Somatic Disorders

CHICAGO – Patients who were suffering from depression at the time of malignant brain astrocytoma surgery had significantly reduced survival compared with nondepressed patients in a retrospective analysis of 1,052 patients.

Although no causative association can be inferred because of the study's retrospective design, recognizing and treating preoperative depression could maximize survival in patients with malignant brain tumors, said Dr. Alfredo Quiñones-Hinojosa at the annual meeting of the American Association of Neurological Surgeons.

Currently, patient age, tumor grade, and functional status are known preoperative prognostic indicators of survival. Identification of any reversible comorbidity would be important, as malignant astrocytoma, also known as glioma or glioblastoma multiforme, typically results in death in about 1 year, even with the latest, most effective therapies.

Researchers at Johns Hopkins School of Medicine in Baltimore, led by Dr. Matthew J. McGirt, analyzed the outcomes of 1,052 patients with malignant astrocytoma who underwent surgery from 1995 to 2006.

Of these patients, 605 underwent primary resection, 410 underwent secondary resection, and 37 had a biopsy only. Excluding the biopsies, 213 tumors were World Health Organization grade III and 802 tumors were grade IV. A total of 204 patients received subtotal resection, 274 received adjuvant therapy, and 136 required subsequent resection.

Only 49 patients (5%) who were taking antidepressant medication for clinical depression at the time of the surgery met the study's definition of having depression.

All demographic and clinical characteristics were similar between the two groups, said Dr. Quiñones-Hinojosa. Their mean age was 51 years and median preoperative Karnofsky Performance Scale (KPS) score was 80. Among survivors, the median follow-up was 12 months (range 3–18 months).

In a Kaplan Meier analysis, patients with depression had more than a 40% increase in the relative risk of mortality compared with nondepressed patients (relative risk 1.41), regardless of KPS, WHO tumor grade, patient age, or clinical presentation.

Median survival was 7 months among patients with depression, compared with 11 months in those without depression. At 2 years post surgery, 5% of patients with depression were alive, compared with 23% of nondepressed patients. The difference was significant.

Dr. Quiñones-Hinojosa acknowledged that the investigators could not be certain that the patients' depression was not a response to the recent diagnosis of a terminal disease. In addition, many patients with clinical depression may have been undiagnosed and unmedicated.

CHICAGO – Patients who were suffering from depression at the time of malignant brain astrocytoma surgery had significantly reduced survival compared with nondepressed patients in a retrospective analysis of 1,052 patients.

Although no causative association can be inferred because of the study's retrospective design, recognizing and treating preoperative depression could maximize survival in patients with malignant brain tumors, said Dr. Alfredo Quiñones-Hinojosa at the annual meeting of the American Association of Neurological Surgeons.

Currently, patient age, tumor grade, and functional status are known preoperative prognostic indicators of survival. Identification of any reversible comorbidity would be important, as malignant astrocytoma, also known as glioma or glioblastoma multiforme, typically results in death in about 1 year, even with the latest, most effective therapies.

Researchers at Johns Hopkins School of Medicine in Baltimore, led by Dr. Matthew J. McGirt, analyzed the outcomes of 1,052 patients with malignant astrocytoma who underwent surgery from 1995 to 2006.

Of these patients, 605 underwent primary resection, 410 underwent secondary resection, and 37 had a biopsy only. Excluding the biopsies, 213 tumors were World Health Organization grade III and 802 tumors were grade IV. A total of 204 patients received subtotal resection, 274 received adjuvant therapy, and 136 required subsequent resection.

Only 49 patients (5%) who were taking antidepressant medication for clinical depression at the time of the surgery met the study's definition of having depression.

All demographic and clinical characteristics were similar between the two groups, said Dr. Quiñones-Hinojosa. Their mean age was 51 years and median preoperative Karnofsky Performance Scale (KPS) score was 80. Among survivors, the median follow-up was 12 months (range 3–18 months).

In a Kaplan Meier analysis, patients with depression had more than a 40% increase in the relative risk of mortality compared with nondepressed patients (relative risk 1.41), regardless of KPS, WHO tumor grade, patient age, or clinical presentation.

Median survival was 7 months among patients with depression, compared with 11 months in those without depression. At 2 years post surgery, 5% of patients with depression were alive, compared with 23% of nondepressed patients. The difference was significant.

Dr. Quiñones-Hinojosa acknowledged that the investigators could not be certain that the patients' depression was not a response to the recent diagnosis of a terminal disease. In addition, many patients with clinical depression may have been undiagnosed and unmedicated.

CHICAGO – Patients who were suffering from depression at the time of malignant brain astrocytoma surgery had significantly reduced survival compared with nondepressed patients in a retrospective analysis of 1,052 patients.

Although no causative association can be inferred because of the study's retrospective design, recognizing and treating preoperative depression could maximize survival in patients with malignant brain tumors, said Dr. Alfredo Quiñones-Hinojosa at the annual meeting of the American Association of Neurological Surgeons.

Currently, patient age, tumor grade, and functional status are known preoperative prognostic indicators of survival. Identification of any reversible comorbidity would be important, as malignant astrocytoma, also known as glioma or glioblastoma multiforme, typically results in death in about 1 year, even with the latest, most effective therapies.

Researchers at Johns Hopkins School of Medicine in Baltimore, led by Dr. Matthew J. McGirt, analyzed the outcomes of 1,052 patients with malignant astrocytoma who underwent surgery from 1995 to 2006.

Of these patients, 605 underwent primary resection, 410 underwent secondary resection, and 37 had a biopsy only. Excluding the biopsies, 213 tumors were World Health Organization grade III and 802 tumors were grade IV. A total of 204 patients received subtotal resection, 274 received adjuvant therapy, and 136 required subsequent resection.

Only 49 patients (5%) who were taking antidepressant medication for clinical depression at the time of the surgery met the study's definition of having depression.

All demographic and clinical characteristics were similar between the two groups, said Dr. Quiñones-Hinojosa. Their mean age was 51 years and median preoperative Karnofsky Performance Scale (KPS) score was 80. Among survivors, the median follow-up was 12 months (range 3–18 months).

In a Kaplan Meier analysis, patients with depression had more than a 40% increase in the relative risk of mortality compared with nondepressed patients (relative risk 1.41), regardless of KPS, WHO tumor grade, patient age, or clinical presentation.

Median survival was 7 months among patients with depression, compared with 11 months in those without depression. At 2 years post surgery, 5% of patients with depression were alive, compared with 23% of nondepressed patients. The difference was significant.

Dr. Quiñones-Hinojosa acknowledged that the investigators could not be certain that the patients' depression was not a response to the recent diagnosis of a terminal disease. In addition, many patients with clinical depression may have been undiagnosed and unmedicated.

CHICAGO – The novel investigational sleep agent eplivanserin improves sleep continuity in patients with chronic primary insomnia without causing next-day drowsiness or rebound insomnia upon discontinuation, clinical trials show.

Eplivanserin's developer, Sanofi-Aventis, is gearing up for the European launch of the drug in 2009 based upon favorable comments from the European drug agency. In addition, the company, which has funded three completed phase III clinical trials, is preparing to file for marketing approval in the United States and Canada, Pierre Gervais said at the annual American Psychiatric Association Institute on Psychiatric Services.

Eplivanserin is the furthest along in development of a new nonsedating drug class known as ASTARs, or Antagonists of Serotonin Two A Receptors. Many sleep disorder experts expect the ASTARs to take over a major chunk of the insomnia treatment market now dominated by zolpidem and other drugs acting on the γ-aminobutyric acid-A receptor, said Mr. Gervais, a pharmacist at Q&T Research of Sherbrooke, Quebec, an independent clinical research firm hired by Sanofi-Aventis to participate in an eplivanserin trial.

He reported on a trial of 351 adults with chronic insomnia who were randomized double blind to 4 weeks of either 1 mg or 5 mg of eplivanserin or placebo in the evening. The 5-mg dose, which is what will be marketed, resulted in a mean 39-minute reduction in the baseline 84-minute wake time after sleep onset. This was significantly greater than the mean 26-minute reduction with placebo.

Also, eplivanserin at 5 mg/day resulted in a 64% reduction in the number of nocturnal awakenings, compared with a 36% decrease with placebo. More eplivanserin-treated patients reported a significant improvement in the refreshing quality of sleep.

The side effect profile of eplivanserin mimicked that of placebo. The exception was dry mouth, which was reported by 1.7% of the placebo group and 5.3% of patients on 5 mg/day of eplivanserin.

The ASTAR was not associated with next-morning drowsiness or difficulty in concentration.

CHICAGO – The novel investigational sleep agent eplivanserin improves sleep continuity in patients with chronic primary insomnia without causing next-day drowsiness or rebound insomnia upon discontinuation, clinical trials show.

Eplivanserin's developer, Sanofi-Aventis, is gearing up for the European launch of the drug in 2009 based upon favorable comments from the European drug agency. In addition, the company, which has funded three completed phase III clinical trials, is preparing to file for marketing approval in the United States and Canada, Pierre Gervais said at the annual American Psychiatric Association Institute on Psychiatric Services.

Eplivanserin is the furthest along in development of a new nonsedating drug class known as ASTARs, or Antagonists of Serotonin Two A Receptors. Many sleep disorder experts expect the ASTARs to take over a major chunk of the insomnia treatment market now dominated by zolpidem and other drugs acting on the γ-aminobutyric acid-A receptor, said Mr. Gervais, a pharmacist at Q&T Research of Sherbrooke, Quebec, an independent clinical research firm hired by Sanofi-Aventis to participate in an eplivanserin trial.

He reported on a trial of 351 adults with chronic insomnia who were randomized double blind to 4 weeks of either 1 mg or 5 mg of eplivanserin or placebo in the evening. The 5-mg dose, which is what will be marketed, resulted in a mean 39-minute reduction in the baseline 84-minute wake time after sleep onset. This was significantly greater than the mean 26-minute reduction with placebo.

Also, eplivanserin at 5 mg/day resulted in a 64% reduction in the number of nocturnal awakenings, compared with a 36% decrease with placebo. More eplivanserin-treated patients reported a significant improvement in the refreshing quality of sleep.

The side effect profile of eplivanserin mimicked that of placebo. The exception was dry mouth, which was reported by 1.7% of the placebo group and 5.3% of patients on 5 mg/day of eplivanserin.

The ASTAR was not associated with next-morning drowsiness or difficulty in concentration.

CHICAGO – The novel investigational sleep agent eplivanserin improves sleep continuity in patients with chronic primary insomnia without causing next-day drowsiness or rebound insomnia upon discontinuation, clinical trials show.

Eplivanserin's developer, Sanofi-Aventis, is gearing up for the European launch of the drug in 2009 based upon favorable comments from the European drug agency. In addition, the company, which has funded three completed phase III clinical trials, is preparing to file for marketing approval in the United States and Canada, Pierre Gervais said at the annual American Psychiatric Association Institute on Psychiatric Services.

Eplivanserin is the furthest along in development of a new nonsedating drug class known as ASTARs, or Antagonists of Serotonin Two A Receptors. Many sleep disorder experts expect the ASTARs to take over a major chunk of the insomnia treatment market now dominated by zolpidem and other drugs acting on the γ-aminobutyric acid-A receptor, said Mr. Gervais, a pharmacist at Q&T Research of Sherbrooke, Quebec, an independent clinical research firm hired by Sanofi-Aventis to participate in an eplivanserin trial.

He reported on a trial of 351 adults with chronic insomnia who were randomized double blind to 4 weeks of either 1 mg or 5 mg of eplivanserin or placebo in the evening. The 5-mg dose, which is what will be marketed, resulted in a mean 39-minute reduction in the baseline 84-minute wake time after sleep onset. This was significantly greater than the mean 26-minute reduction with placebo.

Also, eplivanserin at 5 mg/day resulted in a 64% reduction in the number of nocturnal awakenings, compared with a 36% decrease with placebo. More eplivanserin-treated patients reported a significant improvement in the refreshing quality of sleep.

The side effect profile of eplivanserin mimicked that of placebo. The exception was dry mouth, which was reported by 1.7% of the placebo group and 5.3% of patients on 5 mg/day of eplivanserin.

The ASTAR was not associated with next-morning drowsiness or difficulty in concentration.

NEW ORLEANS – Anger control appears to have beneficial effects on cardiovascular disease risk in African Americans, and conversely, the expression of anger and hostility may be linked with increased levels of an inflammatory marker of cardiovascular disease in this population.

In a study presented at a meeting sponsored by the International Society on Hypertension in Blacks, an unwillingness to express anger outwardly was significantly negatively associated with LDL cholesterol levels and significantly positively associated with HDL cholesterol levels in a convenience sample of 174 normotensive African American adults.

Anger in the participants was assessed using the 20-item Spielberger Anger Expression scale, and plasma cholesterol and triglyceride levels were measured. Items 1 and 8 of the scale, which assessed anger control (“I control my temper” and “I keep my cool,” respectively), were the “highest endorsed” items on the scale, but only item 15 (“I am angrier than I am willing to admit”) was significantly associated with cholesterol levels, Mildred A. Pointer, Ph.D., of North Carolina Central University, Durham, reported in a poster at the meeting.

Avoiding the outward expression of anger may serve as a survival technique in African Americans as they navigate through life, Dr. Pointer suggested, but it also appears to provide protection against cardiovascular disease by improving the ratio of “good” (HDL) cholesterol to “bad” (LDL) cholesterol, she said.

In a separate study, Den'ee T. Mwendwa, Ph.D., of Howard University, Washington, reported that trait depression and anger/hostility both were significantly positively correlated with C-reactive protein (CRP) levels in a study of 155 African American adults.

The purpose of the study–which is part of an ongoing project to identify biologic and psychosocial predictors of renal health outcomes–was to determine whether trait depression and anger/hostility were associated with increases in CRP levels in a community-based sample of middle-aged African Americans, and it followed previous findings suggesting that depression and anger/hostility traits are associated with cardiovascular disease and stroke, Dr. Mwendwa noted in a poster.

Researchers have suggested that chronic inflammation can result from changes in the immune system that are triggered by negative mood states, and the findings of the current study appear to support this theory. Participants underwent neuropsychological and psychosocial evaluation, and CRP levels were used as a measure of inflammation.

The findings suggest that regular screening for anger and depression would be beneficial in African Americans, Dr. Mwendwa concluded.

NEW ORLEANS – Anger control appears to have beneficial effects on cardiovascular disease risk in African Americans, and conversely, the expression of anger and hostility may be linked with increased levels of an inflammatory marker of cardiovascular disease in this population.

In a study presented at a meeting sponsored by the International Society on Hypertension in Blacks, an unwillingness to express anger outwardly was significantly negatively associated with LDL cholesterol levels and significantly positively associated with HDL cholesterol levels in a convenience sample of 174 normotensive African American adults.

Anger in the participants was assessed using the 20-item Spielberger Anger Expression scale, and plasma cholesterol and triglyceride levels were measured. Items 1 and 8 of the scale, which assessed anger control (“I control my temper” and “I keep my cool,” respectively), were the “highest endorsed” items on the scale, but only item 15 (“I am angrier than I am willing to admit”) was significantly associated with cholesterol levels, Mildred A. Pointer, Ph.D., of North Carolina Central University, Durham, reported in a poster at the meeting.

Avoiding the outward expression of anger may serve as a survival technique in African Americans as they navigate through life, Dr. Pointer suggested, but it also appears to provide protection against cardiovascular disease by improving the ratio of “good” (HDL) cholesterol to “bad” (LDL) cholesterol, she said.

In a separate study, Den'ee T. Mwendwa, Ph.D., of Howard University, Washington, reported that trait depression and anger/hostility both were significantly positively correlated with C-reactive protein (CRP) levels in a study of 155 African American adults.

The purpose of the study–which is part of an ongoing project to identify biologic and psychosocial predictors of renal health outcomes–was to determine whether trait depression and anger/hostility were associated with increases in CRP levels in a community-based sample of middle-aged African Americans, and it followed previous findings suggesting that depression and anger/hostility traits are associated with cardiovascular disease and stroke, Dr. Mwendwa noted in a poster.

Researchers have suggested that chronic inflammation can result from changes in the immune system that are triggered by negative mood states, and the findings of the current study appear to support this theory. Participants underwent neuropsychological and psychosocial evaluation, and CRP levels were used as a measure of inflammation.

The findings suggest that regular screening for anger and depression would be beneficial in African Americans, Dr. Mwendwa concluded.

NEW ORLEANS – Anger control appears to have beneficial effects on cardiovascular disease risk in African Americans, and conversely, the expression of anger and hostility may be linked with increased levels of an inflammatory marker of cardiovascular disease in this population.

In a study presented at a meeting sponsored by the International Society on Hypertension in Blacks, an unwillingness to express anger outwardly was significantly negatively associated with LDL cholesterol levels and significantly positively associated with HDL cholesterol levels in a convenience sample of 174 normotensive African American adults.

Anger in the participants was assessed using the 20-item Spielberger Anger Expression scale, and plasma cholesterol and triglyceride levels were measured. Items 1 and 8 of the scale, which assessed anger control (“I control my temper” and “I keep my cool,” respectively), were the “highest endorsed” items on the scale, but only item 15 (“I am angrier than I am willing to admit”) was significantly associated with cholesterol levels, Mildred A. Pointer, Ph.D., of North Carolina Central University, Durham, reported in a poster at the meeting.

Avoiding the outward expression of anger may serve as a survival technique in African Americans as they navigate through life, Dr. Pointer suggested, but it also appears to provide protection against cardiovascular disease by improving the ratio of “good” (HDL) cholesterol to “bad” (LDL) cholesterol, she said.

In a separate study, Den'ee T. Mwendwa, Ph.D., of Howard University, Washington, reported that trait depression and anger/hostility both were significantly positively correlated with C-reactive protein (CRP) levels in a study of 155 African American adults.

The purpose of the study–which is part of an ongoing project to identify biologic and psychosocial predictors of renal health outcomes–was to determine whether trait depression and anger/hostility were associated with increases in CRP levels in a community-based sample of middle-aged African Americans, and it followed previous findings suggesting that depression and anger/hostility traits are associated with cardiovascular disease and stroke, Dr. Mwendwa noted in a poster.

Researchers have suggested that chronic inflammation can result from changes in the immune system that are triggered by negative mood states, and the findings of the current study appear to support this theory. Participants underwent neuropsychological and psychosocial evaluation, and CRP levels were used as a measure of inflammation.

The findings suggest that regular screening for anger and depression would be beneficial in African Americans, Dr. Mwendwa concluded.

KEYSTONE, COLO. – Significant predictors of the onset of disturbed eating behavior within the next several years in girls with type 1 diabetes include concerns with weight and shape, a higher body mass index, depressive symptoms, and poor self-esteem–both globally and specifically with regard to physical appearance, according to a new prospective study.

These are the factors to look out for in clinical practice. Collectively they explained 48% of the variance between young adolescent girls with diabetes who went on to manifest disturbed eating behavior within the next 5 years and those who didn't, Dr. Denis Daneman said at a conference on the management of diabetes in youth.

The study findings raise the possibility that early interventions focused on helping girls who have diabetes develop positive feelings about themselves might protect against later development of disturbed eating behavior.

This hypothesis, however, requires testing, particularly in light of the fact that no successful strategies for the prevention of eating disorders in adolescents and young adults with type 1 diabetes have been reported to date.

Moreover, treatment of eating disorders in this population of girls with type 1 diabetes has proved extremely difficult, much more so than in patients without diabetes, according to Dr. Daneman, who serves as professor and chair of the department of pediatrics at the University of Toronto and pediatrician-in-chief at the Hospital for Sick Children.

The prospective study involved 126 girls with type 1 diabetes who were enrolled at ages 9-13 years at the pediatric hospital and followed for 5 years. They were interviewed annually using the validated, semistructured Eating Disorder Examination.

The study was designed to identify predictors of disturbed eating behavior by following girls as they moved into the peak years of disturbed eating behavior onset, which is ages 15-25, according to Dr. Daneman, who is a pediatrician.

At entry, 25 girls had disturbed eating behavior, defined by dieting for weight control, self-induced vomiting, binge eating, or using insulin omission, laxatives, intense exercise, or diuretics for weight control. An additional 45 girls developed disturbed eating behavior during follow-up (Diabetes Care 2008 July 15 [doi:10.2337/dc08-0333]).

Eating disorders are a huge problem among girls and young women with type 1 diabetes, said Dr. Daneman, who has cowritten nearly two dozen publications on the topic.

His own studies, as well as others conducted in Scandinavia, the United Kingdom, France, and the United States, indicate that 10% of girls with type 1 diabetes in their midteens meet formal DSM-IV criteria for an eating disorder and another 14% have subthreshold eating disorders–that is, their disturbed eating behavior doesn't fulfill DSM-IV criteria for an eating disorder but nonetheless has important clinical consequences, including poor control of blood glucose and early onset of diabetes complications.

The two full-blown DSM-IV eating disorders associated with type 1 diabetes are bulimia nervosa and eating disorder not otherwise specified (EDNOS). Anorexia nervosa is not part of the picture.

“When type 1 diabetes and anorexia nervosa occur together, it's a chance occurrence,” Dr. Daneman said at the conference, which was cosponsored by the Barbara Davis Center for Childhood Diabetes, the University of Colorado, and the Children's Diabetes Foundation at Denver.

Dr. Daneman views it as a major failing of the eating disorders section of DSM-IV that insulin manipulation for the purpose of weight control isn't listed as a major diagnostic criterion.

But he indicated that he is not losing any sleep over the omission, considering what he said is the non-evidence-based nature of the DSM.

KEYSTONE, COLO. – Significant predictors of the onset of disturbed eating behavior within the next several years in girls with type 1 diabetes include concerns with weight and shape, a higher body mass index, depressive symptoms, and poor self-esteem–both globally and specifically with regard to physical appearance, according to a new prospective study.

These are the factors to look out for in clinical practice. Collectively they explained 48% of the variance between young adolescent girls with diabetes who went on to manifest disturbed eating behavior within the next 5 years and those who didn't, Dr. Denis Daneman said at a conference on the management of diabetes in youth.

The study findings raise the possibility that early interventions focused on helping girls who have diabetes develop positive feelings about themselves might protect against later development of disturbed eating behavior.

This hypothesis, however, requires testing, particularly in light of the fact that no successful strategies for the prevention of eating disorders in adolescents and young adults with type 1 diabetes have been reported to date.

Moreover, treatment of eating disorders in this population of girls with type 1 diabetes has proved extremely difficult, much more so than in patients without diabetes, according to Dr. Daneman, who serves as professor and chair of the department of pediatrics at the University of Toronto and pediatrician-in-chief at the Hospital for Sick Children.

The prospective study involved 126 girls with type 1 diabetes who were enrolled at ages 9-13 years at the pediatric hospital and followed for 5 years. They were interviewed annually using the validated, semistructured Eating Disorder Examination.

The study was designed to identify predictors of disturbed eating behavior by following girls as they moved into the peak years of disturbed eating behavior onset, which is ages 15-25, according to Dr. Daneman, who is a pediatrician.

At entry, 25 girls had disturbed eating behavior, defined by dieting for weight control, self-induced vomiting, binge eating, or using insulin omission, laxatives, intense exercise, or diuretics for weight control. An additional 45 girls developed disturbed eating behavior during follow-up (Diabetes Care 2008 July 15 [doi:10.2337/dc08-0333]).

Eating disorders are a huge problem among girls and young women with type 1 diabetes, said Dr. Daneman, who has cowritten nearly two dozen publications on the topic.

His own studies, as well as others conducted in Scandinavia, the United Kingdom, France, and the United States, indicate that 10% of girls with type 1 diabetes in their midteens meet formal DSM-IV criteria for an eating disorder and another 14% have subthreshold eating disorders–that is, their disturbed eating behavior doesn't fulfill DSM-IV criteria for an eating disorder but nonetheless has important clinical consequences, including poor control of blood glucose and early onset of diabetes complications.

The two full-blown DSM-IV eating disorders associated with type 1 diabetes are bulimia nervosa and eating disorder not otherwise specified (EDNOS). Anorexia nervosa is not part of the picture.

“When type 1 diabetes and anorexia nervosa occur together, it's a chance occurrence,” Dr. Daneman said at the conference, which was cosponsored by the Barbara Davis Center for Childhood Diabetes, the University of Colorado, and the Children's Diabetes Foundation at Denver.

Dr. Daneman views it as a major failing of the eating disorders section of DSM-IV that insulin manipulation for the purpose of weight control isn't listed as a major diagnostic criterion.

But he indicated that he is not losing any sleep over the omission, considering what he said is the non-evidence-based nature of the DSM.

KEYSTONE, COLO. – Significant predictors of the onset of disturbed eating behavior within the next several years in girls with type 1 diabetes include concerns with weight and shape, a higher body mass index, depressive symptoms, and poor self-esteem–both globally and specifically with regard to physical appearance, according to a new prospective study.

These are the factors to look out for in clinical practice. Collectively they explained 48% of the variance between young adolescent girls with diabetes who went on to manifest disturbed eating behavior within the next 5 years and those who didn't, Dr. Denis Daneman said at a conference on the management of diabetes in youth.

The study findings raise the possibility that early interventions focused on helping girls who have diabetes develop positive feelings about themselves might protect against later development of disturbed eating behavior.

This hypothesis, however, requires testing, particularly in light of the fact that no successful strategies for the prevention of eating disorders in adolescents and young adults with type 1 diabetes have been reported to date.

Moreover, treatment of eating disorders in this population of girls with type 1 diabetes has proved extremely difficult, much more so than in patients without diabetes, according to Dr. Daneman, who serves as professor and chair of the department of pediatrics at the University of Toronto and pediatrician-in-chief at the Hospital for Sick Children.

The prospective study involved 126 girls with type 1 diabetes who were enrolled at ages 9-13 years at the pediatric hospital and followed for 5 years. They were interviewed annually using the validated, semistructured Eating Disorder Examination.

The study was designed to identify predictors of disturbed eating behavior by following girls as they moved into the peak years of disturbed eating behavior onset, which is ages 15-25, according to Dr. Daneman, who is a pediatrician.

At entry, 25 girls had disturbed eating behavior, defined by dieting for weight control, self-induced vomiting, binge eating, or using insulin omission, laxatives, intense exercise, or diuretics for weight control. An additional 45 girls developed disturbed eating behavior during follow-up (Diabetes Care 2008 July 15 [doi:10.2337/dc08-0333]).

Eating disorders are a huge problem among girls and young women with type 1 diabetes, said Dr. Daneman, who has cowritten nearly two dozen publications on the topic.

His own studies, as well as others conducted in Scandinavia, the United Kingdom, France, and the United States, indicate that 10% of girls with type 1 diabetes in their midteens meet formal DSM-IV criteria for an eating disorder and another 14% have subthreshold eating disorders–that is, their disturbed eating behavior doesn't fulfill DSM-IV criteria for an eating disorder but nonetheless has important clinical consequences, including poor control of blood glucose and early onset of diabetes complications.

The two full-blown DSM-IV eating disorders associated with type 1 diabetes are bulimia nervosa and eating disorder not otherwise specified (EDNOS). Anorexia nervosa is not part of the picture.

“When type 1 diabetes and anorexia nervosa occur together, it's a chance occurrence,” Dr. Daneman said at the conference, which was cosponsored by the Barbara Davis Center for Childhood Diabetes, the University of Colorado, and the Children's Diabetes Foundation at Denver.

Dr. Daneman views it as a major failing of the eating disorders section of DSM-IV that insulin manipulation for the purpose of weight control isn't listed as a major diagnostic criterion.

But he indicated that he is not losing any sleep over the omission, considering what he said is the non-evidence-based nature of the DSM.

KEYSTONE, COLO. – Identifying adolescent type 1 diabetes patients with eating disorders is a lot easier than figuring out how to help them, according to several experts.

“It's a very difficult problem to treat, and none of us knows exactly how to do it,” Dr. Denis Daneman said at a conference on the management of diabetes in youth.

Published reports of treatment success consist of a single case report of a positive outcome with fluoxetine, and a nearly 2-decade-old favorable result with cognitive-behavioral therapy in a small group of patients at the University of Oxford (England).

On the other hand, Dr. Daneman, chair of the department of pediatrics at the University of Toronto, and his colleagues saw no benefit at 6 months' follow-up in terms of glycosylated hemoglobin levels or rates of purging by insulin omission in a study in which 85 girls in a pediatric diabetes clinic who had signs of eating disturbance were randomized to a six-session intensive psychoeducation program or treatment as usual (Int. J. Eat. Disord. 2002;32:230-9).

Rita Temple-Trujillo said helping these young diabetes patients regain control typically involves a one-step-forward/two-steps-back journey. A major frustration, she added, is that traditional eating-disorder treatment programs are seldom helpful. The therapists simply don't understand that the etiology of disturbed eating behaviors in patients with insulin-dependent diabetes is very different from similar behaviors in their usual clientele.

She shared a recent discouraging experience in which, with some difficulty, she got a 20-year-old type 1 diabetes patient and her parents enrolled in an eating-disorders program, only to suffer a major setback.

“When they did the routine lab work and discovered [that her hemoglobin A1c was high], they told us, 'She can't come into our program until she's metabolically stable,'” recalled Ms. Temple-Trujillo, a clinical social worker at the Barbara Davis Center for Childhood Diabetes, which cosponsored the conference along with the University of Colorado and the Children's Diabetes Foundation at Denver.

The irony is that the eating disorder is the reason these young diabetes patients are metabolically unstable.

Dr. Daneman, who is also pediatrician-in-chief at the Hospital for Sick Children, Toronto, discussed the etiologic model of disordered eating in patients with type 1 diabetes that he and Dr. Gary Rodin developed more than 15 years ago. That model holds that the high rate of these pathological behaviors is driven in part by what he termed diabetes-specific vulnerabilities.

These include the insulin-related weight gain that typically occurs just after diabetes is diagnosed. Also, the shift from moderate control of blood glucose to intensive insulin therapy often results in weight gain, which exacerbates feelings of body dissatisfaction and promotes a drive for thinness. The diminished self-esteem accompanying any chronic disease is another factor.

“Nutritional counseling, I believe, is another core feature of diabetes care that lowers the bar,” he said. For example, patients with diabetes are often taught about food differently than are people without diabetes. “And even though we try to demystify the diet and make it less rigid, we're still telling patients to count every gram of carbohydrate they eat. If that isn't dietary restraint, I don't know what is,” the pediatric endocrinologist said.

He predicted that the much-anticipated development of the artificial pancreas will be “a magic bullet,” which will make many of the problems related to disturbed eating behaviors in diabetes patients go away because they will no longer be able to manipulate insulin dosing to control their weight.

When the loop between the continuous glucose monitor and the insulin pump finally gets closed, insulin dosing will be governed by the meter readings without external interference.

'Nutritional counseling … is another core feature of diabetes care that lowers the bar.' DR. DANEMAN

KEYSTONE, COLO. – Identifying adolescent type 1 diabetes patients with eating disorders is a lot easier than figuring out how to help them, according to several experts.

“It's a very difficult problem to treat, and none of us knows exactly how to do it,” Dr. Denis Daneman said at a conference on the management of diabetes in youth.

Published reports of treatment success consist of a single case report of a positive outcome with fluoxetine, and a nearly 2-decade-old favorable result with cognitive-behavioral therapy in a small group of patients at the University of Oxford (England).

On the other hand, Dr. Daneman, chair of the department of pediatrics at the University of Toronto, and his colleagues saw no benefit at 6 months' follow-up in terms of glycosylated hemoglobin levels or rates of purging by insulin omission in a study in which 85 girls in a pediatric diabetes clinic who had signs of eating disturbance were randomized to a six-session intensive psychoeducation program or treatment as usual (Int. J. Eat. Disord. 2002;32:230-9).

Rita Temple-Trujillo said helping these young diabetes patients regain control typically involves a one-step-forward/two-steps-back journey. A major frustration, she added, is that traditional eating-disorder treatment programs are seldom helpful. The therapists simply don't understand that the etiology of disturbed eating behaviors in patients with insulin-dependent diabetes is very different from similar behaviors in their usual clientele.

She shared a recent discouraging experience in which, with some difficulty, she got a 20-year-old type 1 diabetes patient and her parents enrolled in an eating-disorders program, only to suffer a major setback.

“When they did the routine lab work and discovered [that her hemoglobin A1c was high], they told us, 'She can't come into our program until she's metabolically stable,'” recalled Ms. Temple-Trujillo, a clinical social worker at the Barbara Davis Center for Childhood Diabetes, which cosponsored the conference along with the University of Colorado and the Children's Diabetes Foundation at Denver.

The irony is that the eating disorder is the reason these young diabetes patients are metabolically unstable.

Dr. Daneman, who is also pediatrician-in-chief at the Hospital for Sick Children, Toronto, discussed the etiologic model of disordered eating in patients with type 1 diabetes that he and Dr. Gary Rodin developed more than 15 years ago. That model holds that the high rate of these pathological behaviors is driven in part by what he termed diabetes-specific vulnerabilities.

These include the insulin-related weight gain that typically occurs just after diabetes is diagnosed. Also, the shift from moderate control of blood glucose to intensive insulin therapy often results in weight gain, which exacerbates feelings of body dissatisfaction and promotes a drive for thinness. The diminished self-esteem accompanying any chronic disease is another factor.

“Nutritional counseling, I believe, is another core feature of diabetes care that lowers the bar,” he said. For example, patients with diabetes are often taught about food differently than are people without diabetes. “And even though we try to demystify the diet and make it less rigid, we're still telling patients to count every gram of carbohydrate they eat. If that isn't dietary restraint, I don't know what is,” the pediatric endocrinologist said.

He predicted that the much-anticipated development of the artificial pancreas will be “a magic bullet,” which will make many of the problems related to disturbed eating behaviors in diabetes patients go away because they will no longer be able to manipulate insulin dosing to control their weight.

When the loop between the continuous glucose monitor and the insulin pump finally gets closed, insulin dosing will be governed by the meter readings without external interference.

'Nutritional counseling … is another core feature of diabetes care that lowers the bar.' DR. DANEMAN

KEYSTONE, COLO. – Identifying adolescent type 1 diabetes patients with eating disorders is a lot easier than figuring out how to help them, according to several experts.

“It's a very difficult problem to treat, and none of us knows exactly how to do it,” Dr. Denis Daneman said at a conference on the management of diabetes in youth.

Published reports of treatment success consist of a single case report of a positive outcome with fluoxetine, and a nearly 2-decade-old favorable result with cognitive-behavioral therapy in a small group of patients at the University of Oxford (England).

On the other hand, Dr. Daneman, chair of the department of pediatrics at the University of Toronto, and his colleagues saw no benefit at 6 months' follow-up in terms of glycosylated hemoglobin levels or rates of purging by insulin omission in a study in which 85 girls in a pediatric diabetes clinic who had signs of eating disturbance were randomized to a six-session intensive psychoeducation program or treatment as usual (Int. J. Eat. Disord. 2002;32:230-9).

Rita Temple-Trujillo said helping these young diabetes patients regain control typically involves a one-step-forward/two-steps-back journey. A major frustration, she added, is that traditional eating-disorder treatment programs are seldom helpful. The therapists simply don't understand that the etiology of disturbed eating behaviors in patients with insulin-dependent diabetes is very different from similar behaviors in their usual clientele.

She shared a recent discouraging experience in which, with some difficulty, she got a 20-year-old type 1 diabetes patient and her parents enrolled in an eating-disorders program, only to suffer a major setback.

“When they did the routine lab work and discovered [that her hemoglobin A1c was high], they told us, 'She can't come into our program until she's metabolically stable,'” recalled Ms. Temple-Trujillo, a clinical social worker at the Barbara Davis Center for Childhood Diabetes, which cosponsored the conference along with the University of Colorado and the Children's Diabetes Foundation at Denver.

The irony is that the eating disorder is the reason these young diabetes patients are metabolically unstable.

Dr. Daneman, who is also pediatrician-in-chief at the Hospital for Sick Children, Toronto, discussed the etiologic model of disordered eating in patients with type 1 diabetes that he and Dr. Gary Rodin developed more than 15 years ago. That model holds that the high rate of these pathological behaviors is driven in part by what he termed diabetes-specific vulnerabilities.

These include the insulin-related weight gain that typically occurs just after diabetes is diagnosed. Also, the shift from moderate control of blood glucose to intensive insulin therapy often results in weight gain, which exacerbates feelings of body dissatisfaction and promotes a drive for thinness. The diminished self-esteem accompanying any chronic disease is another factor.

“Nutritional counseling, I believe, is another core feature of diabetes care that lowers the bar,” he said. For example, patients with diabetes are often taught about food differently than are people without diabetes. “And even though we try to demystify the diet and make it less rigid, we're still telling patients to count every gram of carbohydrate they eat. If that isn't dietary restraint, I don't know what is,” the pediatric endocrinologist said.

He predicted that the much-anticipated development of the artificial pancreas will be “a magic bullet,” which will make many of the problems related to disturbed eating behaviors in diabetes patients go away because they will no longer be able to manipulate insulin dosing to control their weight.

When the loop between the continuous glucose monitor and the insulin pump finally gets closed, insulin dosing will be governed by the meter readings without external interference.

'Nutritional counseling … is another core feature of diabetes care that lowers the bar.' DR. DANEMAN

CHICAGO – The prevalence of insomnia is roughly three times greater among cancer patients than it is among the general population, according to a secondary analysis of more than 500 patients.

The prevalence of insomnia that meets clinical criteria was 45.6% among cancer patients receiving chemotherapy, which compares with 19% in the general population. An additional 35% of cancer patients had insomnia symptoms, compared with 15% in the general population, reported Oxana Palesh, Ph.D., a radiation oncologist at the University of Rochester (N.Y.), at the annual meeting of the American Society of Clinical Oncology.

Roughly 80% of the patients continued to have insomnia problems throughout chemotherapy. “So insomnia does not go away on its own,” she said.

The researchers also found that the prevalence of insomnia was greatest among lung cancer patients (P less than .05). In addition, younger patients tended to have more insomnia (P less than .05). The researchers found no difference in the prevalence of insomnia between male and female cancer patients.

For the original study, 832 cancer patients were assessed during chemotherapy cycles 1 and 2.

Those found to have fatigue (547 patients) were randomized to receive either 20 mg paroxetine or placebo. Insomnia was assessed using the Hamilton Rating Scale for Depression (cycles 1, 2, 3, 4), and depression was assessed using the Center for Epidemiologic Studies-Depression scale. Fatigue was assessed using the Fatigue Symptom Checklist and the Multidimensional Assessment of Fatigue.

Patients were mostly female (72%) and white (89%), with a mean age of 57 years. Half had breast cancer, and overall 64% were undergoing adjuvant therapy. Fatigue and depression data were previously reported (J. Clin. Oncology 2003;21:4635-41). Although paroxetine did improve depressive symptoms, it had no effect on fatigue. In this analysis, the researchers reported that paroxetine had no significant effect on insomnia, compared with placebo.

Dr. Palesh reported that she has no relevant financial relationships.

CHICAGO – The prevalence of insomnia is roughly three times greater among cancer patients than it is among the general population, according to a secondary analysis of more than 500 patients.

The prevalence of insomnia that meets clinical criteria was 45.6% among cancer patients receiving chemotherapy, which compares with 19% in the general population. An additional 35% of cancer patients had insomnia symptoms, compared with 15% in the general population, reported Oxana Palesh, Ph.D., a radiation oncologist at the University of Rochester (N.Y.), at the annual meeting of the American Society of Clinical Oncology.

Roughly 80% of the patients continued to have insomnia problems throughout chemotherapy. “So insomnia does not go away on its own,” she said.

The researchers also found that the prevalence of insomnia was greatest among lung cancer patients (P less than .05). In addition, younger patients tended to have more insomnia (P less than .05). The researchers found no difference in the prevalence of insomnia between male and female cancer patients.

For the original study, 832 cancer patients were assessed during chemotherapy cycles 1 and 2.

Those found to have fatigue (547 patients) were randomized to receive either 20 mg paroxetine or placebo. Insomnia was assessed using the Hamilton Rating Scale for Depression (cycles 1, 2, 3, 4), and depression was assessed using the Center for Epidemiologic Studies-Depression scale. Fatigue was assessed using the Fatigue Symptom Checklist and the Multidimensional Assessment of Fatigue.

Patients were mostly female (72%) and white (89%), with a mean age of 57 years. Half had breast cancer, and overall 64% were undergoing adjuvant therapy. Fatigue and depression data were previously reported (J. Clin. Oncology 2003;21:4635-41). Although paroxetine did improve depressive symptoms, it had no effect on fatigue. In this analysis, the researchers reported that paroxetine had no significant effect on insomnia, compared with placebo.

Dr. Palesh reported that she has no relevant financial relationships.

CHICAGO – The prevalence of insomnia is roughly three times greater among cancer patients than it is among the general population, according to a secondary analysis of more than 500 patients.

The prevalence of insomnia that meets clinical criteria was 45.6% among cancer patients receiving chemotherapy, which compares with 19% in the general population. An additional 35% of cancer patients had insomnia symptoms, compared with 15% in the general population, reported Oxana Palesh, Ph.D., a radiation oncologist at the University of Rochester (N.Y.), at the annual meeting of the American Society of Clinical Oncology.

Roughly 80% of the patients continued to have insomnia problems throughout chemotherapy. “So insomnia does not go away on its own,” she said.

The researchers also found that the prevalence of insomnia was greatest among lung cancer patients (P less than .05). In addition, younger patients tended to have more insomnia (P less than .05). The researchers found no difference in the prevalence of insomnia between male and female cancer patients.

For the original study, 832 cancer patients were assessed during chemotherapy cycles 1 and 2.

Those found to have fatigue (547 patients) were randomized to receive either 20 mg paroxetine or placebo. Insomnia was assessed using the Hamilton Rating Scale for Depression (cycles 1, 2, 3, 4), and depression was assessed using the Center for Epidemiologic Studies-Depression scale. Fatigue was assessed using the Fatigue Symptom Checklist and the Multidimensional Assessment of Fatigue.

Patients were mostly female (72%) and white (89%), with a mean age of 57 years. Half had breast cancer, and overall 64% were undergoing adjuvant therapy. Fatigue and depression data were previously reported (J. Clin. Oncology 2003;21:4635-41). Although paroxetine did improve depressive symptoms, it had no effect on fatigue. In this analysis, the researchers reported that paroxetine had no significant effect on insomnia, compared with placebo.

Dr. Palesh reported that she has no relevant financial relationships.

SAN DIEGO – There is a strong rationale as well as some evidence supporting the use of tricyclic antidepressants and selective serotonin reuptake inhibitors for the treatment of irritable bowel syndrome, Dr. Lin Chang said at the annual Digestive Disease Week.

Dr. Chang, a gastroenterologist with the Center for Neurovisceral Sciences and Women's Health at the University of California, Los Angeles' division of digestive diseases, discussed the theoretical basis and the available research data supporting the use of selective serotonin reuptake inhibitors and tricyclic antidepressants (TCAs) for treating irritable bowel syndrome.

First, the majority of IBS patients seen in a referral practice–as many as 60%–have some type of psychological disturbance, such as depression, anxiety, personality difficulties, or life stress.

Second, one of the key mechanisms of IBS involves alterations in the brain-gut interaction. As a result, TCAs and SSRIs may be able to change visceral sensitivity and motor activity, or both. Finally, both of these classes of medication appear to help regulate pain.

During her talk, Dr. Chang discussed one of the largest studies on TCAs for the treatment of IBS, in which the investigators evaluated the efficacy of the TCA desipramine in a placebo-controlled 12-week study (Gastroenterology 2003;125:19-31). Patients had moderate to severe functional bowel disorders and most met the criteria for IBS. The researchers started patients at 50 mg of desipramine, moving them up to 100 mg and then 150 mg during the course of the study.

In the IBS patients, 62.5% of those on desipramine had improvement of their symptoms, compared with 37.5% of those on placebo. Only patients who completed treatment were included.

Most patients with IBS have chronic functional abdominal pain that is very difficult to treat, according to Dr. Chang. “Tricyclics can be beneficial in IBS,” she concluded, stating that because of their anticholinergic effects, TCAs have been shown to improve IBS symptoms.

Dr. Chang pointed out that the desipramine study, while demonstrating a benefit, utilized a very high dose of TCAs at the outset with patients, something that she finds difficult to implement in practice. “IBS patients have a lot of drug sensitivity, so I start at a lower dose. I tell them that they may not see an effect [right away] but that they may want to start slower and titrate it up. The slower you go, the fewer side effects you'll have.”

Dr. Chang also discussed two studies that demonstrated the efficacy of SSRIs in the treatment of IBS. One study compared paroxetine with psychotherapy and usual medical treatment by a gastroenterologist (Gastroenterology 2003;124:303-17). The investigators found that both paroxetine and psychotherapy reduced pain scores and improved health-related quality of life compared with usual medical treatment. This study was the first to show that SSRIs are an effective treatment for functional gastrointestinal disorders.

In the other study, investigators conducted a crossover trial on IBS patients, comparing 6 weeks of treatment with citalopram (3 weeks at 20 mg, 3 weeks at 40 mg) with placebo (Gut 2006;55:1095-103). Following 3 and 6 weeks of treatment, there was significant improvement in the group given citalopram with respect to abdominal pain, bloating, the impact of symptoms on daily life, and overall well-being. The impact on stool pattern, however, was only moderate. “There is evidence, separate from mood, that SSRIs may help GI symptoms,” Dr. Chang concluded.

Although literature supporting the use of TCAs and SSRIs is lacking, she said that other medications used for IBS have not been effective and that these medications seem to work. She said she takes care of patients with “very severe” conditions, “which means you have to think outside of the box; you have to be creative.”

SAN DIEGO – There is a strong rationale as well as some evidence supporting the use of tricyclic antidepressants and selective serotonin reuptake inhibitors for the treatment of irritable bowel syndrome, Dr. Lin Chang said at the annual Digestive Disease Week.

Dr. Chang, a gastroenterologist with the Center for Neurovisceral Sciences and Women's Health at the University of California, Los Angeles' division of digestive diseases, discussed the theoretical basis and the available research data supporting the use of selective serotonin reuptake inhibitors and tricyclic antidepressants (TCAs) for treating irritable bowel syndrome.

First, the majority of IBS patients seen in a referral practice–as many as 60%–have some type of psychological disturbance, such as depression, anxiety, personality difficulties, or life stress.

Second, one of the key mechanisms of IBS involves alterations in the brain-gut interaction. As a result, TCAs and SSRIs may be able to change visceral sensitivity and motor activity, or both. Finally, both of these classes of medication appear to help regulate pain.

During her talk, Dr. Chang discussed one of the largest studies on TCAs for the treatment of IBS, in which the investigators evaluated the efficacy of the TCA desipramine in a placebo-controlled 12-week study (Gastroenterology 2003;125:19-31). Patients had moderate to severe functional bowel disorders and most met the criteria for IBS. The researchers started patients at 50 mg of desipramine, moving them up to 100 mg and then 150 mg during the course of the study.

In the IBS patients, 62.5% of those on desipramine had improvement of their symptoms, compared with 37.5% of those on placebo. Only patients who completed treatment were included.

Most patients with IBS have chronic functional abdominal pain that is very difficult to treat, according to Dr. Chang. “Tricyclics can be beneficial in IBS,” she concluded, stating that because of their anticholinergic effects, TCAs have been shown to improve IBS symptoms.

Dr. Chang pointed out that the desipramine study, while demonstrating a benefit, utilized a very high dose of TCAs at the outset with patients, something that she finds difficult to implement in practice. “IBS patients have a lot of drug sensitivity, so I start at a lower dose. I tell them that they may not see an effect [right away] but that they may want to start slower and titrate it up. The slower you go, the fewer side effects you'll have.”

Dr. Chang also discussed two studies that demonstrated the efficacy of SSRIs in the treatment of IBS. One study compared paroxetine with psychotherapy and usual medical treatment by a gastroenterologist (Gastroenterology 2003;124:303-17). The investigators found that both paroxetine and psychotherapy reduced pain scores and improved health-related quality of life compared with usual medical treatment. This study was the first to show that SSRIs are an effective treatment for functional gastrointestinal disorders.

In the other study, investigators conducted a crossover trial on IBS patients, comparing 6 weeks of treatment with citalopram (3 weeks at 20 mg, 3 weeks at 40 mg) with placebo (Gut 2006;55:1095-103). Following 3 and 6 weeks of treatment, there was significant improvement in the group given citalopram with respect to abdominal pain, bloating, the impact of symptoms on daily life, and overall well-being. The impact on stool pattern, however, was only moderate. “There is evidence, separate from mood, that SSRIs may help GI symptoms,” Dr. Chang concluded.

Although literature supporting the use of TCAs and SSRIs is lacking, she said that other medications used for IBS have not been effective and that these medications seem to work. She said she takes care of patients with “very severe” conditions, “which means you have to think outside of the box; you have to be creative.”

SAN DIEGO – There is a strong rationale as well as some evidence supporting the use of tricyclic antidepressants and selective serotonin reuptake inhibitors for the treatment of irritable bowel syndrome, Dr. Lin Chang said at the annual Digestive Disease Week.

Dr. Chang, a gastroenterologist with the Center for Neurovisceral Sciences and Women's Health at the University of California, Los Angeles' division of digestive diseases, discussed the theoretical basis and the available research data supporting the use of selective serotonin reuptake inhibitors and tricyclic antidepressants (TCAs) for treating irritable bowel syndrome.

First, the majority of IBS patients seen in a referral practice–as many as 60%–have some type of psychological disturbance, such as depression, anxiety, personality difficulties, or life stress.

Second, one of the key mechanisms of IBS involves alterations in the brain-gut interaction. As a result, TCAs and SSRIs may be able to change visceral sensitivity and motor activity, or both. Finally, both of these classes of medication appear to help regulate pain.

During her talk, Dr. Chang discussed one of the largest studies on TCAs for the treatment of IBS, in which the investigators evaluated the efficacy of the TCA desipramine in a placebo-controlled 12-week study (Gastroenterology 2003;125:19-31). Patients had moderate to severe functional bowel disorders and most met the criteria for IBS. The researchers started patients at 50 mg of desipramine, moving them up to 100 mg and then 150 mg during the course of the study.

In the IBS patients, 62.5% of those on desipramine had improvement of their symptoms, compared with 37.5% of those on placebo. Only patients who completed treatment were included.

Most patients with IBS have chronic functional abdominal pain that is very difficult to treat, according to Dr. Chang. “Tricyclics can be beneficial in IBS,” she concluded, stating that because of their anticholinergic effects, TCAs have been shown to improve IBS symptoms.

Dr. Chang pointed out that the desipramine study, while demonstrating a benefit, utilized a very high dose of TCAs at the outset with patients, something that she finds difficult to implement in practice. “IBS patients have a lot of drug sensitivity, so I start at a lower dose. I tell them that they may not see an effect [right away] but that they may want to start slower and titrate it up. The slower you go, the fewer side effects you'll have.”

Dr. Chang also discussed two studies that demonstrated the efficacy of SSRIs in the treatment of IBS. One study compared paroxetine with psychotherapy and usual medical treatment by a gastroenterologist (Gastroenterology 2003;124:303-17). The investigators found that both paroxetine and psychotherapy reduced pain scores and improved health-related quality of life compared with usual medical treatment. This study was the first to show that SSRIs are an effective treatment for functional gastrointestinal disorders.

In the other study, investigators conducted a crossover trial on IBS patients, comparing 6 weeks of treatment with citalopram (3 weeks at 20 mg, 3 weeks at 40 mg) with placebo (Gut 2006;55:1095-103). Following 3 and 6 weeks of treatment, there was significant improvement in the group given citalopram with respect to abdominal pain, bloating, the impact of symptoms on daily life, and overall well-being. The impact on stool pattern, however, was only moderate. “There is evidence, separate from mood, that SSRIs may help GI symptoms,” Dr. Chang concluded.

Although literature supporting the use of TCAs and SSRIs is lacking, she said that other medications used for IBS have not been effective and that these medications seem to work. She said she takes care of patients with “very severe” conditions, “which means you have to think outside of the box; you have to be creative.”

CHICAGO – The investigational agent pimavanserin appears to lessen the symptoms of psychosis in patients with Parkinson's disease without worsening motor function, according to data from a multicenter randomized phase II trial involving 60 patients.

Pimavanserin is a potent, active 5-hydroxytryptamine 2a (5-HT_2a) serotonin receptor antagonist, according to Dr. Revell of Acadia Pharmaceuticals Inc., which sponsored the study. However, it lacks the dopamine receptor (D₂) and histamine receptor (H₁) binding that are linked to intolerable adverse effects of other antipsychotics. Pimavanserin is being developed as a cotherapy for schizophrenia, as well as for Parkinson's disease psychosis.

Patients in the study had Parkinson's disease and psychosis and received either pimavanserin (n = 29) or placebo (n = 31) on an outpatient basis for 28 days, starting at 20 mg daily on day 1, with dose escalations to 40 mg and 60 mg on day 8 and 15, respectively, depending on individual clinical response.

Patients treated with pimavanserin demonstrated a 40% improvement in the Scale for the Assessment of Positive Symptoms (SAPS) combination score for hallucination and delusion, as compared with an 11% improvement for patients treated with placebo, Dr. Stephen Revell and associates reported in a poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

Statistically significant improvements also were observed for patients treated with pimavanserin on the mentation, behavior, and mood part of the Unified Parkinson's Disease Rating Scale (UPDRS).

There was no clinically significant difference between patients treated with placebo vs. pimavanserin in absolute mean change from baseline to day 28 in UPDRS motor scores (−3.05 vs. −1.24) or activities of daily living scores (−2.51 vs. −0.70).

No differences were observed between groups on the Schwab and England Activities of Daily Living Scale part of the UPDRS or the Clinical Global Impression Scale severity of illness subscale.

The most common adverse events in patients treated with pimavanserin were somnolence, edema, and increased blood urea–each occurring in three patients, the authors wrote.

In a second poster presented at the meeting, pimavanserin was well tolerated and did not worsen Parkinsonism symptoms in 39 patients (mean age 72 years) with Parkinson's and psychosis at doses up to 60 mg/day for up to 42 months (mean 14 months). Adverse events commonly experienced with clozapine and quetiapine–such as somnolence, fatigue, and dizziness–were uncommon with pimavanserin, according to Dr. Roger Mills, also of Acadia, who led the industry-sponsored, open-label extension safety study.

Only one patient who experienced somnolence discontinued pimavanserin treatment. A single case of rhabdomyolysis was the only serious adverse event considered to be possibly treatment-related.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – The investigational agent pimavanserin appears to lessen the symptoms of psychosis in patients with Parkinson's disease without worsening motor function, according to data from a multicenter randomized phase II trial involving 60 patients.

Pimavanserin is a potent, active 5-hydroxytryptamine 2a (5-HT_2a) serotonin receptor antagonist, according to Dr. Revell of Acadia Pharmaceuticals Inc., which sponsored the study. However, it lacks the dopamine receptor (D₂) and histamine receptor (H₁) binding that are linked to intolerable adverse effects of other antipsychotics. Pimavanserin is being developed as a cotherapy for schizophrenia, as well as for Parkinson's disease psychosis.

Patients in the study had Parkinson's disease and psychosis and received either pimavanserin (n = 29) or placebo (n = 31) on an outpatient basis for 28 days, starting at 20 mg daily on day 1, with dose escalations to 40 mg and 60 mg on day 8 and 15, respectively, depending on individual clinical response.

Patients treated with pimavanserin demonstrated a 40% improvement in the Scale for the Assessment of Positive Symptoms (SAPS) combination score for hallucination and delusion, as compared with an 11% improvement for patients treated with placebo, Dr. Stephen Revell and associates reported in a poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

Statistically significant improvements also were observed for patients treated with pimavanserin on the mentation, behavior, and mood part of the Unified Parkinson's Disease Rating Scale (UPDRS).

There was no clinically significant difference between patients treated with placebo vs. pimavanserin in absolute mean change from baseline to day 28 in UPDRS motor scores (−3.05 vs. −1.24) or activities of daily living scores (−2.51 vs. −0.70).

No differences were observed between groups on the Schwab and England Activities of Daily Living Scale part of the UPDRS or the Clinical Global Impression Scale severity of illness subscale.

The most common adverse events in patients treated with pimavanserin were somnolence, edema, and increased blood urea–each occurring in three patients, the authors wrote.

In a second poster presented at the meeting, pimavanserin was well tolerated and did not worsen Parkinsonism symptoms in 39 patients (mean age 72 years) with Parkinson's and psychosis at doses up to 60 mg/day for up to 42 months (mean 14 months). Adverse events commonly experienced with clozapine and quetiapine–such as somnolence, fatigue, and dizziness–were uncommon with pimavanserin, according to Dr. Roger Mills, also of Acadia, who led the industry-sponsored, open-label extension safety study.

Only one patient who experienced somnolence discontinued pimavanserin treatment. A single case of rhabdomyolysis was the only serious adverse event considered to be possibly treatment-related.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – The investigational agent pimavanserin appears to lessen the symptoms of psychosis in patients with Parkinson's disease without worsening motor function, according to data from a multicenter randomized phase II trial involving 60 patients.

Pimavanserin is a potent, active 5-hydroxytryptamine 2a (5-HT_2a) serotonin receptor antagonist, according to Dr. Revell of Acadia Pharmaceuticals Inc., which sponsored the study. However, it lacks the dopamine receptor (D₂) and histamine receptor (H₁) binding that are linked to intolerable adverse effects of other antipsychotics. Pimavanserin is being developed as a cotherapy for schizophrenia, as well as for Parkinson's disease psychosis.

Patients in the study had Parkinson's disease and psychosis and received either pimavanserin (n = 29) or placebo (n = 31) on an outpatient basis for 28 days, starting at 20 mg daily on day 1, with dose escalations to 40 mg and 60 mg on day 8 and 15, respectively, depending on individual clinical response.

Patients treated with pimavanserin demonstrated a 40% improvement in the Scale for the Assessment of Positive Symptoms (SAPS) combination score for hallucination and delusion, as compared with an 11% improvement for patients treated with placebo, Dr. Stephen Revell and associates reported in a poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

Statistically significant improvements also were observed for patients treated with pimavanserin on the mentation, behavior, and mood part of the Unified Parkinson's Disease Rating Scale (UPDRS).

There was no clinically significant difference between patients treated with placebo vs. pimavanserin in absolute mean change from baseline to day 28 in UPDRS motor scores (−3.05 vs. −1.24) or activities of daily living scores (−2.51 vs. −0.70).

No differences were observed between groups on the Schwab and England Activities of Daily Living Scale part of the UPDRS or the Clinical Global Impression Scale severity of illness subscale.

The most common adverse events in patients treated with pimavanserin were somnolence, edema, and increased blood urea–each occurring in three patients, the authors wrote.

In a second poster presented at the meeting, pimavanserin was well tolerated and did not worsen Parkinsonism symptoms in 39 patients (mean age 72 years) with Parkinson's and psychosis at doses up to 60 mg/day for up to 42 months (mean 14 months). Adverse events commonly experienced with clozapine and quetiapine–such as somnolence, fatigue, and dizziness–were uncommon with pimavanserin, according to Dr. Roger Mills, also of Acadia, who led the industry-sponsored, open-label extension safety study.

Only one patient who experienced somnolence discontinued pimavanserin treatment. A single case of rhabdomyolysis was the only serious adverse event considered to be possibly treatment-related.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE – A peer-led program appeared to be successful in decreasing the risk of eating disorders among female college athletes, according to early results involving 64 participants.

The risk of eating disorders among female college athletes is at least as high as that among college women generally, said Carolyn B. Becker, Ph.D., of the department of psychology at Trinity University, San Antonio. Female athletes are a unique group with unique issues, she pointed out. “There is certainly a pervasive belief among many athletes and many coaches that weight loss is going to enhance performance,” she said at an international conference sponsored by the Academy for Eating Disorders.

The Female Athlete Body Project was derived in part from a parent program at the university, the Sorority Body Image Program, which found that a peer-led, cognitive dissonance-based intervention reduced risk factors for eating disorders among sorority members, Dr. Becker said (J. Consult. Clin. Psychol. 2008;76:347-54).

The new program uses two interventions–a cognitive dissonance-based intervention and a healthy-weight intervention–that have been modified specifically for female athletes to cover topics such as sport-related body ideals and the female athlete triad. The former intervention focuses on rejecting thin ideals, whereas the latter focuses on embracing the healthy ideal, Dr. Becker explained at the conference, which was cosponsored by the University of New Mexico.

Attendance in the program is mandatory for all women participating in varsity sports and cheerleading at the university. The interventions are delivered in small, interactive group sessions that are conducted within teams, both to facilitate team building and to best address the differences in body image by sport. In the first year, half of the team receives the cognitive dissonance intervention and the other half receives the healthy-weight intervention; in the second year, the groups switch. The interventions are delivered over three sessions lasting for 1 hour and 15 minutes, each led by peers.

Participants are assessed at baseline, at the end of each intervention, and at the 6-week and 1-year follow-ups, according to Dr. Becker. In all, 112 athletes have participated in the program in its first year. She described results for the first 64 participants, who were from the basketball, softball, tennis, swimming/diving, and cross-country teams. Results for the remaining athletes are still being analyzed.

Regardless of the type of intervention received (cognitive dissonance or healthy weight), the athletes significantly improved from baseline in terms of thin-ideal internalization, as measured with the Ideal Body Stereotype Scale-Revised (IBSS-R); negative affect, as measured with the Positive and Negative Affect Schedule-Expanded Form (PANAS-X); eating pathology, as measured with the Eating Disorder Examination Questionnaire-Bulimia Nervosa scale (EDEQ-BN); and body dissatisfaction, as measured with the EDEQ scales for shape concern (EDEQ-SC) and weight concern (EDEQ-WC). With the exception of thin-ideal internalization, all measures were significantly improved from baseline at the 6-week follow-up.

Four athletes approached the head athletic trainer with concerns that they might have the female athlete triad–something that had never happened before during his tenure, Dr. Becker said.

“To us, in fact, that was the most exciting outcome that we had,” she commented. Future goals, according to Dr. Becker, include taking the program through its second year to determine if there are additive benefits of the two interventions, and exploring options for making the program sustainable.

Dr. Becker reported that the study was supported by a grant from the National Institute of Mental Health. She did not have any conflicts of interest to disclose.

Cognitive dissonance-based and healthy-weight interventions have been modified specifically for female athletes. DR. BECKER

SEATTLE – A peer-led program appeared to be successful in decreasing the risk of eating disorders among female college athletes, according to early results involving 64 participants.

The risk of eating disorders among female college athletes is at least as high as that among college women generally, said Carolyn B. Becker, Ph.D., of the department of psychology at Trinity University, San Antonio. Female athletes are a unique group with unique issues, she pointed out. “There is certainly a pervasive belief among many athletes and many coaches that weight loss is going to enhance performance,” she said at an international conference sponsored by the Academy for Eating Disorders.

The Female Athlete Body Project was derived in part from a parent program at the university, the Sorority Body Image Program, which found that a peer-led, cognitive dissonance-based intervention reduced risk factors for eating disorders among sorority members, Dr. Becker said (J. Consult. Clin. Psychol. 2008;76:347-54).

The new program uses two interventions–a cognitive dissonance-based intervention and a healthy-weight intervention–that have been modified specifically for female athletes to cover topics such as sport-related body ideals and the female athlete triad. The former intervention focuses on rejecting thin ideals, whereas the latter focuses on embracing the healthy ideal, Dr. Becker explained at the conference, which was cosponsored by the University of New Mexico.

Attendance in the program is mandatory for all women participating in varsity sports and cheerleading at the university. The interventions are delivered in small, interactive group sessions that are conducted within teams, both to facilitate team building and to best address the differences in body image by sport. In the first year, half of the team receives the cognitive dissonance intervention and the other half receives the healthy-weight intervention; in the second year, the groups switch. The interventions are delivered over three sessions lasting for 1 hour and 15 minutes, each led by peers.

Participants are assessed at baseline, at the end of each intervention, and at the 6-week and 1-year follow-ups, according to Dr. Becker. In all, 112 athletes have participated in the program in its first year. She described results for the first 64 participants, who were from the basketball, softball, tennis, swimming/diving, and cross-country teams. Results for the remaining athletes are still being analyzed.

Regardless of the type of intervention received (cognitive dissonance or healthy weight), the athletes significantly improved from baseline in terms of thin-ideal internalization, as measured with the Ideal Body Stereotype Scale-Revised (IBSS-R); negative affect, as measured with the Positive and Negative Affect Schedule-Expanded Form (PANAS-X); eating pathology, as measured with the Eating Disorder Examination Questionnaire-Bulimia Nervosa scale (EDEQ-BN); and body dissatisfaction, as measured with the EDEQ scales for shape concern (EDEQ-SC) and weight concern (EDEQ-WC). With the exception of thin-ideal internalization, all measures were significantly improved from baseline at the 6-week follow-up.

Four athletes approached the head athletic trainer with concerns that they might have the female athlete triad–something that had never happened before during his tenure, Dr. Becker said.

“To us, in fact, that was the most exciting outcome that we had,” she commented. Future goals, according to Dr. Becker, include taking the program through its second year to determine if there are additive benefits of the two interventions, and exploring options for making the program sustainable.

Dr. Becker reported that the study was supported by a grant from the National Institute of Mental Health. She did not have any conflicts of interest to disclose.

Cognitive dissonance-based and healthy-weight interventions have been modified specifically for female athletes. DR. BECKER

SEATTLE – A peer-led program appeared to be successful in decreasing the risk of eating disorders among female college athletes, according to early results involving 64 participants.

The risk of eating disorders among female college athletes is at least as high as that among college women generally, said Carolyn B. Becker, Ph.D., of the department of psychology at Trinity University, San Antonio. Female athletes are a unique group with unique issues, she pointed out. “There is certainly a pervasive belief among many athletes and many coaches that weight loss is going to enhance performance,” she said at an international conference sponsored by the Academy for Eating Disorders.

The Female Athlete Body Project was derived in part from a parent program at the university, the Sorority Body Image Program, which found that a peer-led, cognitive dissonance-based intervention reduced risk factors for eating disorders among sorority members, Dr. Becker said (J. Consult. Clin. Psychol. 2008;76:347-54).

The new program uses two interventions–a cognitive dissonance-based intervention and a healthy-weight intervention–that have been modified specifically for female athletes to cover topics such as sport-related body ideals and the female athlete triad. The former intervention focuses on rejecting thin ideals, whereas the latter focuses on embracing the healthy ideal, Dr. Becker explained at the conference, which was cosponsored by the University of New Mexico.

Attendance in the program is mandatory for all women participating in varsity sports and cheerleading at the university. The interventions are delivered in small, interactive group sessions that are conducted within teams, both to facilitate team building and to best address the differences in body image by sport. In the first year, half of the team receives the cognitive dissonance intervention and the other half receives the healthy-weight intervention; in the second year, the groups switch. The interventions are delivered over three sessions lasting for 1 hour and 15 minutes, each led by peers.

Participants are assessed at baseline, at the end of each intervention, and at the 6-week and 1-year follow-ups, according to Dr. Becker. In all, 112 athletes have participated in the program in its first year. She described results for the first 64 participants, who were from the basketball, softball, tennis, swimming/diving, and cross-country teams. Results for the remaining athletes are still being analyzed.

Regardless of the type of intervention received (cognitive dissonance or healthy weight), the athletes significantly improved from baseline in terms of thin-ideal internalization, as measured with the Ideal Body Stereotype Scale-Revised (IBSS-R); negative affect, as measured with the Positive and Negative Affect Schedule-Expanded Form (PANAS-X); eating pathology, as measured with the Eating Disorder Examination Questionnaire-Bulimia Nervosa scale (EDEQ-BN); and body dissatisfaction, as measured with the EDEQ scales for shape concern (EDEQ-SC) and weight concern (EDEQ-WC). With the exception of thin-ideal internalization, all measures were significantly improved from baseline at the 6-week follow-up.

Four athletes approached the head athletic trainer with concerns that they might have the female athlete triad–something that had never happened before during his tenure, Dr. Becker said.

“To us, in fact, that was the most exciting outcome that we had,” she commented. Future goals, according to Dr. Becker, include taking the program through its second year to determine if there are additive benefits of the two interventions, and exploring options for making the program sustainable.

Dr. Becker reported that the study was supported by a grant from the National Institute of Mental Health. She did not have any conflicts of interest to disclose.

Cognitive dissonance-based and healthy-weight interventions have been modified specifically for female athletes. DR. BECKER

SEATTLE – Education and the collaborative efforts of a team of professionals are important for preventing the female athlete triad, according to Sharon H. Thompson, Ed.D.

The definition of the female athlete triad has been expanded recently, said Dr. Thompson, professor of health promotion at the Coastal Carolina University in Conway, S.C. Previously, the triad was viewed as consisting of disordered eating, amenorrhea, and osteoporosis. Now, athletes are considered to be affected if they have low energy availability, menstrual disorders, and low bone mineral density.

“The extent of disordered eating in athletes is really unclear,” Dr. Thompson said at an international conference sponsored by the Academy for Eating Disorders. Studies suggest that perhaps two-thirds of female athletes are affected. Athletes who are not consuming enough calories often become deficient in nutrients as well, and some of these (calcium, vitamin D, vitamin K, phosphorus, magnesium, and fluoride) are critical for bone health, she noted.

Amenorrhea in female athletes is associated with a two- to fourfold increased risk of stress fractures, Dr. Thompson said at the conference, which was cosponsored by the University of New Mexico. But they may have other types of menstrual dysfunction, including oligomenorrhea, anovulation, and luteal phase deficiency, which also affects their bones.

“Very often, it's thought that if a female athlete doesn't have a menstrual cycle, it may be a sign of enough training or hard training, or [may even be] looked upon as a luxury,” she said. “But this certainly is not the case, because any disturbance of the menstrual cycle can affect bone health.”

It would be rare to find a female athlete who has frank osteoporosis, Dr. Thompson noted. However, “we know that athletes who have amenorrhea have 10%-25% lower bone mineral density at their lumbar spine, compared to control athletes. Bone loss may be accelerated in this population by estrogen deficiency, low energy availability, and a decreased rate of new bone formation.

“Bottom line, female athletes should have higher bone mineral density than non-female athletes,” she asserted. “Any female athlete who has lower bone mineral density is going to be more at risk for stress fractures and, it is also suggested, possibly more at risk for osteoporosis later on down the line.”

A survey that Dr. Thompson conducted among 300 female collegiate cross-country runners found that 83% had body mass indexes within the average category (J. Coll. Health. 2007;56:129-36). Some (19%) had previous or current eating disorders, but only a quarter of this group had ever been treated. In all, 23% had irregular menstrual cycles, and 29% had inadequate calcium intake, raising concerns about bone health. “The conclusion from this study is the importance of nutrition education for athletes, especially in the area of calcium-rich foods that might be added to their diet,” she said.

Educational efforts aimed at preventing the female athlete triad are generally lacking, according to Dr. Thompson. For example, fewer than 41% of Division I athletic teams and fewer than 33% of high schools have programs for their students that address eating disorders.

“It's important to realize, when [you screen] for the female athlete triad, that the main priority really should be looking for low energy intake, which of course could be some type of disordered eating for these female athletes,” Dr. Thompson said. She recommended that screening questions be part of the routine medical history to avoid calling undue attention to them. And athletes suspected of having disordered eating should be interviewed in person and given surveys that have been validated in this population (J. Athl. Train. 2008;43:80-108).

When drafting educational programs for athletes, institutions can refer to guidelines from the National Collegiate Athletic Association and the American College of Sports Medicine, Dr. Thompson said. Such programs should present factual information and resources on eating disorders, nutrition, weight, and menstrual health to avoid any stigmatization, she advised.

Since many coaches lack formal education on the female athlete triad, Dr. Thompson recommended mandatory, comprehensive training for this group at least annually so they are better prepared to recognize and deal with the condition.

“The bottom line is researchers have found that coaches who have more education are more likely to emphasize healthy eating rather than weight standards for their athletes,” she said.

Certified athletic trainers can look to educational competencies for working with athletes outlined by the National Athletic Trainers' Association, according to Dr. Thompson. “Prevention efforts do work and should be implemented,” Dr. Thompson concluded. “It's important that a team of professionals be there to work with athletes.” Mental health, athletic-training, medicine, and nutrition professionals; coaches; and athletic administrators “can all work together to improve the health of the female athlete.”

Dr. Thompson reported that her survey was funded by a grant from the South Carolina Osteoporosis Coalition, and the South Carolina Department of Health and Environmental Control.

A survey of 300 female collegiate cross-country runners found that 23% had irregular menstrual cycles. ©Galina Barskaya/Fotolia.com

SEATTLE – Education and the collaborative efforts of a team of professionals are important for preventing the female athlete triad, according to Sharon H. Thompson, Ed.D.

The definition of the female athlete triad has been expanded recently, said Dr. Thompson, professor of health promotion at the Coastal Carolina University in Conway, S.C. Previously, the triad was viewed as consisting of disordered eating, amenorrhea, and osteoporosis. Now, athletes are considered to be affected if they have low energy availability, menstrual disorders, and low bone mineral density.

“The extent of disordered eating in athletes is really unclear,” Dr. Thompson said at an international conference sponsored by the Academy for Eating Disorders. Studies suggest that perhaps two-thirds of female athletes are affected. Athletes who are not consuming enough calories often become deficient in nutrients as well, and some of these (calcium, vitamin D, vitamin K, phosphorus, magnesium, and fluoride) are critical for bone health, she noted.

Amenorrhea in female athletes is associated with a two- to fourfold increased risk of stress fractures, Dr. Thompson said at the conference, which was cosponsored by the University of New Mexico. But they may have other types of menstrual dysfunction, including oligomenorrhea, anovulation, and luteal phase deficiency, which also affects their bones.

“Very often, it's thought that if a female athlete doesn't have a menstrual cycle, it may be a sign of enough training or hard training, or [may even be] looked upon as a luxury,” she said. “But this certainly is not the case, because any disturbance of the menstrual cycle can affect bone health.”

It would be rare to find a female athlete who has frank osteoporosis, Dr. Thompson noted. However, “we know that athletes who have amenorrhea have 10%-25% lower bone mineral density at their lumbar spine, compared to control athletes. Bone loss may be accelerated in this population by estrogen deficiency, low energy availability, and a decreased rate of new bone formation.

“Bottom line, female athletes should have higher bone mineral density than non-female athletes,” she asserted. “Any female athlete who has lower bone mineral density is going to be more at risk for stress fractures and, it is also suggested, possibly more at risk for osteoporosis later on down the line.”

A survey that Dr. Thompson conducted among 300 female collegiate cross-country runners found that 83% had body mass indexes within the average category (J. Coll. Health. 2007;56:129-36). Some (19%) had previous or current eating disorders, but only a quarter of this group had ever been treated. In all, 23% had irregular menstrual cycles, and 29% had inadequate calcium intake, raising concerns about bone health. “The conclusion from this study is the importance of nutrition education for athletes, especially in the area of calcium-rich foods that might be added to their diet,” she said.

Educational efforts aimed at preventing the female athlete triad are generally lacking, according to Dr. Thompson. For example, fewer than 41% of Division I athletic teams and fewer than 33% of high schools have programs for their students that address eating disorders.

“It's important to realize, when [you screen] for the female athlete triad, that the main priority really should be looking for low energy intake, which of course could be some type of disordered eating for these female athletes,” Dr. Thompson said. She recommended that screening questions be part of the routine medical history to avoid calling undue attention to them. And athletes suspected of having disordered eating should be interviewed in person and given surveys that have been validated in this population (J. Athl. Train. 2008;43:80-108).

When drafting educational programs for athletes, institutions can refer to guidelines from the National Collegiate Athletic Association and the American College of Sports Medicine, Dr. Thompson said. Such programs should present factual information and resources on eating disorders, nutrition, weight, and menstrual health to avoid any stigmatization, she advised.

Since many coaches lack formal education on the female athlete triad, Dr. Thompson recommended mandatory, comprehensive training for this group at least annually so they are better prepared to recognize and deal with the condition.

“The bottom line is researchers have found that coaches who have more education are more likely to emphasize healthy eating rather than weight standards for their athletes,” she said.

Certified athletic trainers can look to educational competencies for working with athletes outlined by the National Athletic Trainers' Association, according to Dr. Thompson. “Prevention efforts do work and should be implemented,” Dr. Thompson concluded. “It's important that a team of professionals be there to work with athletes.” Mental health, athletic-training, medicine, and nutrition professionals; coaches; and athletic administrators “can all work together to improve the health of the female athlete.”

Dr. Thompson reported that her survey was funded by a grant from the South Carolina Osteoporosis Coalition, and the South Carolina Department of Health and Environmental Control.

A survey of 300 female collegiate cross-country runners found that 23% had irregular menstrual cycles. ©Galina Barskaya/Fotolia.com

SEATTLE – Education and the collaborative efforts of a team of professionals are important for preventing the female athlete triad, according to Sharon H. Thompson, Ed.D.

The definition of the female athlete triad has been expanded recently, said Dr. Thompson, professor of health promotion at the Coastal Carolina University in Conway, S.C. Previously, the triad was viewed as consisting of disordered eating, amenorrhea, and osteoporosis. Now, athletes are considered to be affected if they have low energy availability, menstrual disorders, and low bone mineral density.

“The extent of disordered eating in athletes is really unclear,” Dr. Thompson said at an international conference sponsored by the Academy for Eating Disorders. Studies suggest that perhaps two-thirds of female athletes are affected. Athletes who are not consuming enough calories often become deficient in nutrients as well, and some of these (calcium, vitamin D, vitamin K, phosphorus, magnesium, and fluoride) are critical for bone health, she noted.

Amenorrhea in female athletes is associated with a two- to fourfold increased risk of stress fractures, Dr. Thompson said at the conference, which was cosponsored by the University of New Mexico. But they may have other types of menstrual dysfunction, including oligomenorrhea, anovulation, and luteal phase deficiency, which also affects their bones.

“Very often, it's thought that if a female athlete doesn't have a menstrual cycle, it may be a sign of enough training or hard training, or [may even be] looked upon as a luxury,” she said. “But this certainly is not the case, because any disturbance of the menstrual cycle can affect bone health.”

It would be rare to find a female athlete who has frank osteoporosis, Dr. Thompson noted. However, “we know that athletes who have amenorrhea have 10%-25% lower bone mineral density at their lumbar spine, compared to control athletes. Bone loss may be accelerated in this population by estrogen deficiency, low energy availability, and a decreased rate of new bone formation.

“Bottom line, female athletes should have higher bone mineral density than non-female athletes,” she asserted. “Any female athlete who has lower bone mineral density is going to be more at risk for stress fractures and, it is also suggested, possibly more at risk for osteoporosis later on down the line.”

A survey that Dr. Thompson conducted among 300 female collegiate cross-country runners found that 83% had body mass indexes within the average category (J. Coll. Health. 2007;56:129-36). Some (19%) had previous or current eating disorders, but only a quarter of this group had ever been treated. In all, 23% had irregular menstrual cycles, and 29% had inadequate calcium intake, raising concerns about bone health. “The conclusion from this study is the importance of nutrition education for athletes, especially in the area of calcium-rich foods that might be added to their diet,” she said.

Educational efforts aimed at preventing the female athlete triad are generally lacking, according to Dr. Thompson. For example, fewer than 41% of Division I athletic teams and fewer than 33% of high schools have programs for their students that address eating disorders.

“It's important to realize, when [you screen] for the female athlete triad, that the main priority really should be looking for low energy intake, which of course could be some type of disordered eating for these female athletes,” Dr. Thompson said. She recommended that screening questions be part of the routine medical history to avoid calling undue attention to them. And athletes suspected of having disordered eating should be interviewed in person and given surveys that have been validated in this population (J. Athl. Train. 2008;43:80-108).

When drafting educational programs for athletes, institutions can refer to guidelines from the National Collegiate Athletic Association and the American College of Sports Medicine, Dr. Thompson said. Such programs should present factual information and resources on eating disorders, nutrition, weight, and menstrual health to avoid any stigmatization, she advised.

Since many coaches lack formal education on the female athlete triad, Dr. Thompson recommended mandatory, comprehensive training for this group at least annually so they are better prepared to recognize and deal with the condition.

“The bottom line is researchers have found that coaches who have more education are more likely to emphasize healthy eating rather than weight standards for their athletes,” she said.

Certified athletic trainers can look to educational competencies for working with athletes outlined by the National Athletic Trainers' Association, according to Dr. Thompson. “Prevention efforts do work and should be implemented,” Dr. Thompson concluded. “It's important that a team of professionals be there to work with athletes.” Mental health, athletic-training, medicine, and nutrition professionals; coaches; and athletic administrators “can all work together to improve the health of the female athlete.”

Dr. Thompson reported that her survey was funded by a grant from the South Carolina Osteoporosis Coalition, and the South Carolina Department of Health and Environmental Control.

A survey of 300 female collegiate cross-country runners found that 23% had irregular menstrual cycles. ©Galina Barskaya/Fotolia.com