More frequent than ever, anorexia nervosa is a serious, potentially fatal, behavioral disorder affecting food intake. Receptiveness and listening are most essential to win a patient's trust and provide assistance for problem solving through health rather than through pathology.

Considered for a long time as a whim, anorexia nervosa was identified as a clinical pathological disorder in the XIXth century by Lasègue and Gull. Studies on long term follow-up of patients beyond the first few months following weight restoration unveiled the seriousness of the disease. Epidemiological research showed that within the past ten years, the frequency of anorexia nervosa has risen from 1-2% to 5% of adolescent females. Onset is usually between the ages of 15 and 25, with 95% prevalence among women, and 5% among male adolescent.

Diagnosis of anorexia nervosa is based on the following 5 universal criteria:
- weight loss of more than 15% of usual weight,
- onset of the disorder before 25 years of age,
- severely distorted eating behavior,
- absence of any other physical of psychiatric disorder associated with weight loss,
- morbid fear of weight gain and obesity.

According to Feighner et al., at least two of the following symptoms should also be identified:
- amenorrhea
- lanugo (down on back, cheeks and forearms)
- bradycardia (less than 60 beats per minute)
- hypothermia
- physical hyperactivity
- vomiting
- episodic binge eating (in one third of cases)

Unfortunately, it is often only after considerable weight loss that a diagnosis is made. The first symptoms go unnoticed while they are trivialized, of course, by the patient and family members. In many cases, early treatment could avoid severe weight loss, which is sometimes fatal, as well as other complications from anorexia nervosa (Table 1).

Weight loss indicates the severity of the disease. However, it has to be considered under three criteria:

- total weight loss, i.e. the difference between maximal weight, usually reached just before onset of the disorder, and weight at the time of first consultation;
- rate of weight loss, i.e. total weight loss over the span of time since onset of the disease;
- severity of weight loss, indicated by the body mass index (BMI: weight/height²), measured in absence of edema or ascites. Normal BMI values for young women range from 18.5 to 23 kg/m². Anorexia nervosa is considered moderate if the BMI falls below 17.5, severe below 15, and critical for vital functions below 12.5 kg/m².

Complications from anorexia nervosa may be linked to a prolonged energetic deprivation that leads to a cachectic state, but also to repeated self-induced vomiting episodes, observed in one third of cases. An almost total loss of adipose tissue, considerable muscle atrophy, dry skin with micro-circulation defects and acrocyanosis, disseminated lunago and arterial hypotension are as many factors indicating the gravity of the disease. Edema appears in extreme cases as well as severe hypoalbuminemia. On a biological level, especially in presence of vomiting, iron deficiency anemia and hypokalemia are to be investigated (Table 2).

* To be measured for clinical use.
Table 2
From SCHEEN A.J., 1995

There are four absolute and closely related objectives to keep in mind during the long and difficult treatment:
- to reach a minimal normal weight: BMI of 18.5 kg/m2,
- to reach an energy intake that will maintain such a weight,
- to develop a normal eating behavior "without fear and without guilt",
- to open mental doors: right to speak out, struggle against anguish and poor self-esteem, but also against narcissism and perfectionism.

For the patient to reach a minimal normal weight, she should be asked to maintain a food diary so the physician may measure qualitatively and quantitatively her daily food intake. Slowly, she will be encouraged to progressively reintroduce fats and complex carbohydrates, two nutrients usually excluded first from diets of patients suffering from anorexia nervosa. These two objectives go hand in hand, as a satisfying weight could not be attained without satisfying energy and quality food intakes. Butter and seasoning oils that have been long absent from the diet will be reintroduced. So will starchy foods, first in small amounts, to gradually reach 200 to 250 g per meal a few weeks later. Protein intake is usually maintained better in cases of anorexia nervosa, although patients often suffer from red meat phobia (long before mad cow's disease). By recommending mixed food preparations or exotic recipes (as a Chinese dish), we can easily bring these young women to eat red meat at least twice a week.

Linked to the two initial objectives, a third is to develop a normal eating behavior "without fear and without guilt". During discussions with the patient, food behavior has to be depicted as an answer to vital needs, but also as an individual and a shared pleasure. Meals with family and friends will be encouraged. Surrounded by people who are not as concerned about her food intake, the patient may find a peaceful setting to enjoy a shared moment around food. We have to beware, however, that she does fall into a bulimic behavior, with the suicide risk that it entails.

The fourth objective is at the center of anorexia nervosa. According to Jeammet: anorexia nervosa frequently appears as "an answer to rather common problems that are part of the personality changes encountered during adolescence". Rapidly, an anorexic behavior looses touch with the causes that brought it up and becomes an almost automatic answer to any tension. That explains why, at first, besides their food behavior problem these patients are easily approachable and seem to have no conflict at all, especially to people close to them who never complain about these "problemless children". It is important to rapidly intervene to prevent the patient from reorganizing her pleasure habits, her methods of dealing with tensions and her relationship patterns around her food behavior. A true therapeutic mobilization is suggested:
- by encouraging discussions with parents and putting an emphasis on the importance of the father figure (often missing),
- by prescribing, if necessary, massage or relaxation sessions that will allow the rediscovery of a realistic body image and diminish the inner fight against the fear to regain weight,
- by suggesting fixed and repeated appointments, many in the beginning, to incite the patient to verbalize some of her conflicts. By considering only a reduction of symptoms, patients of all ages that are left to themselves develop a serious risk of relapse.

Anorexia nervosa is a serious behavioral disorder affecting food intake characterized by the desire to be thin, the fear to eat and of becoming obese. The starvation state it causes can become extremely severe and eventually lead to death. Treatment of an anorexic patient takes a lot of patience, but also a lot of hindsight for not being fooled by an often manipulative attitude. It is possible to treat this disease without hospitalization. Nevertheless, physicians must always know their limits and never hesitate to require a hospitalization for nutrition support. Even in the most severe cases, nutrition therapy should not be at the expense of active listening, which will guide patients to find healthier ways of problem solving than through a pathology of self-denial.

Dr Agnès MOUTON-GENSBURGER
Dr. Daniel RIGAUD
Paris

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