6 ‘M’s to keep in mind when you next see a patient with anorexia nervosa

Anorexia nervosa is associated with comorbid psychiatric disorders, se­vere physical complications, and high mortality. To help you remember im­portant clinical information when working with patients with anorexia, we propose this “6 M” model for screening, treatment, and prognosis.

Monitor closely. Anorexia can go undiag­nosed and untreated for years. During your patients’ office visits, ask about body image, exercise habits, and menstrual irregulari­ties, especially when seeing at-risk youth. During physical examination, reluctance to be weighed, vital sign abnormalities (eg, or­thostatic hypotension, variability in pulse), skin abnormalities (lanugo hair, dryness), and marks indicating self-harm can serve as diagnostic indicators. Consider hospitaliza­tion for patients at <75% of their ideal body weight, who refuse to eat, or who show vi­tal signs and laboratory abnormalities.

Media. By providing information on healthy eating and nutrition, the Internet can be an excellent resource for people with an eating disorder; however, you should also be aware of the impact of so-called pro-ana Web sites. People with anorexia use these Web sites to discuss their illness, but the sites sometimes glorify eating disorders as a lifestyle choice, and can be a place to share tips and tricks on extreme dieting, and might promote what is known as “thin­spiration” in popular culture.

Meals. The American Dietetic Association recommends that anorexic patients begin oral intake at no more than 30 to 40 kcal/kg/day, and then gradu­ally increase it, with a weight gain goal of 0.5 to 1 lb per week.

This graduated weight gain is done to prevent refeeding syndrome. After chronic starvation, intracellular phosphate stores are depleted and once carbohydrate intake resumes, insulin release causes phosphate to enter cells, thereby leading to hypophos­phatemia. This electrolyte abnormality can result in cardiac failure. As a result, consid­er regular monitoring of phosphate levels, especially during the first week of reintro­ducing food.

Multimodal therapy. Despite be­ing notoriously difficult to treat, pa­tients with anorexia might respond to psychotherapy—especially family thera­py—with an increased remission rate and faster return to health, compared with other forms of treatment. With a multimodal regimen involving proper refeeding tech­niques, family therapy, and medications as appropriate, recovery is possible.

Medications might be a helpful adjunct in patients who do not gain weight despite psychotherapy and proper nutritional mea­sures. For example:

• There is some research on medications such as olanzapine and anxiolytics for treat­ing anorexia.
• A low-dose anxiolytic might benefit patients with preprandial anxiety.
• Comorbid psychiatric disorders might improve during treatment of the eating disorder.
• Selective serotonin reuptake inhibi­tors and second-generation antipsychotics might help manage severe comorbid psy­chiatric disorders.

Because of low body weight and altered plasma protein binding, start medications at a low dosage. The risk of adverse effects can increase because more “free” medica­tion is available. Consider avoiding medi­cations such as bupropion and tricyclic antidepressants, because they carry an in­creased risk of seizures and cardiac effects, respectively.

Morbidity and mortality. Untreated an­orexia has the highest mortality among psychiatric disorders: approximately 5.1 deaths for every 1,000 people.¹ Recent meta-analyses show that patients with anorexia may have a 5.86 times greater risk of death than the general population.¹ Serious sequelae include cardiac com­plications; osteoporosis; infertility; and comorbid psychiatric conditions such as substance abuse, depression, and obsessive-compulsive disorder.²