Anorexia seams to affect the nicest girls from good families. The girls are smart, popular in school, and attractive. From the outside, everyone thinks they have it made. From the inside, though it is a living nightmare and it just gets worse and worse. Anorexia creeps up on girls, stalks them until it has them firmly in its grip and by the time, the mother realizes something is wrong, it is too late. The dye is cast and she is already down 15 lbs, withdrawn from her friends, having awful thoughts about herself and thinking about how to do it.

Most parents go immediately into denial. They try to “make it alright.” Dad tries to “fix it.” Of course nothing works. They eventually take her to the pediatrician. Sometimes you’re lucky and he or she realizes how serious this is and gets the girl to the local expert. That can be a lifesaver. If the pediatrician or more likely today the PA is clueless, the problem was brushed off and of course, the parents are even more lost.

After a lot of hard work the parents finally find out what the problem is then there is the new problem. Your insurance company only pays for in-network providers, the number of visits to them is limited, and the place of service where she can be treated is limited. To your dismay, the best practitioners for anorexia in your area are not in network. The ones that are have little or no experience treating anorexia. The plan will not approve a residential treatment program, which is often necessary for the most ill girls.

From Wikipedia: Anorexia nervosa, often referred to simply as anorexia is an eating disorder characterized by a low weight, fear of gaining weight, a strong desire to be thin, and food restriction. Many people with anorexia see themselves as overweight even though they are in fact underweight. If asked they usually deny they have a problem with low weight. Often they weigh themselves frequently, eat only small amounts, and only eat certain foods. Some will exercise excessively, force themselves to vomit, or use laxatives to produce weight loss.

Complications include osteoporosis, infertility, and heart damage, among others.  Women will often stop having menstrual periods.

The cause is not known. There appear to be some genetic components with identical twins more often affected than non-identical twins. Cultural factors also appear to play a role with societies that value thinness having higher rates of disease. Additionally, it occurs more commonly among those involved in activities that value thinness such as high-level athletics, modeling, and dancing. Anorexia often begins following a major life-change or stress-inducing event. The diagnosis requires a significantly low weight. The severity of disease is based on body mass index (BMI) in adults with mild disease having a BMI of greater than 17, moderate a BMI of 16 to 17, severe a BMI of 15 to 16, and extreme a BMI less than 15. In children, a BMI for age percentile of less than the 5th percentile is often used.

The patients I have seen with anorexia a very like those described in Wikipedia. The condition rarely affects men. It always begins in adolescent girls but extends well into the life of young adult women. It is seen in middle aged and older women who survive.

Some women have a variant called Anorexia Athletica. These women exercise excessively and keep their weight below healthy levels with a combination of exercise and food restriction. Running is the exercise of choice for these women and a sign that they are at risk for this condition is when the exceed 25 miles of roadwork each week. At that threshold, it is common for them to experience loss of the menses. The combination of amenorrhea, excess exercise of any type, and a BMI < 17 is diagnostic of anorexia athletica

The stress from starvation and/or excessive exercise and the physiologic effect of the emotional impact of the psychiatric disease results is suppression of the gonadotropins in the pituitary. When the gonadotropins are suppressed, the ovaries shut down and the menses cease. Ovarian production of estrogen and testosterone ceases, as does the release of eggs.

The adrenal gland continues to secrete DHEA, which becomes to only source of estrogen and testosterone for women with ovarian failure. This alternative supply is inadequate to prevent bone growth interruption in the girls affected by anorexia. During adolescence, girls are modeling their skeleton into its adult form. During modeling, the adolescent is adding a significant percentage of the adult bone structure and mineral to the skeleton. One of the consequences of ovarian failure is to halt bone modeling. This interruption if prolonged results in a permanent deficit in her adult bone mass. The bone mass is both the structure of the bone tissue and the bone mineral that is stored there. When girls suffer with anorexia for years and become young women with this disease, for the reasons cited they, fail to achieve and normal peak bone mass. It is common for them to cease growing their bones while they are still in the osteoporosis range. Untreated, they will never achieve a normal bone mass. In the past, it was impossible to correct this but now this can be treated.

Except for the bone mass, the bone tissue in girls and women with anorexia is normal. It is healthy happy bone, just reduced in amount. Because it is good quality human bone, it is able to respond to the growth signals modern medical scientists at Lilly, Amgen, and Radius have discovered, tested, and proven to be safe and effective for treating people with osteoporosis. This new class of drugs is called biologicals and they work by different ways to persuade the cells to make and breakdown bone to restore the health of the skeleton and prevent fractures due to osteoporosis. There are 4 of the drugs available now that are perfect answers for women with anorexia in remission who are now ready to deal with their osteoporosis and put things right.

In my opinion, the most important thing is to stabilize the patients underlying psychiatric condition first. Until this is accomplished, it is fruitless to employ one of the biologicals. Girls and women with this disorder are not easy to work with. They have been often been traumatized by the healthcare system especially if they have had life threatening disease. Everyone who cares for these women has difficult providing adequate care because they are often so needy. There is not enough insurance reimbursement to cover the cost of what these girls and women actually need and deserve.

Atlanta Acute Care Anorexia Resources
Page Love, RD is someone who has dedicated her practice to helping girls and women with this and other eating disorders recover. With Nutri Fit Sport Therapy Inc., Page has branched out into all areas of nutrition and fitness but you can bet that there will always be a special place in her heart for girls with anorexia. She offers a total outpatient package that is very therapeutic without being clinical. Page has a number of caring young women on her team who work closely with the clients, especially the girls with anorexia. She has a comprehensive program in Atlanta that addresses all aspects of the issue and I highly recommend her for those seeking answers and help. Visit her website, and make an appointment to see her or one of her staff nutritionists to discuss your specific issues.

Atlanta is also home to the Center for Discovery that offers a complete program for managing girls and women with anorexia. Here is a comment from their website:

An eating disorder is a complex psychological condition characterized by abnormal eating habits that can significantly impact an individual’s quality of life, interpersonal relationships, occupational functioning, and overall wellness. Eating disorders arise from underlying triggers such as past trauma, abuse, poor coping mechanisms, low-self esteem, difficulty communicating negative emotions, difficulty resolving conflict, and a perfectionist personality and they often lead to intense emotional pain and suffering. Without some form of intervention or treatment, an eating disorder can become chronic, have devastating emotional and physical consequences, and can be life-threatening. Eating disorders, specifically anorexia nervosa, have the highest mortality rate out of all mental health disorders worldwide. Center For Discovery Atlanta, GA specializes in treating the following eating disorders: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Orthorexia Nervosa, Compulsive Overeating, and Selective Eating Disorder (ARFID).

Medical Management of Unstable Ammenorrhetic Girls and Women due to Anorexia
As a stopgap measure before instituting complex and expensive restorative therapy, is to place these girls and young women on birth control pills and a1 mg topical testosterone supplement. This will ameliorate the loss of estrogen and testosterone that characterizes ovarian failure. The testosterone is anabolic and without it, women will not maintain their muscle and bone mass as well and cannot make new muscle. Estrogen is will prevent loss of female characteristics, hold vasomotor symptoms at bay, restore normal sex steroid related sleep patterns and a host of other benefits. Administering the BCP cyclically will establish a regular menses that helps to support a regular life pattern that is age and gender appropriate. These should be continued until the patient is in remission and/or wishes to try to become pregnant.

Treatment of Women with Osteoporosis Due to Anorexia In a Stable Remission
In my experience, anorexia does go into remission in most women in the 30s when they are able to live normal lives. Once settled down and in a steady remission they are in a position to deal with the osteoporosis. It is not necessary to add osteoporosis to the treatment mix when other more critical issues confront the patient and must be properly managed first.

When they are ready, Forteo, 1-34 parathyroid hormone is my drug of choice to help these women. This bone-building anabolic hormone is able to restore the bone she never built due to her disease. After Forteo restores her bone mass to a nearly normal level, other treatment will be needed to guarantee it remains. One approach is use of prescription bioidentical balanced hormone supplement. This means topical estradiol, DHEA, and testosterone. The supplement is low dose and will support her endogenous sex hormone production. It is not a high enough dose to suppress her gonadotropins. This means she will have normal menstrual cycles and could become pregnant if she wished to. If she was planning to do that, the hormone supplement would be stopped because even the low dose might interfere.

The combination of her natural ovarian sex hormones and those in the supplement are usually adequate to protect the bone mass developed on Forteo. If DXA monitoring shows bone is being lost, Prolia therapy is added. It is also necessary to ensure adequate calcium and vitamin D nutrition. Moderate, regular exercise and sensible nutrition that has a balance of proteins, fats, and carbohydrates is essential. Maintaining a healthy weight and body image goes hand in hand with maintaining a durable recovery.