Medical Research Needs for Treating Patients with Anorexia Nervosa and Bulimia Nervosa
By Philip S. Mehler, MD, FACP, FAED
In last month’s article we reviewed some of the 2014 medical research highlights in eating disorders. Herein we will define some research studies that are sorely needed to help improve the medical care of these patients. They are:
- For the patient with anorexia nervosa it would be extremely helpful to definitively know what body mass index (BMI) is associated with a significant likelihood of gastroparesis and above what BMI it is usually not an issue. Such a study would help direct optimization of the early phases of refeeding.
- Currently there exists marked disparity in refeeding rates, initial calorie levels and the composition of the meal plans for patients with anorexia nervosa. These inconsistencies in refeeding practices create uncertainty as to the optimal administration of nutrition, their archetypal basic life support. A well-designed interventional large study is therefore needed that compares the physiological impact of different energy intakes and compositions for patients with anorexia nervosa.
- Given the high prevalence of osteoporosis in patients with anorexia nervosa, prospective studies and randomized controlled trials are needed to determine clinical risk factors for this devastating and perhaps permanent complication of anorexia nervosa, both in adolescents and adults. In addition, rigorous head to head trials are needed which compare bisphosphonates with parathyroid hormone congeners (teriparatide) to elucidate the most efficacious medication to improve bone mineral density.
- The development of substantial edema with cessation of purging behaviors is a substantial barrier to recovery early in the treatment of patients with bulimia nervosa. Defining laboratory and clinical risk factors which predict the development of edema will help guide clinicians to proactively institute measures to reduce this risk, such as for whom and when to use spironolactone.
- Similarly, patients with bulimia nervosa often perseverate on the potential for edema formation, which distracts the early phases of their recovery and their ceasing to continue purging. Research studies are needed to define how long aldosterone levels remain elevated and predispose these patients to an ongoing risk for edema formation.
- The consequences of excessive stimulant laxative abuse can have devastating long-term complications in the form of the cathartic colon syndrome wherein the colon is transformed into an inert tube incapable of propagating fecal material. Formal studies to define the amount of laxative abuse that predisposes to this devastating syndrome will help guide how clinicians counsel these patients about their aberrant behaviors.
There are many other medical questions for which properly designed research studies might help to improve the prognosis for these patients. For instance, do abnormalities in the heart muscle persist after weight restoration? What types of ventricular arrhythmias are causative for sudden cardiac death in anorexia nervosa? Are patients who purge via self-induced vomiting at increased long-term risk for the development of Barrett’s esophagus and esophageal carcinoma? What degree of hypokalemia and metabolic alkalosis predispose patients with bulimia nervosa to dangerous cardiac arrhythmia?
Each of the aforementioned studies, if done with proper rigor and design, would substantially improve the evidence based medicine knowledge for the care of these patients. These and other studies need to be kept in mind as we seek to provide better care for our patients with anorexia nervosa and bulimia nervosa.
About the author –
Philip S. Mehler, MD, FACP, FAED
Philip S. Mehler, MD, FACP, FAED, is the Executive Medical Director & Chief Medical Officer at the Eating Recovery Center in Denver and the Medical Director of ACUTE at Denver Health. A Phi Beta Kappa and an Alpha Omega Alpha Graduate of The University of Colorado School of Medicine. Dr. Mehler is a Professor of Medicine at the University of Colorado School of Medicine where he holds the Glassman Endowed Chair.
He has published over 350 manuscripts in the area of anorexia nervosa and bulimia and hospital quality improvement and two books on the medical complications of eating disorders. Dr. Mehler has been listed in Best Doctors in America since 1996 for eighteen consecutive years and recently in US News & World Report’s as the top 1% of internists. For many years Dr. Mehler has been named by 5280 Magazine as a Top Internal Medicine Physician. He is recognized as a national and international expert in the medical complications of anorexia nervosa. He has won numerous teaching and research awards from the University of Colorado School of Medicine. In June of 2014, Dr. Mehler retired from Denver Health as its Medical Director and Chief Clinical Officer after a 28 year career.