Prognosis in Anorexia Nervosa

In the “Update” section of the millennium issue (January/February 2000), mention was made of our longitudinal study of 61 patients with anorexia nervosa. We would like to provide additional information about our study and to add our perspectives on the issue of prognosis among patients with anorexia nervosa.

In our study, the length of follow-up was 6 to 10 years (mean: 8 years). The study included biological parameters and measurements of total body nitrogen and total body potassium, which were also correlated with bone density and outcome such that patients who did not reach a body mass index (BMI) of 19 or more during index hospitalization were doing less well at follow up (Gross et al, Annals of the New York Academy of Science [in press]). The study supports the necessity for early, adequate weight restoration.

These results were strongly echoed by the 20-year follow-up study from Heidelberg reported by Zipfel et al (Lancet 2000;355:721). Here the seriousness of anorexia nervosa was demonstrated by the death rate of 16.7% and the persistence of full-blown anorexia nervosa in 10.4% of patients. A correlation between poor prognosis, duration of illness, and low BMI was also demonstrated, emphasizing the need for early intervention and adequate weight restoration.

These findings verify what all of us who treat patients with anorexia nervosa have always known, namely that prompt, adequate weight restoration is the vitally important first step on the long road to recovery—whether this occurs in an inpatient setting, day program or on an outpatient basis. Yet there are those who would argue with this principle of treatment, even as we are becoming less able to convince funding authorities to provide appropriately for clinical services or research. In Australia the situation has been rapidly deteriorating, to the point where publicly funded services are inadequate and inaccessible and private eating disorders units are fighting for survival.

Outpatient treatment is excellent for patients who have not been ill for more than a year or so, particularly when they are treated with a multidisciplinary team, a user-friendly approach, and well-trained, involved general practitioners. These services come at a cost, can only be provided in the private sector, and are not readily available to those who cannot afford to pay for them. Not all patients fit into this early intervention category. Some inevitably require higher levels of containment and medical care. With very ill patients, of whom we still have many, we still do not know the optimal way in which to facilitate weight restoration. More research is needed and funding remains all but impossible to secure, at least in Australia.

Despite their high public profile, anorexia nervosa and other eating disorders are still not being taken seriously enough, particularly when the first essential goal of treatment has been so clearly demonstrated. The question is, what else can we do to get this message across?