A Novel Anorexia Treatment
BY ERIC LERNER
ANOREXIA NERVOSA MAY BE A FAR LESS COMMON EATING problem than obesityafflicting only 0.5 percent of womenbut it is extremely deadly, with the highest mortality rate of any psychological condition.
The Eating Disorders Clinic of the New York State Psychiatric Institute offers a new family-based therapy for this devastating disease. The therapy was first developed at Maudsley Hospital in London approximately 20 years ago. It regards the adolescent patients parents as the main allies in treating the patient.
The traditional approach to anorexia views it as a maladaptive attempt by the patient to achieve control and autonomy, in response to over-controlling parents, says Dr. Katharine Loeb, a postdoctoral research fellow in psychiatry and director of the anorexia program. In contrast, the family therapy approach does not postulate the cause of the disease. But the Maudsley method seeks to change behavior, initially by transferring control of eating fully to the parents.
The approach, while controversial, achieves good results, Dr. Loeb says. Of 33 girls with anorexia that we and our colleagues at the University of Chicago have treated, 73 percent gained enough weight to resume menstruation. The average weight of all those weve treated rose from 83 percent of ideal weight to 95 percent.
Anorexia is hard to treat, with a relapse rate after hospital re-feedings of between one-third and two-thirds. While comparisons with other methods, such as individual therapy, have not been done on a large scale, Dr. Loeb says initial studies at Maudsley showed that for adolescent girls between 12 and 18 years old, family therapy definitely worked better than individual therapy. In one study, 90 percent of patients treated with the Maudsley method were still fully recovered at a five-year follow-up.
The Maudsley therapy consists of three phases, which occur in approximately 20 sessions over one year. In the first phase, the parents are put in charge of the feeding process. Parents send the message to their child that self-starvation is not an option. Most parents are willing to consider hospitalization as an alternative, but adolescents overwhelmingly prefer being at home to hospital re-feeding, says Dr. Loeb. The parents are encouraged to develop their own strategies to get the patient to eat a weight-gain diet and then return to a normal diet. But in the early phase, the choice of food is put into the hands of parents, just as in a case of a young child.
In the second phase, once normal weight has been achieved, control of eating is gradually transferred to the adolescent. The final phase involves problem solvingdealing with how to prevent the recurrence of anorexic behavior. The third phase also addresses more general adolescent development issues.
The treatment is not for everyone. Abusive parents are excluded from family therapy.
The treatment is suitable only for minors living at home, where some degree of parental control is assumed. For young adult anorexics, individual therapy seems to work best, says Dr. Loeb.
The Eating Disorders Clinic is one of only three clinics in the United States offering the Maudsley family therapy for anorexia; the others are at Stanford and the University of Chicago. The clinic also has programs dealing with bulimia nervosa and binge eating. Since the clinic is a research facility it offers treatment for free to adolescent boys and girls with anorexia nervosa, to adult women with anorexia and bulimia, and to both men and women with binge-eating disorder.
For the past two years, Dr. Loeb, Dr. B. Timothy Walsh, the William & Joy Ruane Professor of Pediatric Psychopharmacology (in psychiatry) and acting chairman of psychiatry, and colleagues at Stanford University (Dr. James Lock) and the University of Chicago (Dr. Daniel le Grange) have been collecting data in a pilot project to test the feasibility of administering the Maudsley treatment in the United States. With their data, they have applied for grants to study the Maudsley method in approximately 200 patients compared with more traditional family therapy and individual psychodynamic therapy.
Obesity Surgery Clinic Uses New Technique
BY ERIC LERNER
OBESITY IS ONE OF THE MOST WIDESPREAD MEDICAL PROBLEMS in the United States, with approximately 59 percent of adult men and 51 percent of adult women significantly overweight. For the 5 percent of adults who are morbidly obese, defined as more than 100 pounds over their ideal weight, weight threatens their lives. Obesity contributes to diabetes, high blood pressure, and sleep apnea. Obesity also can cause infertility, joint pain, and shortness of breath. For many morbidly obese patients, however, dieting simply does not work.
For morbidly obese patients, surgery can reduce the size of the stomach to greatly reduce the amount of food that can be consumed. In addition to offering standard gastric bypass procedures among its comprehensive obesity management program, the New York-Presbyterian Center for Obesity Surgery offers innovative new laparoscopic methods allowing for adjustments to the diameter of a band placed around the stomach. Restriction procedures stop people from eating as much as they were able to eat before, says Dr. Marc Bessler, assistant professor of surgery and center director. Its forced behavior modification. Procedures are usually covered by insurance as medically necessary if patients are 100 pounds over ideal weight or even 80 pounds overweight, if the weight is associated with significant health problems.
The most common procedure, gastric bypass, creates a small pouch from the upper portion of the stomach, near the esophagus, and then connects this with the middle portion of the small intestine, bypassing the rest of the stomach. Not only does this surgery greatly decrease the capacity of the stomach, it makes it difficult to eat more than a small amount of fats or sweets. If the patient eats sweets or fatty foods, they empty directly into the small intestine, irritating it and causing discomfort, says Dr. Bessler.
It is major surgery and not without risk. As a less drastic alternative, the center has been pioneering the use of a new laparoscopic technique, called the Lap Band. In this procedure, a thin, adjustable band is inserted through laparoscopic surgery and wrapped around the upper end of the stomach, again creating a small pouch. The pouch fills up quickly, so the patient feels full after eating a small amount of solid food. The operation was approved by the Food and Drug Administration in June 2001.
The new technique is a considerable improvement over the older and related vertical banded gastroplasty, which created a pouch with a permanent, non-adjustable band. Often the band was simply the wrong size for the patient, allowing too little or too much food to pass through, says Dr. Bessler. With the Lap Band, the size of the opening can be adjusted externally by tightening or loosening the band as needed. Lap Band is not as effective as gastric bypass since high-calorie liquids like milk shakes can pass through the pouch unimpeded. But more than 70 percent of patients still lose half their excess weight.
The center is now studying whether the reductions in appetite achieved with gastric bypass also occur with Lap Band surgery. In bypass, a hormone called ghrelin, which causes the sensation of hunger, almost disappears, so appetite is very low, says Dr. Bessler. We are now looking at whether the same thing happens with Lap Band. If the results are positive, more patients may chose Lap Band as a safe and yet effective way to overcome morbid obesity.
New Guidelines for Following Up on Irregular Pap Tests
BY SHARON W. LINSKER
WHEN THE AVERAGE WOMAN HEARS SHE HAS AN ABNORMAL Pap test, she often assumes she has cervical cancer. Her return visits to the doctors office for repeat testing or colposcopy, during which the cervix is examined with a special type of microscope and biopsies are taken, only increase her anxiety.
Now, new national consensus guidelines will help spare many women the needless apprehension of retesting. Each year, approximately 3.5 million women in the United States have an abnormal Pap test that requires some form of further evaluation or treatment. But of those, 2.5 million women have only a mild change from normal that only rarely indicates that cervical cancer is present.
Dr. Thomas C. Wright, associate professor of pathology and associate attending in pathology at New York-Presbyterian Hospital, helped spearhead the effort that led to the publication of the 2001 Consensus Guidelines in the April 24, 2002, issue of JAMA. The guidelines are available without charge at http://www.ama-assn.org.
The American Society for Colposcopy and Cervical Pathology (ASCCP) sponsored the research that led to the guidelines, which, according to Dr. Wright, are the first to take a formalized evidence-based approach to appropriate follow-up after an abnormal Pap test. He worked with experts across the United States to evaluate medical literature from the past decade and to draw on the results of the National Cancer Institutes ongoing clinical trial of more than 5,000 women with abnormal results.
The ASCCP sought recommendations that would be used in all kinds of medical practice. In the past gynecologists tended to practice one way, internists another, and the STD clinics another, says Dr. Wright. So it was important to develop guidelines that were just as applicable to a nurse practicing in Florida as to a gynecologist in New York City.
The guidelines describe how best to utilize new technologies, including liquid-based cytology and DNA testing for human papillomavirus, a sexually transmitted virus that is the primary cause of cervical cancer. A key recommendation addresses women with the most common type of abnormal Pap test, an inconclusive result referred to as ASC-US, or atypical squamous cells of undetermined significance. The new guidelines say the conventional approach of repeating the Pap test or of doing colposcopy on women with ASC-US may still be used, but that HPV testing is preferred whenever liquid-based Pap tests are employed.
If the liquid test is used, the laboratory can test the same sample used for the original Pap test for HPV, eliminating the stress and expense of a repeat doctor visit. The test rapidly assures women who are HPV negative that they are unlikely to have cervical cancer and that they simply need regular annual Pap tests. This is approximately 1.25 million women each year in the United States. It also identifies women who are HPV positive and need further evaluation.
The guidelines also have economic benefits, according to research Dr. Wright published with Harvard colleagues in the May 8, 2002, issue of JAMA. They examined the clinical outcomes and cost-effectiveness of different management approaches to abnormal Pap tests. One finding stands out: Using HPV DNA testing when patients have ACS-US results would end up saving more than $15 billion over the lifetime of a group of women 18 to 24 years old.
Dr. Wright is a nationally and internationally recognized leader in the field of cervical cancer research. His interest in effective diagnosis has led him to design and implement models for new and simple ways to screen for cervical cancer in developing countries, where an estimated 190,000 women die of the disease each year. Mortality from cervical cancer is prevalent becauseunlike the situation in the United Statesaccess to screening has not been available to most women. Since 1996, Dr. Wright, along with U.S. and South African colleagues, have been evaluating new approaches to cervical cancer screening that do not require Pap tests and plan to extend their work to other countries.