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EATING DISORDERS IN
ADOLESCENTS AND
YOUNG ADULTS
Richard E. Kreipe, MD, and Susan A. Birndorf, DO

Three principles for the medical care of adolescents with eating

disorders were proposed by C ~ m e r c i (1) : ~ early restoration of a normal
nutritional and physiologic state; (2) establishment of trust; and (3) a
team approach (therapeutic partnership). This article reviews and clarifies
the definitions, epidemiology, pathogenesis, and clinical aspects of eating
disorders in internal medicine practice. The early restoration of health
requires early recognition of the disorder from the basis of a broad
differential diagnosis. An understanding of eating disorders by the clini-
cian is needed to establish trust with patients, who are often wary of
any recommendations to gain weight or change their eating habits.
Because patients with eating disorders often present with physical symp-
toms caused by starvation, induced emesis, or diet pill and laxative
abuse, the primary care provider may be the first person to diagnose an
eating disorder and to establish the therapeutic team. Many of the
psychiatric aspects of eating disorders have been discussed in numerous
earlier articles and chapters', 5, 7, 31 and are not discussed in detail here.
For the sake of clarity, female pronouns are used in reference to patients
because at least 90% of patients with eating disorders are adolescent and
young adult women. The approach to males is similar, however.

DEFINITIONS AND DIAGNOSTIC CRITERIA

The standard diagnostic criteria for eating disorders are in the DSM-
IV (see accompanying box).la In practice, anorexia nervosa is defined as a

From the Division of Adolescent Medicine, Department of Pediatrics, University of Roches-

ter, Rochester, New York

MEDICAL CLINICS OF NORTH AMERICA

VOLUME 84 * NUMBER 4 *JULY 2000 1027

1028 KREII’E & BIRNDORF

syndrome in which caloric intake insufficient to maintain weight is

associated with a delusion of being fat and an obsession to be thinner,
and neither the delusion nor the obsession diminishes with weight loss.
Patients with anorexia nervosa believe they are fat, even when emaci-
ated, and may feel driven to lose weight through a variety of means,
including dieting and increasing energy expenditure. Exercise is used by
more than three fourths of patients with anorexia nervosa, whereas
vomiting and cathartics are less commonly used. A feature that differen-
tiates simple dieting from anorexia nervosa is the difficulty of an affected
individual to identify or to be satisfied with a healthy weight goal. An
initial weight goal of 110 Ib drops to 105 Ib, then to 100 lb, then to 95 lb
relentlessly. True anorexia does not occur until there has been extreme
weight loss. Before that time, there is a refusal to acknowledge or to
submit to one’s appetite because eating is perceived as a vice, whereas
fasting is considered virtuous.

Diagnostic Criteria for Anorexia Nervosa, Bulimia Nervosa, Binge

Eating Disorder According to DSM-IV
Anorexia nervosa: 307.10
Refusal to maintain body weight greater than minimally normal (e.g.,
<85%) weight for age and height
Intense fear of weight gain or becoming fat, even though underweight
Disturbance in the way in which one’s body weight, size, or shape is
experienced
Undue influence of body weight or shape on self-evaluation
Denial of seriousness of the current low body weight
In postmenarcheal girls, the absence of at least three consecutive men-
strual cycles
Two subtypes
Restricting
Binge eating/purging
Bulimia nervosa: 307.51
Recurrent episodes of binge eating, characterized by both
Eating, in a discrete period of time (e.g., within any 2-hour period), an
amount of food that is definitely larger than most people would eat
during a similar period of time and under similar circumstances
A sense of lack of control during the episode (e.g., a feeling that one
cannot stop eating or control what or how much one is eating)
Recurrent inappropriate compensatory behavior to prevent weight gain
Self-induced vomiting
Misuse of laxatives, diuretics, enemas, other medications
Fasting
Excessive exercise
Episodes average at least twice a week for 3 months
Self-evaluation unduly influenced by body shape and weight
Does not occur exclusively during episodes of anorexia nervosa
Subtypes
Purging
Nonpurging
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1029

Binge-eating disorder (proposed research criteria)

Recurrent episodes of binge eating
Large amounts of food in a short period of time
Lack of control over eating during episode
Marked distress regarding binge eating
At least three of the following associated findings
Rapid eating
Eating until becoming uncomfortably full
Eating large amounts when not hungry
Eating alone because of embarrassment
Disgust, depression, or guilt because of eating patterns
Frequency of binge eating at least twice a week for at least 6 months

Data from American Psychiatric Association: Diagnostic and Statistical Manual of

Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.

The key clinical feature of bulimia nervosa is not, as often assumed,

vomiting. Binge eating is the sine qua non for bulimia. An awareness
that the eating pattern is abnormal is associated with depressed moods
and self-deprecating thoughts. Temporary relief of this distress is sought
through methods that are intended to rid the body of the effects of
calories. More than 80% of patients with bulimia nervosa engage in self-
induced vomiting or laxative or diuretic abuse for this purpose. Fasting,
exercise, or both may be the primary methods used to avoid weight
gain, often unsuccessfully, because many patients with bulimia nervosa
are normal weight to slightly overweight. Patients with bulimia are more
likely than patients with anorexia nervosa to be impulsive, not only in
eating behavior, but also in their use of drugs and alcohol, self-mutilation
or self-harm, sexual promiscuity, lying, stealing, and other manifesta-
tions of personality disturbance.12,29, 30,32 Such character pathology makes
it difficult to establish a therapeutic relationship with patients and re-
quires consistency and patience by the provider.23
Anorexia and bulimia are not mutually exclusive. Approximately
40% of patients with anorexia nervosa have a bulimic phase in the
course of their illness or recovery.16The three main categories of eating
disorders that are presently recognized clinically are (1) anorexia ner-
vosa, restrictive subtype, in which dieting and weight loss predominate;
(2) anorexia nervosa, with binge eating, purging, or both, in which
dieting and binge eating are intermixed with various forms of purging;
and (3) bulimia nervosa, in which binge eating is the predominant
behavior in association with behaviors, either purging or nonpurging, to
minimize weight gain. Patients not meeting all criteria are categorized
as eating disorder not otherwise specified and may represent the largest
category of patients in practice.

EPIDEMIOLOGY OF EATING DISORDERS

Eating disorders are not distributed uniformly in the population. Of
patients that present with classic signs and symptoms of anorexia or
1030 KREIPE & BIRNDORF

bulimia, greater than 90% are female, greater than 95% are white, and
greater than 75% are adolescents when they first develop the eating
disorder. Most patients are from middle-class to upper-middle-class
socioeconomic status families, but patients can be of any sex, race, age,
or social stratum. Prevalence rates that include the entire population as
the denominator grossly underestimate the prevalence of eating disor-
ders in target groups. Age-specific and sex-specific estimates suggest
that about 0.5% to 1%of teenage girls develop anorexia nervosa, whereas
5% of older adolescent and young adult women develop bulimia ner-
vosa. Disordered eating that does not meet full diagnostic criteria but
that still presents a threat to normal growth and development is com-
mon. For example, the 1997 Youth Risk Behavior Survey found that 60%
of female students and 23% of male students reported trying to lose
weight in the previous month, whereas the rate of taking diet pills was
8% for females and 2% for males.14 Many teenagers and young adults
feel a need to diet or lose weight and are at risk of adopting potentially
harmful weight-loss habits. The increased prevalence of eating disorders
since the 1980s is accounted for mostly by an increased incidence of
bulimia nervosa; increased media attention, improved detection, and
less stringent diagnostic criteria probably also account for the apparent
epidemic of eating disorders.

PATHOGENESIS

Eating disorders are extremely complex conditions with roots in

biologic, psychologic, and social issues. It is better to view them as a
final common pathway having multiple determinants. Rather than seeking
the causes, it is more useful to consider predisposing, precipitating,
and perpetuating factors. Because each of these factors has important
developmental considerations, it is useful clinically to consider eating
disorders as developmental, rather than mental, conditions. This consid-
eration also avoids the stigmatization that patients may associate with a
psychiatric diagnostic label.
Predisposing factors that make an individual vulnerable to devel-
oping an eating disorder include (1) being a female, especially in an
industrialized country; (2) having a family history of eating disorders;
(3) being perfectionistic and eager to please others; (4) having difficulty
communicating negative emotions, such as anger, sadness, or fear;
(5) having difficulty resolving conflict; and (6) having low self-esteem. Pa-
tients who are overweight and receive compliments when they begin to
lose weight may be especially vulnerable to developing an eating disor-
der because the reinforcements to continue to lose weight are powerful.
Precipitating factors often relate to developmental tasks of adoles-
cence. Maturation fears are most common in younger patients (10 to 14
years old) and are often related to sexual development. Menarche may
be threatening because it is often associated with a spurt of weight gain.
Early adolescents who develop an eating disorder often seem to be
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1031

retreating into childhood. Likewise, they may be eager to please, espe-

cially with highly revered peers or adults. Independence and autonomy
struggles are most common in middle adolescents (15 to 16 years old),
and they may be acted out through an eating disorder. These adolescents
may have ambivalence about growing up because for some adolescents
attaining adulthood is equated with being abandoned, isolated, or lonely.
For these individuals, a healthy developmental transition is from depen-
dence to interdependence, rather than to independence. Identity conflicts
are most common in older patients (>17 years old) and may be related
to transitions, such as graduating from high school, entering college, or
getting married. Not certain who they are or where they are going in
life, these young adults find solace in the identity of an eating disorder,
in which they have a sense of achievement, efficacy, and empowerment.
Sexual abuse is frequently identified as a precipitant to eating disorders.
Most patients with eating disorders do not have a history of sexual
abuse or trauma, however, but individuals who have an eating disorder
and a history of sexual misuse tend to be more difficult to treat.
Perpetuating factors serve to maintain the eating disorder once the
dysfunctional patterns of weight control are established. Biologic as well
as psychologic influences can act as powerful reinforcers and sustain the
eating disorder. The biologic issues that must be appreciated by the
physician include the signs and symptoms of starvation and the princi-
ples of refeeding the malnourished individual. In addition, the psy-
chologic coping that the eating disorder engenders must be appreciated.
In treating the illness, the clinician may threaten the homeostatic balance
that has been achieved within the family system. There may be denial,
resistance, and anger directed at the physician treating the eating disor-
der. In contrast to many conditions in which the patient and the internist
are in alliance to eliminate an illness, eating disorders may present a
special challenge because the patient frequently is ambivalent: desiring
but afraid of recovery. An appreciation of these various factors facilitates
the development of a trusting relationship between patient and provider.

CLINICAL ASPECTS

Symptoms

The symptoms experienced by the patient are related to the various

habits used to control weight (Tables 1 and 2). Symptom checklists
facilitate taking the symptom history and are generally answered hon-
estly. In this regard, privacy and confidentiality should be respected as
it is in any clinical interaction with an adolescent or young adult patient.
Likewise, the history should be taken with the goal of developing a plan
of action to help the patient feel better and not merely to rule-out an
eating disorder.
A review of symptoms usually elicits many positive responses that
can be interpreted as evidence that all is not well with the patient.17
1032 KREIPE & BIRNDORF

Table 1. SYMPTOMS AND SIGNS ASSOCIATED WITH WEIGHT-CONTROL HABITS IN

ANOREXIA NERVOSA
Symptoms of Inadequate
Energy Intake Signs of Inadequate Energy Intake
Physical Health Mental Health Positive Negative
Amenorrhea Concentration Hypothermia Normal fundi and
Cold hands or Decisions Acrocyanosis visual fields
feet Irritability Resting bradycardia No organomegaly
Constipation Depression Hypotension No lymphadenopathy
Dry skin or hair Social Orthostatic blood No or minimal breast
loss withdrawal pressure and pulse atrophy
Headaches Obsessiveness Loss of muscle mass
Fainting or (food) Abnormal laboratory
dizziness test values
Lethargy Low blood glucose
Anorexia Elevated liver
function tests
Low white blood
cells
ECG low voltage;
prolonged Q-Tc;
Nonspecific T
wave changes

ECG = electrocardiogram.

Most commonly, patients with anorexia complain of fatigue, cold intoler-

ance, hair loss, constipation, and amenorrhea. Patients with bulimia
complain of the same symptoms if they are underweight. If they are
normal or above their ideal body weight range, they likely complain of
being overweight and report symptoms related to purging through
emesis; restriction of food and fluids; and use of diet pills, diuretics, or

Table 2. SYMPTOMS AND SIGNS ASSOCIATED WITH WEIGHT-CONTROL HABITS IN

BULIMIA NERVOSA

Signs and Symptoms Signs and Symptoms of Vomiting

of Binge Eating or Laxative Abuse
Physical Health Mental Health Physical Health Mental Health
Weight gain Guilt Weight loss Guilt
Bloating, fullness Depression Electrolyte Depression
Lethargy Anxiety disturbances Anxiety
Salivary gland Hypokalemic, Confusion
enlargement hypochloremic
metabolic
alkalosis
(vomiting)
Dental enamel erosion
Hypovolemia
Knuckle calluses
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1033

laxatives. Patients who induce emesis frequently report symptoms of

gastrointestinal pain or dysfunction. Symptoms often resemble those of
gastroesophageal reflux. They may complain of burning or irritation in
the throat. Patients who restrict food or fluid intake or use laxatives
or diuretics may complain of dizziness or other symptoms related to
hypovolemia. Patients using diet pills may experience palpitations and
anxiety. A complete review of systems is helpful to rule out other
diseases, such as thyroid dysfunction, inflammatory bowel disease, and
cancer, that may present with a similar constellation of symptoms. Be-
cause depression is often a component of eating disorders, it is important
to screen thoroughly for ideation or intent of self-harm or suicide.
Communication with adolescents and young adults with eating
disorders is often difficult, yet several considerations may facilitate com-
munication between patient and provider to optimize information
gained through history taking. First, it is important to make the office
ado2escent friendly. An environment that welcomes adolescents sends a
message that they are welcome in the care setting. Second, evidence-
based, adolescent-oriented screening forms, such as those provided by
Guidelines for Adolescent Preventive Services (GAPS) or Bright Futures
Guidelines, save time and effort and provide documentation for the
patient’s record. These forms are easily obtained through the Department
of Adolescent Health, American Medical Association (http:/ / www.ama-
assn.org/ adolhlth/ adolhlth.htm), or Bright Futures (http:/ / www.bright-
futures.org). They also screen for other risk factors and behaviors asso-
ciated with eating disorders, such as mental health problems and
substance use. Third, it is helpful to focus on the patient’s symptoms,
rather than on a diagnosis. Dev’elopmentally, adolescents may or may
not have the cognitive ability to identify their poor eating behaviors and
their symptoms, whereas adults may still be struggling with unresolved
adolescent developmental issues, such as identity development or auton-
omy. For example, a patient who feels tired and cold and has difficulty
concentrating because she is malnourished may not relate her symptoms
to lack of food and fluid intake throughout the day. Fourth, interviewing
patients with eating disorders takes more time than other patients. If
one does not allow for this, either the patient feels rushed, or the
physician feels frustrated. Recognizing the individual needs of the pa-
tient and focusing on the patient’s symptoms can facilitate communica-
tion and help develop a therapeutic relationship.

Signs

Regardless of how good a patient may look or how normal the

weight is, a detailed physical examination is indicated whenever there
is concern about an eating disorder. Patients often dress in baggy clothes
that hide their cachexia. Likewise, they may attach weights to their
underwear or drink fluids before being weighed to make weight. As is
1034 KREIPE & BIRNDORF

true of symptoms associated with weight-control habits, signs found on

physical examination can be used as evidence that the patient is not
healthy. A thorough physical examination is also important because it
may indicate the presence of another condition, such as inflammatory
bowel disease (right lower quadrant mass) or central nervous system
lesion (papilledema). For patients who primarily restrict their food in-
take, characteristic findings in severe starvation relate to hypothalamic
dysregulation and malnourishment and include cachexia, hypothermia,
resting bradycardia with orthostatic hypotension, lanugo, acrocyanosis,
dry skin, thinning scalp hair, and a depressed mental status. Patients
that primarily binge and purge usually are normal weight or overweight
and present with enlarged salivary glands, dental enamel erosion, and
calluses over the proximal interphalangeal joint knuckles (Russell sign).
Patients with concurrent depression or history of sexual abuse may have
signs of intentional self-harm, including cutting.
The purpose of physical examination is not only to detect organic
pathology, but also to emphasize to the patient that the body is adapting
to an unhealthy state.21From a developmental viewpoint, adolescents are
often egocentric; one should focus on issues that have direct relevance to
their body-signs and symptoms. Concerns about future health prob-
lems, such as osteoporosis or infertility, may have less importance to
patients than staying thin. Using scare tactics is futile, if the purpose is
to motivate change in behavior toward health. For example, thin patients
often have slow capillary refill in their cold, blue hands and feet. This
can be explained to the patients: ”Your temperature is very low, so your
body is conserving energy by not allowing much blood to go all the
way out to your hands and feet, where a lot of heat can be lost. What
little blood is flowing through the skin is very cold and is moving very
slowly. Because so much oxygen is being removed, the blood in your
skin is blue. If you take in more energy (calories) by eating more
nutritious food, you will feel warmer and less tired.” Likewise, the loss
of menstrual periods, fall in blood pressure and pulse, drop in tempera-
ture, and growth of lanugo-type hair over the upper body represent
physiologic adaptation to starvation, similar to the changes in a hibernat-
ing animal. Finally, although the patient tends to focus on the loss of fat
as the primary goal of weight loss, the loss of muscle mass that inevita-
bly attends significant weight loss can be described in terms of loss of
power, strength, endurance, flexibility, and physical fitness. This loss of
muscle mass frequently provides an incentive for patients that can be
addressed during the physical examination, especially patients who are
athletic or sports-minded, to improve their nutrition and gain weight.

Laboratory Tests

Because the diagnosis of an eating disorder is clinical, there are no

confirmatory laboratory tests. Laboratory studies used to evaluate pa-
tients with eating disorders include the following:
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1035

Complete blood count with erythrocyte sedimentation rate

Urinalysis
Blood chemistries
Other tests as indicated
In the presence of an eating disorder, laboratory abnormalities are due
to the weight-control habits used or the complications thereof. A routine
screening battery could include a complete blood count (with differen-
tial), erythrocyte sedimentation rate, and blood chemistries. The results
of many tests depend on the state of hydration. Persistently abnormal
values should be followed closely and may indicate the presence of an
underlying organic illness. Because many patients have normal labora-
tory studies, it is important to emphasize that studies are obtained as a
baseline, not to establish the diagnosis. Imaging studies do not have a
place in the routine evaluation of eating disorders but may be indicated
in individual cases. For example, bone densitometry may be necessary
to determine the extent of osteopenia in a severely malnourished patient
with long-standing anorexia. An electrocardiogram may be useful to
evaluate for the corrected QT interval in patients who are taking drugs
that could place them at risk for a prolonged interval, predisposing them
to potentially harmful dysrhythmias. Leukopenia and thrombocytopenia
may occur with starvation; leukopenia is due to increased margination
of the leukocytes, and patients do not have an increased risk of infection.
The erythrocyte sedimentation rate is uniformly normal; an elevated
value should trigger a search for an occult organic illness, such as
inflammatory bowel disease. The hemoglobin is typically normal, al-
though it may be elevated in dehydration or reduced when iron intake
is drastically reduced, as in a vegetarian diet. Because patients with
anorexia nervosa are uniformly amenorrheic, menstrual blood loss is
rarely an explanation for anemia, which deserves further evaluation if
it occurs.
The glucose is often low because of lack of glucose precursors in
the diet or glycogen stores. Renal function is usually normal, but the
blood urea nitrogen can vary between high (dehydration) and low (low
protein intake). Electrolytes are usually normal unless the patient is
vomiting or taking laxatives and usually revert to normal quickly on
cessation of purging. Vomiting is typically associated with hypokalemic
hypochloremic metabolic alkalosis; laxative abuse may be associated
with acidosis.
Serum protein and albumin are generally normal. The small amount
that patients eat generally contains high-quality protein so that visceral
proteins remain normal; prealbumin, with its shorter half-life, may be
low, however. Liver function tests may reveal mildly elevated (1.5 to 2
times normal) enzyme levels but are not in the hepatitic range. Bilirubin
metabolism is normal so that total and conjugated levels of bilirubin are
normal. Cholesterol levels are often elevated, sometimes dramatically, in
starvation states. There appear to be at least three reasons for this
elevation: (1) Cholesterol breakdown is related to triiodothyronine (T3)
1036 KREIPE & BIRNDORF

levels, which may be depressed; (2) cholesterol binding globulin is often

low; and (3) with fatty infiltration, there may be a leakage of intrahepatic
cholesterol. When fractionated, most of the cholesterol is in the high-
density lipoprotein form.
In most cases, it is advisable to inform the patient and parents that
normal results are expected before the laboratory studies are obtained.17
Otherwise, a patient resistant to treatment could use negative results as
evidence that nothing is wrong. Some practitioners also routinely obtain
thyroid screening; if abnormal, the T, is usually low, a means of reducing
the metabolic rate in association with low caloric intake. Patients typi-
cally have a clinical picture that suggests both hypothyroidism (fatigue,
constipation, bradycardia, hypothermia) and hyperthyroidism (weight
loss, excessive activity, anxiety), but the treatment for these symptoms
is healthy nutrition and weight gain. The other endocrinopathy that is
suggested by the constellation of weight loss, fatigue, and a small heart
is Addison's disease; serum cortisol tends to be high in anorexia nervosa,
however.

MANAGEMENT

Early or Mild Stage

The DSM-IVIa includes a category eating disorder not otherwise speci-

fied, applicable to patients who display subthreshold attitudes, behaviors,
or signs. Recognizing that many patients with disordered eating may not
progress to develop a classic eating disorder syndrome, it is nonetheless
prudent to intervene when patients show dysfunctional eating or
weight-control patterns. Features that place a patient in this category
include (1) mildly distorted body image; (2) weight 90% or less of
average weight for height; (3) no symptoms or signs of excessive weight
loss, but (4)use of potentially harmful weight-control methods or a
strong drive to lose weight.
Treatment begins with the assessment of weight loss or control
because the practitioner can emphasize the importance of maintaining
health. In this regard, the importance of setting a goal weight early in
treatment cannot be overemphasized. If a patient is unable to identify a
target weight or seeks an unreasonably low weight, close follow-up is
indicated. By setting a limit on weight loss, the primary care provider
establishes a boundary for excessive weight loss. The magnitude of the
drive for thinness experienced by a patient can be estimated from her
reluctance to agree on a healthy weight goal. Referral to a dietitian
should be made if there is a request for one or if the patient has
become vegetarian or has adopted unhealthy, unusual, or monotonous
food choices.
Ideally a dietitian should be involved in the evaluation and treat-
ment of adolescents with eating disorders. The dietitian can (1)evaluate
the diet and identify specific deficiencies or excesses, (2) educate the
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1037

patient (and family) regarding nutrient needs during adolescence and

dispel dietary misconceptions frequently held by patients, ( 3 ) develop a
balanced meal plan within a target caloric range to achieve weight gain
or maintenance, (4) apply a food exchange system to allow variety and
flexibility in food selection, (5) assess diet journals recorded by the
patient to identify dysfunctional eating patterns that persist or arise
during the course of treatment, and (6) provide feedback to the patient
to encourage continued progress toward health.21
The journals used to evaluate nutrition can also be used to deter-
mine dysfunctional habits (e.g., eating only a piece of toast for breakfast),
associated mood disturbances (e.g., refusing to eat dinner because of an
argument), and accomplishments (e.g., eating high-calorie food). All of
these issues can be overlooked or forgotten in the course of a primary
care office visit, but the data contained in such records assist the patient
and the physician to recognize important patterns or events. Also, if the
recorded intake in the journal is normal, further diagnostic evaluation
may be indicated before definitive treatment because malabsorption
could be occurring, or the patient could be vomiting surreptitiously.
Reevaluation by the physician within 1 to 2 months ensures that
weight is not changing precipitously, that health is being maintained,
and that dysfunctional eating habits have not developed. Data obtained
on the follow-up visit (e.g., change in eating habits, weight, and physical
examination) clarify the diagnosis. Follow-up also provides the clinician
the opportunity to evaluate psychosocial development and adjustment.
At this time, the patient may declare herself as a more difficult case,
requiring referral. The opportunity to show to herself that the patient is
not able to maintain health despite the best of intentions, however,
often reduces resistance to referral for mental health when it becomes
necessary.
If the patient responds to treatment by eating normally and attains
and maintains a normal weight and health with little evidence of dis-
tress, outpatient follow-up should be for routine health maintenance.
Even though the diagnosis of an eating disorder might be questioned
under this circumstance, anticipatory guidance is indicated. The patient
should be aware of the warning signals of out-of-control weight loss,
including falling below the established goal weight, feeling guilty after
eating but in control when not eating or losing weight, having arguments
over meals, and experiencing symptoms or signs of excessive weight
loss. Surveillance of these patients may prevent progression to more
severe phases of illness or trigger a definitive treatment response should
the condition worsen.

Established or Moderate Stage

Patients who progress to a clearly established or moderate eating

disorder often require the additional services of professionals who have
experience in treating eating disorders.21Specialists in adolescent medi-
1038 KREIPE & BIRNDORF

cine? nutrition, psychiatry, and psychology each have a role in the

treatment of the more-difficult-to-manage patient. Features of patients
in this category include (1)definitely distorted body image that has not
diminished with weight loss; (2) weight goal less than 85% of average
weight for height associated with a refusal to gain weight; (3) symptoms
or signs of excessive weight loss associated with a denial that any
problems exist; and (4)unhealthy means to lose weight, such as eating
fewer than 1000 cal/ day, purging, or excessive exercise. Additional fac-
tors that justify placement in this category include evidence of family
dysfunction or anticipated lack of cooperation with treatment recom-
mendations.
A patient with a distorted body image continues to feel fat despite
having lost weight. Treatment of this distortion does not include chal-
lenging the patient’s perceptions. To the contrary, it is helpful to ac-
knowledge the desire to lose weight. This desire, however, must be
balanced against the reality of being too thin, as manifested by the
symptoms and signs of excessive weight loss. This maneuver can be
tremendously therapeutic. By noting that feeling fat cannot be challenged
because feelings are subjective and that being too thin cannot be chal-
lenged because of objective data, the physician indicates an awareness
of the dilemma the patient faces. This understanding furthers the devel-
opment of trust in the physician and is a welcomed relief from common
responses, such as ”How can you possibly feel fat, when you’re so
skinny?” or ”Why don’t you just eat?” Such statements indicate a lack
of appreciation of the patient’s perceptions, potentially increasing resis-
tance to treatment.
Similarly, rational arguments for the need to gain weight, such as
plotting weight for height on a growth chart, have little place in the
treatment of more advanced disease. Because anorexia nervosa is based
on certain premises that the patient has regarding herself (being ineffec-
tive, inadequate, of low worth), simplistic explanations such as these are
usually not compelling. The developmental issues over which the patient
perceives no evidence of control are metaphorically embodied in the
struggle to restrict eating to achieve weight loss. To make eating and
weight gain a battle dooms treatment to failure. If the patient wins the
battle by losing weight, health is lost; if the patient loses the battle by
gaining weight, perceptions of being ineffective, powerless, and worth-
less are only reinforced. There is no safe way out. If the physician joins
with the patient in gaining control over the eating disorder, a healthy
and growth-promoting alternative is available.
Contrary to popular belief, it is not necessary to confront denial
immediately. Frequently, such denial stems from misconceptions regard-
ing the meaning of the diagnosis of an eating disorder. Some patients
argue that they cannot have anorexia nervosa because they are not thin
enough. Others fear that having the diagnosis means that they are crazy
or that they will be hospitalized and force fed. More important than
labeling the patient is the need to identify threats to health and to
develop a treatment plan that addresses, monitors, and improves health
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1039

status. It is necessary for the parents to understand the seriousness of

the diagnosis because they may be confronted with the need for long-
term treatment and hospitalization. Denial on the part of one or both
parents can undermine all treatment interventions.
To restore the patient with an established or moderate eating disor-
der to nutritional and physiologic health, it is usually necessary to
provide structure to daily activities that ensures adequate caloric intake
and limits expenditure of calories. This plan should take into consider-
ation the present weight, the minimal goal weight for health, and the
expected rate of weight gain. Behavioral contracts tend not to be as
effective in outpatient management as they are in hospital settings
because of difficulties with monitoring such plans. In general, the goal
of outpatient treatment is to shift the burden of responsibility to the
patient to eat adequately and attain health. For the young adult, this
means self-monitoring. A contract also implies that both parties enter
into the agreement freely, which is usually not the case for the patient.
Negotiating a program or plan to assist the patient to attain and maintain
health emphasizes the most important aspects of this intervention.
Younger adolescents need closer parental involvement.
The daily structure should include eating three meals a day. Break-
fast is typically eliminated and lunch drastically reduced in eating disor-
ders. Patients with anorexia nervosa tend to continue their restriction
through dinner, whereas patients with bulimia nervosa tend to binge eat
and purge after school or after dinner. Eating adequately at breakfast
maximizes the likelihood of adequate daily caloric intake and should be
emphasized by the physician and the dietitian. Eating an insufficient
amount of food at meals can result in weight loss or subsequent binge
eating. Parents of adolescents should be encouraged to ensure that
healthy food is available and that mealtimes are planned into the day
but not to assume responsibility for the patient’s eating. As long as
parents believe it is their duty to force their adolescent to eat, eating
becomes a battle that cannot be won. If the patient gives in and eats to
please parents, purging often ensues.
In addition to increasing caloric intake, it may be necessary to limit
physical activity. Restricting activity, such as participating in sports or
exercise classes, has numerous advantages. It helps maintain weight by
decreasing energy expenditure and emphasizes the seriousness of the
condition to the patient and parents. It can act as a motivator to eat
properly to allow return to favorite activities. Parents and coaches often
are relieved when the patient is restricted from excessive activity on
medical grounds. It may be useful to explain the purpose of the restric-
tions to the coach or school nurse so that they can reinforce the impor-
tance of health. The patient often finds it reassuring that someone is
assuming authority in a situation over which she has a decreasing sense
of control.
A potential disadvantage of limiting activity is the removal of posi-
tive influences because ballet, soccer, or cheerleading may be important
for a patient’s ability to cope with stress. Parents of adolescents may
1040 KREIPE & BIRNDORF

worry that activity restriction may cause a retreat further into the eating
disorder or cause the adolescent to give up. It should be emphasized
that the restrictions are for medical, not disciplinary, purposes and are
temporary limitations in response to the patient’s physical condition.
For example, one could tell a patient and her parents:
I am concerned about the physical symptoms and signs that your body is
having as a result of your poor nutrition. Until you get healthier, I cannot give
medical permission to run track. I know how much you want to run, but you
need to be healthier to do that, and that means making some changes in your
nutrition. A sports nutritionist who helps my patients with eating disorders
plans what they will eat and drink in a way that will help them improve their
sports performance and get healthy at the same time. Now this will mean
gaining some weight, but you need to know that our plan will result in you
gaining more lean weight than fat. How does that sound?
The goal is to ensure healthy participation, not to exclude from participa-
tion. It is unfair to expose the patient to potential injury or suboptimal
performance because of malnutrition. Finally, a drive for weight control
that overpowers all other desires is potentially life-threatening and must
be taken seriously. If the patient responds, ”I won’t gain weight, even if
it means I can’t run track,” she demonstrates that weight loss is more
important than running and more likely that running is a means to the
end of losing weight. Before one attempts to make such restrictions,
however, it is important to make certain that the parents will support
the decision not to have their daughter participate until she has reached
some goal weight or other set of parameters.
When the patient has no interest in exercise, there is little opportu-
nity to conserve calories, and there may be few motivators for healthy
eating. Going to the mall or on family outings may need to be restricted
in these situations. More important is the need to identify rewarding
activities when appropriate behavior does occur. Serious depression or
severe anorexia nervosa should be considered when the adolescent or
young adult has no interest other than losing weight. During follow-up
visits, the patient and parents should receive ongoing medical, nutri-
tional, and mental health counseling as dictated by individual circum-
stances. Frequently, consultation with or referral to specialists in the
treatment of eating disorders is required at this stage of illness.
The process by which the patient is referred for treatment can
be crucial to the acceptance of complex and often difficult treatment
recommendations. The trust in the primary care physician is not readily
transferred to specialists merely because they are experts. In this respect,
referral is often facilitated when the specialists are identified as consul-
tants, rather than as independent agents. A statement such as, ”To
provide you with the best overall care, I need the help of some profes-
sionals who specialize in treating eating disorders” emphasizes that the
team approach has shown effectiveness, whereas continuity of care is
made explicit. This approach can be especially important in referral for
mental health treatment. “You need to see a psychiatrist” often elicits
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1041

“But, I’m not crazy.” A more therapeutic message is as follows: ”You

seem angry, sad, and a little hopeless about this whole situation. My
patients find it helpful to talk to a professional about such feelings, so
they can get on with their life. I’d like you to see Dr. Smith, who is a
psychiatrist. She can help us with this aspect of your care.” To the
patient’s mother the physician can say the following: ”It’s clear that this
eating disorder is affecting your whole family. Even though Melissa is
the one who’s losing weight, I think we need to include the rest of the
family in coming up with solutions. Dr. Johnson is a therapist who often
helps me in working with families in such situations. Here’s his phone
number and address. I’ll call in the referral and will see you again
in two weeks to see how the first meeting went and to check on
Melissa’s health.”
To reinforce the importance of the referral, the primary care physi-
cian should schedule a follow-up appointment after treatment by special-
ists has begun. It is common for a patient or parent to resist treatment,
noting, “I don’t like talking about it,” ”She’s not helping,” ”It’s too
expensive,” or ”It’s not that big of a deal.” To lessen the conflict related
to the eating disorder, parents may decide to discontinue treatment
prematurely, hoping that conflict will resolve spontaneously. Reinforce-
ment is often needed: ”I know how difficult it is to deal with these
problems, but it will be worth it. Keep up with treatment for at least
another 2 months, then we can see how things are going. I think
you’ll start to see some change soon if everybody works together.” The
emphasis of the team approach helps the adolescent and parents realize
that they are not alone in their struggle.

Interdisciplinary Team Approach

The referral to a team of specialists implies that such a team is

available to the physician; outside of metropolitan areas, this may not
be the case. Because adolescent medicine is now a board-certified sub-
specialty, however, physicians capable of managing all but the most
difficult cases of anorexia nervosa should be increasingly ac~essible.~ It
is especially important for the patient and primary care provider to have
contact with a physician who has experience in managing the medical
aspects of eating disorders, including inpatient care. In less severe cases,
this specialist may need only one or two visits with the patient to help
establish the diagnosis and a treatment plan that the primary care
provider can execute. In more severe or acute cases, this specialist may
assume primary responsibility for coordinating care specifically related
to the treatment of the anorexia nervosa, including hospitalization. Ide-
ally the same specialty team offers outpatient and inpatient services
because the transition between settings can be difficult.
The therapeutic team should also include a dietitian and mental
health care providers. In some situations, the involvement of a psycholo-
gist and a psychiatrist is indicated; the former may provide family
1042 KREIPE & BIRNDORF

therapy, whereas the latter provides individual therapy and, if needed,

prescribes psychoactive medication, such as antidepressants, or oversees
psychiatric hospitalization. Communication among members is crucial
to the professionals functioning as a team. This communication can be
facilitated by treatment of the adolescent and family in a dedicated
eating disorder program. Commitment to providing optimal care is
the most important credential, however, and an effective team can be
assembled under the leadership of the primary care physician.

Hospitalization

Indications for hospitalization in eating disorders5 are outlined in

the accompanying box. Some clinicians include falling below a preset
minimum weight as an indication for hospitalization. Low weight is
only one index of malnutrition; weight should never be used as the sole
criterion for admission to the hospital. Most adolescents are sophisti-
cated enough to realize that weight on a scale can be falsified. They may
drink water or diet beverages or hide heavy objects in their underwear
before weighing if weight alone determines hospital admission. This
approach may result in acute hyponatremia or dangerous degrees of
unrecognized weight loss.

Indications for Hospital Admission for Anorexia Nervosa

Physiologic decompensation
Temperature <36°C
Pulse <45/min or orthostatic pulse differential >30/min
Altered mental status, fainting, or other signs of significant malnutrition
Rapid (>lo% in 2 months) or excessive (>15% overall) weight loss that
cannot be curtailed as an outpatient
Complications of weight-control habits (fluid or electrolyte imbalance or true
loss of appetite)
Inability to break the cyc/e of disordered eating as outpatient
Inability to initiate effective outpatient psychotherapy
I

Adequate preparation for inpatient treatment can prevent some

negative perceptions regarding hospitalization. The patient may perceive
admission to the hospital as a punishment: One mother said to her
daughter, “If you don’t eat they’ll put you in the hospital and feed you
through a tube in your nose! You don’t want that, do you?” Parents
may fear that hospitalization indicates a serious deterioration in their
daughter’s condition. One father asked, ”Will she ever get better?” By
identifying hospitalization as a necessary component of treatment under
specific conditions, the physician minimizes its use as a threat to achieve
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1043

compliance with treatment and emphasizes the therapeutic purpose of

inpatient care. Parents especially must be aware of the need to view
hospitalization, if required, as an intensification of treatment that is
best avoided through effective outpatient management but that is not
something to be feared. Reinforcing the purpose of hospitalization as
well as the specific goals and objectives of inpatient treatment (e.g.,
changes in metabolic and physiologic variables, planning and ingesting
healthy meals, establishing improved communication skills, gaining in-
sight into underlying conflicts, developing alternative coping strategies)
directly with the patient and the parents can maximize the therapeutic
impact of admission to the hospital. Outpatient follow-up should be
planned before discharge so that continuity from inpatient to outpatient
care is ensured.
During hospitalization, dysfunctional habits of choosing, preparing,
and eating food can be reversed. This reversal may require behavior
modification, wherein patients learn how to eat with professional guid-
ance. Patterns of interaction within the family that were previously
dominated by arguments relating to the eating disorder can become
focused on issues other than food, eating, and weight as the patient
is restored to health. Equally important, however, is attention to the
developmental issues that drive the eating disorder. Low self-esteem,
lack of assertiveness, a sense of inadequacy and ineffectiveness, and
underlying mood disturbance or other emotional problems should be
addressed. The scope of hospital management is beyond the scope of
this article, but the primary care provider needs to be aware of the issues
related to successful treatment.

PROGNOSIS

Poor prognosis has been associated in the literature most consis-

tently with long duration of illness, disturbed parent-child relationships,
concomitant personality disorder, and the presence of vomiting (the
latter two more common in bulimia). Degree of weight loss is not
generally related to prognosis. Early age of onset has been proposed as
a predictor of good outcome, but several studies have not found this to
be the case. Regardless of the presence of good or poor prognostic
indicators, the primary care provider’s role in the treatment of anorexia
nervosa remains the early identification and initiation of effective inter-
ventions. Even with early treatment, the clinician should expect treat-
ment to last 6 months to 2 years or more, and expectations for a quick
fix need to be tempered.
Anorexia nervosa, previously treated almost exclusively by mental
health care professionals, has been considered a chronic condition with
a variable but generally poor prognosis. Data from treatment programs
based in adolescent medicine suggest that more favorable outcomes
can be expected with early identification and definitive treatment of
adolescents and their families. For example, applying standardized mea-
1044 KREIPE & BIRNDORF

sures to determine outcome, 71% to 86% of patients reported in the

literature from adolescent medicine programs had a satisfactory out-
come.5,16*21 An exception to this generalization may be the future devel-
opment of osteoporosis. Adolescent girls and women with eating disor-
ders have numerous risk factors for suboptimal bone accretion (low
weight, poor calcium intake, hypoestrogenemia, and hypercortisolemia),
placing them at risk for osteoporosis; evidence suggests that adolescents
may be at even higher risk than adults.'l, 22 Studies are now underway
to define those at greatest risk and treatment options to minimize the
likelihood of fracture of the hip and spine. Despite these generally
encouraging results, persistence or worsening of the illness over time,
often with the development of personality or affective disturbances,
occurs in 15% to 25% of patients in pediatric series. Mortality is less
than 5% with treatment, however.
The prognosis and outcome for patients with bulimia is less certain
because it was identified as a separate condition in research studies only
in the 1980s. Features that tend to be associated with poorer prognosis
include the presence of significant depression, comorbidity with sub-
stance abuse, coexistent personality disorder, and a history of sexual
abuse.

MEDICAL CONCERNS IN EATING DISORDERS

Myocardial Impairment

Bradycardia was recognized as a prominent feature of weight loss

in the first case of anorexia nervosa described in the literature9 in 1874.
Almost 50 years ago, young men underwent voluntary starvation under
experimental conditions and were found by KeysI5 to have significant
cardiovascular changes, including profound bradycardia (average rest-
ing pulse of 37 beats/min); decreases in amplitude of P, QRS, and T
waves; decreased heart size in all dimensions; decreased systolic and
diastolic blood pressure; decreased stroke volume; and reduction in all
variables related to physical work done by the heart. The volunteers
experienced fatigue, weakness, and acrocyanosis but no evidence of
dyspnea or other symptoms suggestive of cardiovascular distress.
During the period of nutritional rehabilitation after the studies of
starvation were completed, there was a rapid return of heart size but a
slower return of cardiac function, which eventually did return to normal
in all subjects within 32 weeks of refeeding and weight restoration.
There appeared to be less cardiac reserve during rehabilitation than
during starvation, attributed to a more rapid return of metabolic demand
than of cardiac output. During the phase of most rapid weight gain,
subjects experienced a rapid increase in metabolic rate, tachycardia,
venous pressure elevation, dyspnea, and refeeding edema. When given
the opportunity to eat freely, one subject ate 10,000 calories a day and
developed congestive heart failure. This event may have been due to a
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1045

slowed response in up-regulation of muscle mass relative to the rapid

increase in blood volume and afterload. An additional concern with
refeeding is the precipitation of significant hypophosphatemia as energy
is restored.21Applied to patients with eating disorders, these data indi-
cate that the rehabilitation phase may be more dangerous than the
starvation phase.
Clinically, it is useful to categorize myocardial abnormalities in
eating disorders into physiologic adaptations, such as sinus bradycardia,
sinus arrhythmia, low blood pressure, or myocardial abn0rma1ities.I~
The former occur gradually, are not life-threatening, yet still meet the
needs of decreasing demands of tissue perfusion. Prolonged corrected
QT interval, ventricular dysrhythmias, and abnormal contractility are
evidence of a myocardial abnormality, occur more quickly, and can be
lethal.13Patients who have prolonged corrected QT should be
monitored for hypokalemia or hypomagnesemia, especially if they vomit
or take laxatives. The most serious cardiac dysfunction affecting patients
with eating disorders is ventricular tachyarrhythmia.26This condition is
more common in patients who have been chronically starved. There
have not been consistent findings regarding abnormal contractility in
the literature. Mitral valve prolapse has been associated with significant
weight loss, but this is a functional abnormality caused by a decrease in
chamber size relative to the fixed size of the mitral valve and does not
require any treatment other than weight gain.
Orthostatic blood pressure and pulse measurements form the foun-
dation of cardiovascular monitoring in patients with eating disorders. A
baseline electrocardiogram is indicated if there are any concerns based
on the history or physical examination but is not routinely repeated
unless abnormal. Studies have indicated that increases in orthostatic
pulse from supine or sitting to standing indicate the degree of autonomic
balance. In anorexia nervosa, a pulse differential of greater than 30
beats/ min, especially if there is resting bradycardia, suggests excess
vagotonia that is counterbalanced by excess sympathetic tone on stand-
ing.Is In normal-weight patients with bulimia, this pulse differential
more likely indicates hypovolemia resulting from excessive purging.
Regardless of the cause, this abnormality improves with fluid and nutri-
tional rehabilitation and weight gain.

Osteoporosis

Hypoestrogenemic osteoporosis is commonly seen in the amenor-

rheic athlete and young woman with anorexia nervosa.H,22, 25 Although
sex hormone replacement therapy is clearly beneficial to postmenopausal
women with respect to reducing bone loss, there are few data regarding
such treatment for adolescent girls with anorexia nervosa.20Existing
studies are equivocal, many lacking adequate power, time, or both to
detect treatment effect.IO, Because the data are inconclusive and because
the mechanism for starvation-induced amenorrhea differs from that for
1046 KREIPE & BIRNDORF

postmenopausal amenorrhea, patients may be offered the alternative of

sex steroids with the understanding that they may or may not help
preserve bone mineral density. Risks and benefits of treatment with
hormones need to be weighed carefully and individually with the patient
and parents. Many older adolescents are capable of making the decision
for themselves based on the objective benefits and disadvantages of
therapy. Patients who choose hormones should be aware that they may
experience withdrawal bleeding but will not be menstruating; the medi-
cations are working at the level of the endometrium, not the hypothala-
mus.*' The use of transdermal patches, especially those containing com-
bined estrogen and progesterone, may provide an alternative means of
delivering hormones without many of these negative effects.

Amenorrhea

The absence of menses, a hallmark feature of anorexia nervosa in

postmenarcheal girls, is due to hypothalamic dysfunction associated
with starvation and weight Patients who are moderately low
weight because of cystic fibrosis or inflammatory bowel disease are more
likely to maintain menstruation than patients with eating disorders at
similar degrees of thinness. This difference may be due to the fact that
at least 75% of patients with anorexia nervosa also exercise compulsively
and may have cortical suppression of menses because of the stress
associated with an eating disorder. A study suggested that menstrual
suppression is related more to dysfunctional eating habits than weight
per se. Amenorrhea occurs in only about one third of patients with
bulimia who maintain a normal weight.
Shomento and Kreipe2*have conducted long-term follow-up studies
of patients who recovered from anorexia nervosa and found that more
than 90% of them were menstruating regularly. Using a standard formula
for average body weight (ABW) for height (100 lb for 5 ft of height plus
5 lb for each inch over 5 ft tall), the ABW at which patients regained or
established their menses was 92% k 7.4%. That is, a 64-inch patient
(whose ABW is 120 lb) was, on average, 110 lb when she began menstru-
ating. The authors used this formula rather than formal weight charts
to facilitate rapid calculation of the menstrual weight in the office in
response to the frequently asked question, "How much weight do I need
to gain to get my periods back?"
For patients with eating disorders who are having unprotected
sexual intercourse, amenorrhea does not preclude the possibility of con-
ception. Bonne et a12 reported two cases of amenorrheic women with
eating disorders who had unexpected, unplanned, and unintended preg-
nancy, with significant negative results on their emotional health. This
risk is greatest in normal-weight women, who are more likely to be
sexually active than extremely emaciated individuals because cachexia
also tends to be associated with loss of libido, regardless of the cause of
weight loss. In addition to being more likely to have a normal weight,
 EATING DISORDERS IN ADOLESCENTS AND YOUNG ADULTS 1047

patients with bulimia are more likely than those with anorexia nervosa
to have a history of sexual abuse as well as engage in promiscuous
sexual activity. Normal-weight amenorrheic patients with this profile
deserve special attention to prevent pregnancy.
The history of amenorrhea did not necessarily have significant long-
term effects on fertility, if patients were eventually able to achieve and
maintain weight in the target range. It appears as if patients may need
to gain more weight to begin to ovulate than they do to menstruate.
That is, some patients reported regaining menses at around 90% of ABW
but having difficulty conceiving. When they gained to around 100% of
ABW, they were able to conceive. Data from the authors’ program
suggest that a history of anorexia nervosa does not in itself increase the
risk of infertility as long as the patient is able to gain weight to within
a normal range and maintain relatively normal eating and weight-
control habits.
For young adults with an eating disorder who are seeking advice
regarding fertility, the authors recommend that they focus on eating and
exercising healthfully and attend to mental health issues that may be
underlying body image distortion, rather than to focus on weight. If
they normalize their eating and activity habits, the weight normalizes
on its own. The fear of gaining excess weight may be quite strong, so a
gradual weight gain is recommended. Gaining weight by eating large
meals is contraindicated because it may trigger binge eating. Eating three
balanced meals and at least one snack daily minimizes the likelihood of
patients with anorexia nervosa developing bulimia. If the patient regains
menses but still has difficulty becoming pregnant, the best advice is to
gain a small amount of more weight. The addition of only 2 or 3 lb
appears to be sufficient to result in ovulation. The use of ovulation
induction with clomiphene should be considered only if the patient is
maintaining a normal weight and appears to have recovered from her
eating di~order.~ In the authors’ follow-up, they learned that a patient
with an active eating disorder and weighing only about 80% of ABW
was given clomiphene, resulting in a pregnancy with triplets. She was
neither physically nor psychologically prepared for this and has had
experienced significant ongoing problems that might have been avoided
had she recovered from her eating disorder before attempting to become
pregnant.

CONCLUSION

Eating disorders are relatively common and frequently result in

medical signs and symptoms. Armed with an appreciation of the protean
manifestations of these complex health problems as well as an apprecia-
tion of the biopsychosocial approach needed to help the adolescent or
young adult woman recover, the primary care physician is in an excellent
position to have a therapeutic role in the recovery from these chronic
conditions. By recognizing the medical aspects of eating disorders, the
1048 KREIPE & BIRNDORF

oversimplified viewpoint of considering them as purely psychiatric disor-

ders can be avoided. Open and consistent communication with patients,
with a focus on health rather than dysfunction and mental illness,
facilitates the acceptance of a comprehensive approach in which the
internist, dietitian, and mental health provider all have a role.

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Address reprint requests to

Richard E. Kreipe, MD
Division of Adolescent Medicine
Department of Pediatrics, Box 690
601 Elmwood Avenue
University of Rochester
Rochester, NY 14642

e-mail: Richard-Kreipe@urmc.rochester.edu