were studied in 15 semistarvated malnourished anorexia nervosa (AN) patients during exercise on an ergometric bicycle (3-min steps of 30 W) before and after 8, 30, and 45 d of refeeding.

The performance improved dramatically during refeeding, reaching normal values after 45 d of refeeding, despite fat-free mass and leg muscle circumference values that were still 20% lower in AN patients than in control subjects.

At this time, the exercise-related VO2 remained unchanged, being approximately 25% lower than that of the control subjects when corrected for muscle mass differences.

In AN patients muscle performance was restored by refeeding long before the patients achieved normal nutritional status. The economic cost of physical activity for these malnourished patients allows them to maintain a relatively high level of physical activity. This relative overactivity has two goals in AN: it reinforces anorexia and contributes to the excess of energy expenditure needed for weight loss.

Rigaud D et al., Refeeding improves muscle performance without normalization of muscle mass and oxygen consumption in anorexia nervosa patients. Am J Clin Nutr, 1997 Jun, 65:6, 1845-51.

Nutritional management


The importance of weight restoration has been well documented. Despite the importance of nutritional rehabilitation, few controlled studies that address the clinical efficacy of various dietary treatment regimens have been conducted.

Nutritional disorder of anorexia nervosa: a review. Rock-CL; Curran-Celentano-J. Int-J-Eat-Disord. 1994 Mar; 15(2): 187-203.

Nutritional management

Abnormal nutritional status and dietary patterns are central features of the eating disorders. Normalization of these features are key components of treatment and recovery because they are powerful perpetuating factors. Restrictive diets, fat avoidance, and abnormal cognitive and perceptual patterns are typically present, in addition to altered nutritional parameters because of hormonal and metabolic factors.

The primary goal of nutrition intervention in the patient with anorexia nervosa is to promote weight gain through increased energy intake, expansion of the diet, and knowledgeable and empathetic dietary counseling. A regular pattern of nutritionally balanced, planned meals and snacks, and the avoidance of restrictive dieting, are essential elements of treatment for the patient with bulimia nervosa.

As a member of the multidisciplinary treatment team, the dietitian or nutrition professional with knowledge of nutritional science, counseling skills, and a nonjudgmental attitude can provide expertise in this area.

Rock CL & Curran-Celentano J Nutritional management of eating disorders. Psychiatr Clin North Am, 1996 Dec, 19:4, 701-13.


To assess a new computer-based method of health education ("DIET") for patients with bulimia and anorexia nervosa.

The DIET group members were significantly improved when compared to the placebo group in terms of both their knowledge and attitudes towards their disorder. The patients rated the DIET program as being both easy to use and helpful.

The DIET program has been found to be a resource-efficient means of health education for patients with eating disorders. Further research is required to assess whether the program has therapeutic effects in terms of behavioural improvement.

Andrewes DG et al., Computerised psychoeducation for patients with eating disorders. Aust N Z J Psychiatry, 1996 Aug, 30:4, 492-7.


Therapy (1)

Twenty-two female patients with anorexia nervosa, restricted type, 14-35 years old, were treated with a 4-month course of combined cognitive-behavioral therapy, nutritional counselling and antidepressant drugs (nortriptyline for 7, fluoxetine for 15).

Patients were monitored for body mass index (BMI), for eating disorder symptoms by the Eating Disorder Inventory (EDI) and the Bulimic Investigation Test (BITE) and for depression and anxiety by the Hamilton Rating Scales for Depression and for Anxiety (HRS-D and -A). The scores were determined before and after 1, 2 and 4 months of therapy.

BMI, depression, anxiety and EDI scores improved significantly and equally in both groups during the 4 months of therapy, while BITE scores did not change.

Brambilla F et al., Combined cognitive-behavioral, psychopharmacological and nutritional therapy in eating disorders. 1. Anorexia nervosa--restricted type. Neuropsychobiology, 1995, 32:2, 59-63.

Therapy (2)

Research was conducted to obtain a profile of nutrition therapy currently in practice for patients with anorexia nervosa, bulimia nervosa, and anorexia/bulimia (mixed diagnosis) and to identify the areas of dietetics education and research regarding eating disorders that need more attention.

Nutrition therapy administered varied among dietitians treating inpatients, outpatients, and both. Three community groups were identified as most important to reach for prevention of eating disorders: junior high school students, coaches, and parents. Crucial areas of research were perceived by 94 dietitians to be comparative effectiveness of techniques of medical nutrition therapy (n = 55) and of techniques of prevention (n = 26) and increased understanding of etiology in relation to identification of high-risk groups and prevention (n = 21). Dietitians desired further information on multiple topics related to eating disorders.

Medical nutrition therapy for eating disorders is a specialization that requires education and training beyond the minimum required for dietetic registration. Some of the techniques required are unique to this specialization due, in part, to the psychological nature of the disorders. All dietitians, however, must be able to recognize and refer patients with eating disorders; these skills must be included in basic undergraduate programs and internships.

Whisenant SL & Smith BA: Eating disorders: current nutrition therapy and perceived needs in dietetics education and research. J Am Diet Assoc, 1995 Oct, 95:10, 1109-12.


Many reports describe the difficulty for anorexia nervosa patients to gain weight during refeeding. To assess whether an increase in diet-induced thermogenesis (DIT) participates to this resistance, we studied DIT by indirect calorimetry in 11 severely malnourished anorexia nervosa patients for two purposes:

1) to compare DIT in a strict semistarvation state with that obtained after 1 wk refeeding, when metabolism is shifted to a dynamic trend toward regaining weight, without significant change in body composition;
2) to study the effect on DIT of two energetic loads representing each one-third of the energy intake during semistarvation and refeeding, respectively: 1.25 and 2.92 MJ. To avoid bias, the two liquid loads were infused intragastrically in a random double-blind fashion.

A significant increase in DIT during refeeding was observed for the two loads (204 +/- 23 kJ for the 1.25-MJ liquid meal and 482 +/- 78 kJ for the 2.92-MJ one). The higher the load, the larger the increase with refeeding.

This increment in DIT exceeded the increase in active lean body mass and was poorly correlated with lean body mass.

These results provide clear evidence of a strong cellular "waste" mechanism in anorexia nervosa patients during the early phase of refeeding, which enhances the adaptative resistance to overfeeding that we have already shown for resting energy expenditure.

Moukaddem M et al., Increase in diet-induced thermogenesis at the start of refeeding in severely malnourished anorexia nervosa patients. Am J Clin Nutr, 1997 Jul, 66:1, 133-40.

Zinc deficiency

Zinc Deficiency
Zinc and Vegetarianism
Zinc, Vegetarian and Nonvegetarian Patients

Zinc Deficiency

Twenty-six children with anorexia nervosa were evaluated through a specialized eating disorder program at a children's hospital. Zinc deficiency was found common by measuring 24 hour fasting plasma zinc levels and 24 hour urinary excretion using atomic absorption spectrophotometry. The reintroduction of a normal diet resulted in a normalizing of zinc levels and weight to height ratios. A trial of zinc supplementation was attempted by using a 12-week, double-blind crossover design. It was done with 6 weeks on a placebo and 6 weeks on treatment.
Zinc sulfate at 50 mgs was given orally each day. Of the 7 trials of zinc supplementation, only 3 were completed. An inadequate intake of oral zinc threatened the health of the remaining 4. The authors conclude that low levels of zinc are common in patients with anorexia nervosa. Low zinc levels can be rapidly normalized without zinc supplementation with the introduction of a diet. Low zinc levels are related to self-starvation.

"Zinc Deficiency and Child-Onset Anorexia Nervosa", Lask, Bryan, MD, et al, Journal of Clinical Psychiatry, February 1993;54:2:63-66.

Zinc and Vegetarianism

Zinc deficiency and anorexia nervosa have similar symptoms including weight loss, changes in appetite and taste, depression and amenorrhea. Zinc deficiency and anorexia nervosa is most common in young females. Approximately half the women with anorexia nervosa are vegetarians. Young women with anorexia nervosa who are also vegetarians increase their risk of becoming deficient in zinc. Evaluating 3-day dietary records of 20 consecutive female anorexic outpatients 15 to 46 years of age, showed zinc and other nutrient levels in the vegetarians were lower than nonvegetarians, except for the caloric intake of carbohydrates, which was higher in vegetarians. The high levels of physical activity characteristic of women with anorexia nervosa may be greater for vegetarians, increasing the risk of zinc deficiency. Most vegetarian anorexics do not have an adequate dietary intake of zinc or the nutrients enhancing zinc absorption.
Zinc can be lost through perspiration with intense physical activity. Zinc absorption can also be impaired through changes in gastrointestinal function. Iron supplementation without need, occurring in some women with anorexia nervosa, may affect zinc status. Inorganic iron consumed without meat may reduce the bioavailability of zinc and decrease zinc retention. The authors advise vegetarians with eating disorders to implement good nutritional management and perhaps mineral supplements to help the quality and bioavailability of zinc in their diets.

"Anorexia Nervosa, Vegetarianism and Zinc. Supply, Absorption are Reduced", Nutrition and the MD, June 1993;3.

Zinc, Vegetarian and Nonvegetarian Patients

This study evaluated the dietary intake of zinc and other nutrients in nine outpatients, suffering from vegetarian, anorexia nervosa. Eleven nonvegetarian anorexia nervosa patients were also studied. Vegetarian anorexia nervosa patients had significantly lower dietary intakes of zinc, fat, and protein, and significantly higher intakes of calories from carbohydrates than the nonvegetarian anorexic patients. The authors concluded zinc should be routinely assessed in vegetarian anorexic patients, and zinc supplementation in the diets may be indicated. It is noted that young women who are on vegetarian diets to lose weight, should be educated regarding potential problems with zinc status on a meatless diet.

"Dietary Zinc Intake of Vegetarian and Nonvegetarian Patients With Anorexia Nervosa," Bakan, Rita, et al, International Journal of Eating Disorders, 1993;13(2):229-233.


Bone loss is a potentially debilitating condition in women with eating disorders. Complications may include failure to achieve peak bone mass, increased risk of premature fractures, and inability to reach the height potential

Evaluated 58 women with anorexia nervosa (AN), bulimia (BUL) and anorexia/bulimia (AB), comparing bone mineral density (BMD) to physical parameters, biochemical indices, and markers for bone formation and resorption.

BMDs were significantly lower in patients with AN than in those with AB and BUL, and overt osteopenia was uncommon in AB and BUL.

Hypercortisolism was the best laboratory marker to assess the risk of osteopenia in patients with AN.

Although the prognosis for complete recovery to normal BMD is poor, treatment of the underlying depressive disorder, improvement in nutrition with increased weight, and spontaneous resumption of menses are associated with restoring bone health.

Carmichael KA & Carmichael DH Bone metabolism and osteopenia in eating disorders. Medicine (Baltimore), 1995 Sep, 74:5, 254-67.

Leptin levels & Anorexia

Leptin plays an important role in reproductive function.

Hypothesized that low leptin synthesis is associated with amenorrhea. Therefore determined serum leptin levels in 43 underweight female students, who were screened for lifetime occurrence of amenorrhea. Assessed the predictive value of leptin, body mass index (BMI), fat mass and percent body fat, respectively, for lifetime occurrence of amenorrea.

Furthermore, the relationships between serum leptin levels and of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol and progesterone, respectively, were evaluated.

Only leptin predicted lifetime occurrence of amenorrhea in the student cohort. The critical leptin level was in the range of 1.85 micrograms L-1. This level served to largely separate anorectic from bulimic patients. In patients with AN mean serum log10 leptin levels over the first 4 weeks of inpatient treatment were correlated with mean FSH, LH and estradiol levels, respectively. Evidently, a critical leptin level is needed to maintain menstruation.

In affluent populations eating disorders are likely to be a major cause of a low leptin synthesis.

Kopp W et al., Low leptin levels predict amenorrhea in underweight and eating disordered females [see comments]. Mol Psychiatry, 1997 Jul, 2:4, 335-40.