Anorexia nervosa patients who gain weight while being treated often spiral back into the eating disorder. Now new research may shed some light on why relapse rates are so high.
The study shows that women who seemed to be getting better while participating in a hospital-based behavioral treatment program continued to show disturbed eating behaviors when their food intake was not carefully monitored.
Although the women had regained much of their lost weight with treatment and had shown improvements in depression and other psychological symptoms, they ate far fewer calories when given an unrestricted test meal than women without anorexia.
"We saw a lot of psychological changes over the course of hospitalization," researcher Robyn Sysko of the Rutgers University Eating Disorders Clinic tells WebMD. "But when given more control over their eating, these patients still tended to eat less than they should."
Eating Behaviors Examined
Nine out of 10 anorexics are female, and most develop the disorder as preteens, teens, or young adults.
Research suggests that one in three women treated as inpatients for the eating disorder experiences a relapse within two years of discharge from the hospital.
Improvements in psychological symptoms and weight have been documented during hospitalization for anorexia nervosa. But it is not clear whether a similar improvement in eating occurs, Sysko and colleagues write in the August issue of the American Journal of Clinical Nutrition.
To test this, the researchers fed 12 hospitalized women with anorexia and 12 women without eating disorders the same number of calories at breakfast followed by an unrestricted-calorie test meal at lunch.
The test meal consisted of a large strawberry yogurt shake. Study participants were told to drink as much or as little as they liked. The anorexic patients were given the test both early in their hospital stay and later, after they had gained back a good deal of weight.
The nonanorexic study participants ended up drinking about half of their shakes, taking in approximately 500 calories. Early in treatment the anorexic patients took in about 145 calories at the test meal, and later in treatment they took in 240 — still less than half of that eaten by the women without anorexia nervosa.
During both test meals, the hospitalized patients took in fewer calories than they would have if they had been eating their regular, supervised lunch.
"The fact that these patients didn't show as much improvement in eating behavior as they did in other aspects of their treatment illustrates the importance of continuing care once hospitalization ends," Sysko says.
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Follow-Up a Must
National Eating Disorders Association spokeswoman Sondra Kronberg, MF-RD, CDN, couldn't agree more. She tells WebMD that weight gain is only a first step in anorexia treatment.
"Restoring someone's weight is certainly a necessary aspect of treatment because a starving brain isn't going to respond well to therapy," she says. "But addressing the underlying emotional issues that led to the disorder and the behavioral issues that make it so hard to get better is also critical. That really can't be done in a month or two of treatment."
Kronberg says these days insurance or other medical coverage rarely pays for hospital stays of much longer than this and that critical follow-up care may not be available. She is director and co-founder of Eating Disorder Associates Treatment and Referral Centers in New York City.
The stakes are high, Kronberg says, because the death rate from anorexia nervosa is greater than for any other mental illness.
"There is a big difference between a hospital program where someone is making the food choices for you and the real world," she says. "In the hospital setting patients can either comply or not comply. Those are their only two choices. But in the real world they face constant choices about food. And with anorexia, thought processes become so ingrained that what you learn over a few months of treatment may not stack up well to what your brain has been telling you for years."
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By Salynn Boyles, Reviewed by Michael W. Smith, MD
SOURCES: Sysko, R. American Journal of Clinical Nutrition, August 2005; vol 82: pp 296-301. Robyn Sysko, doctoral candidate, Rutgers University Eating Disorders Clinic, Piscataway, N.J. Sondra Kronberg, MF-RD, CDN, spokeswoman, National Eating Disorders Association; director and co-founder, Eating Disorder Associates Treatment and Referral Centers, New York City. WebMD Medical News: "Women with Anorexia Nervosa Often Relapse."
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