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DIET AND NUTRITION THE IMPORTANCE OF NUTRITION AS THE BEST MEDICINE FOR EATING DISORDERS Carolyn Coker Ross, MD, MPH

ver seven million girls and women groups. Current research demonstrates to 24, and the suicide rate was 75 times and one million boys and men that symptoms may be as higher. will suffer from an eating disorder common or more common among certain Medical consequences of eating disor- in their lifetime. Up to 3.7% of ethnic groups (Asians, blacks, and Hispan- ders include arrested sexual maturity and O 6 females will be diagnosed with anorexia ics) when compared with whites. There growth failure in prepubertal patients. nervosa and an estimated 4.2% will have was no difference found in dieting and Many with eating disorders may look and bulimia nervosa.1 The majority of adoles- restraint scores between Asian, Latino, feel deceptively well and may have normal cent patients seen in referral centers fit and white adolescent girls and boys7 and electrograms but are still at high risk for into a third category, “eating disorder not no difference in binging or BED in obese cardiac arrhythmias and sudden death. otherwise specified” or EDNOS and do patients who sought to lose weight with Prolonged amenorrhea is associated with not fit strict criteria for either anorexia or bariatric surgery.8 These changes may be an increased risk of osteopenia and rate of bulimia.2 Nineteen percent of college- related to an extension of cultural ideals in fractures. Neuroimaging studies with com- aged females are bulimic; many go undi- these ethnic populations of what is attrac- puterized tomography (CT) have demon- agnosed until much later. At the other end tive as seen through the public media, or strated structural brain abnormalities in of the spectrum, 1% to 5% of the popula- may represent past underreporting. How- both anorexics and bulimics.14,15 Bulimia tion falls into the category of binge eating ever, an analysis of 18 studies (1987-2001) is associated with electrolyte, fluid, and disorder, not yet an approved psychiatric concluded that African-American women mineral imbalance; increased cardiac risk; diagnosis.3 Anorexics are more likely to be were less likely than white women to have gastrointestinal bleeding; dental enamel female (90%-95%); 80% of bulimics are an eating disorder.9 As well, a study in erosion; peripheral muscle ; car- female and 60% of BEDs are female.4 In school age girls demonstrated that Native diomyopathy; and hypometabolism.16 the United States, food and weight are sig- American girls had higher rates of restrict- Despite normal weight, bulimics and BED nificant issues, as witnessed by the fact ing/purging and dieting than white or patients may be severely malnourished. that almost half of the population is con- nonwhite/non-Native American popula- The effects of poor nutrition are no- sidered overweight and/or obese. tions.10 where as pronounced as in the case of eat- Eating disorders begin early, with 10% Eating disorders have one of the highest ing disorders. Although many may think being diagnosed in children less than 10 death rates of all psychiatric diagnoses. that undernutrition or is a years of age. One third of patients are di- The number of deaths in anorexics is 11.6 side effect of eating disorders, studies have agnosed as preteens and adolescents up to times what would be expected in others of documented that it can be the cause of age 15. In total, 86% of patients are diag- their same age and sex; for bulimics, this many of the symptoms seen in eating dis- nosed with eating disorders before the age number is 1.3 times greater than expected. orders. The earliest study to demonstrate of 20. For this reason, the Society for Ad- The most shocking number is the 56.9 this was done by Ancel Keys and his col- olescent Medicine5 issued this statement: times increased number of observed ver- leagues at the University of Minnesota in “Because of the potentially irreversible ef- sus expected deaths in anorexics from sui- 1950.17 Young, healthy, psychologically fects of an eating disorder on physical and cide. If either of these groups abused alco- normal males were recruited for the study emotional growth and development in ad- hol, the death rates were even higher.11 as an alternative to military service. Of 100 olescents, because of the risk of death, and is a major risk factor for both who applied, 36 were selected for being in because of the evidence suggesting im- substance use disorder and bulimia and the best physical and psychological proved outcome with early treatment, the explains to a great degree the association health. This study is known as the “starva- threshold for intervention in adolescents between substance use disorder and eating tion study,” and its intent was not to study should be lower than in adults.” Irrevers- disorders.12 A meta-analysis by Sullivan13 eating disorders but to develop a better ible risks are growth retardation, pubertal found 178 deaths in 3,006 patients: 54% understanding of how best to manage the delay or arrest, impaired acquisition of died from complications of their eating refeeding of concentration camp survi- peak bone mass, and increased risk of os- disorder, 27% from suicide, and 19% from vors. teoporosis. other and/or unknown causes. The overall In the study, the men ate normally and Earlier studies of eating disorders sug- rate of .56% mortality per year in this continued their normal activities for the gested disparities in the occurrence of eat- study was 12 times greater than the ex- first three months while their behavior, ing disorders among different ethnic pected mortality rate for women aged 15 personality, and eating patterns were stud-

Diet and Nutrition EXPLORE March/April 2007, Vol. 3, No. 2 153 ied. Over the next six months, their diet vosa or BED showed that a protein sup- pressants. Both low B12 and low folic acid was restricted to half of what they nor- plement given three hours before a meal have been noted in patients with depres- mally ate, resulting in a 25% loss of reduced binge eating as compared with a sion. As well, in population studies, an weight. Of note, the amount of calories carbohydrate supplement. Participants in association has been found between de- prescribed in the study is the same as that the study also consumed less food at meals pression and low levels of these two vita- being used in treating obesity. After this and had less hunger after receiving the mins. Low levels of folate have been im- period of , the men were slowly protein supplementation.18 A small study plicated in poor response rates to standard refed. The results of the study were re- by Dalvit-McPhillips19 in the 1980s therapy.26 B also ported for only 32 of the original 36 par- showed that a nutrient-dense diet (one convert glucose into energy in the brain ticipants, as four dropped out either dur- without blood sugar destabilizers—white cells and assists in the manufacture of neu- ing or at the end of the “semistarvation” flour, refined sugar, alcohol, , fla- rotransmitters. B12 is essential for nerve phase. All participants experienced very vor enhancers, and decreased salt) given to cell health. Studies in animals document dramatic changes—physical, psychologi- bulimic women had a dramatic effect on that it can slow the rate at which rats learn. cal, and social. binge behavior. This type of diet today Other micronutrients have been shown The striking changes included an in- may be consistent with a diet without to be missing in eating disorder patients. crease in preoccupation with food. During foods that have a low glycemic index. Par- Symptoms of zinc deficiency include de- the 12-week refeeding period, binging ticipants were also given C, a B- crease in smell and taste, loss of , continued, and several of the men experi- complex vitamin, and a multivitamin. mental lethargy, generalized hair loss, di- enced nausea and vomiting. Serious binge Those on the nutrient-dense diet ceased arrhea, rough and dry skin, slow wound eating occurred in a subset of volunteers. binging and were able to lose weight ef- healing, and delayed puberty. Binges consisted of up to 10,000 calories, fortlessly and remained binge free for 2.5 Zinc and the mineral copper must be with volunteers reporting continued hun- years. When the control group was put on kept in balance. Copper, calcium, and ger even after binging to the point of be- the nutrient-dense diet, they also stopped phosphorus all increase the effectiveness coming ill. Normalization of eating be- binging. This study suggests that malnutri- of zinc. Zinc is also vital in the metabolism haviors took approximately five months tion and blood sugar– level are im- of essential fatty acids—levels of essential for the majority of the volunteers. portant factors in the binging behavior of fatty acids were decreased in anorexics. Es- The volunteers also experienced emo- bulimics. Therefore, the use of nutrition sential fatty acids are important in zinc tional changes, including depression, irri- supplements can be a valuable addition to absorption, and zinc is necessary for two tability, anxiety, and apathy. Two devel- standard dietary therapy in the treatment stages of essential fatty acid metabolism. of eating disorders for the following rea- oped psychosis. These changes persisted Zinc is a cofactor in the absorption of the sons: for some time during the refeeding period. , as is manganese and magne- The men became increasingly isolated sium. Zinc is vital in the regulation of gene during the semistarvation period and re- REPLACING MISSING NUTRIENTS expression, immune function, wound ported decreased sex drive, which took al- Studies have shown deficiencies in a num- healing, reproduction, growth and devel- most eight months to be restored to their ber of specific nutrients in patients with opment, behavior and learning, blood previous level of functioning. eating disorders. Eating disorder patients clotting, thyroid hormone function, and There were other changes in the volun- who restrict intake of food have been insulin action. In a study of adolescent teers as well, including decreased concen- found to have deficiencies in calcium, anorexics, when zinc was supplemented tration and other cognitive changes; phys- iron, riboflavin, folic acid,20 vitamins A (50 mg elemental zinc per day), there was a ical changes that included decreased need and C,21 and vitamin B622 and essential decrease in depression and anxiety levels for sleep; gastrointestinal problems; dizzi- fatty acids.23 It has been postulated that as measured on the Zung Depression Scale 27 ness; ; noise and light sensitiv- anorexia may be a subclinical form of pel- and the State-Trait Anxiety Inventory. ity; weakness; fluid retention; cold intol- lagra, and one study showed low Zinc supplementation (100 mg of zinc glu- erance; and difficulties with hearing and intake in anorexics24; niacin supplementa- conate) has been shown to help with sight. There was a 40% slowing of basal tion has been shown in several case reports weight gain in anorexics, increasing their 28 metabolic rate, low body temperature, de- to improve appetite and mental state. body mass index twice as fast as placebo. crease in heart rate, and respiration. Other small studies have shown deficien- Zinc also lowers the severity and duration This study is important because many cies in eating disorder patients for vita- of diarrhea associated with malnutrition. of the symptoms seen in eating disorders mins D, C, and E, as well as micronutri- Omega-3 fatty acids have not been spe- were present in the starvation study, and ents such as copper and zinc.25 Nutrition cifically tested in the treatment of eating given that the volunteers were psycholog- supplementation for eating disorders is disorders but may be useful in the treat- ically healthy, could not be blamed on targeted at replacing missing nutrients and ment of many of the symptoms of eating psychological problems. treating symptoms seen in these disorders. disorders. Omega-3 fatty acids are impor- There are other studies in modern re- The B vitamins are implicated in the tant in brain cell communication, there- search that demonstrate the importance of mood disorders seen in eating disorder pa- fore having significant effects on brain nutrition and its effect on symptoms of tients. B12 and folic acid have significant function and mood. In the overweight or disordered eating. For example, a study mood-enhancing benefits when used obese patient, omega-3 fatty acids have done on women with either bulimia ner- alone and in combination with antide- been shown to lower serum triglyceride

154 EXPLORE March/April 2007, Vol. 3, No. 2 Diet and Nutrition levels, especially in those with high triglyc- sus the placebo group—but had no de- occurring gut flora. Probiotics are present erides, such as diabetics. Consumption of crease in their mania.34 in some foods, one example being Lacto- four grams per day of omega-3 was shown Borderline personality disorder is also bacillus in yogurt. Probiotics in the gastro- in a review of studies to reduce common in patients with eating disorders. intestinal tract are affected by the use of serum triglyceride levels by 25% to 30%, In one small study, patients with moder- antibiotics, excess alcohol or drugs, stress, increase low-density lipoprotein by 5% to ately severe borderline personality disor- chronic constipation, and some . 10% and high-density lipoprotein by 1% der treated with one gram of ethyl-EPA Probiotics are used to manage lactose in- to 3%. Consumption of omega-3 fatty ac- demonstrated less aggression and de- tolerance by converting lactose from ids has a beneficial effect on insulin sensi- creased depression than those on pla- foods such as milk and other dairy prod- 35 tivity and glucose tolerance, a useful ben- cebo. ucts to lactic acid, which is better toler- efit for eating disorder patients who are ated. Lactic acid bacteria have been shown obese or diagnosed with metabolic syn- to have a cholesterol-lowering benefit, possibly by breaking down bile in the gut, drome (central obesity, impaired glucose OSTEOPOROSIS PREVENTION thus reducing its reabsorption (entering tolerance, hypertension, and dyslipide- Anorexics are at increased risk of osteopo- the blood as cholesterol). Foods contain- mia).29,30 rosis due to lowered intake, being under- ing lactic acid bacteria have been shown to Omega-3 fatty acids have been shown weight, and decreased estrogen related to decrease the inflammatory response, im- in research to reduce the incidence of sud- amenorrhea. Calcium supplementation in prove absorption of minerals, and im- den death syndrome from ventricular ar- pubertal girls may increase peak bone 36 prove immune function. The most com- mass. Calcium supplementation may in- rhythmias by 45% to 50% and all-cause mon source of probiotics in food are dairy mortality by 20%.31 Anorexics are at crease the beneficial effects of physical ac- 37 products and foods fortified with probiot- tivity on bone. Deficiency of higher risk of sudden death, and although ics. They are also available in capsule or there have been no studies specifically ad- in young people can affect their ability to 38 tablet form. Capsules may be more effec- reach peak bone mass. Special risks in dressing the use of omega-3 fatty acids in tive because of their ability to elude de- 16 eating disorder patients for osteoporosis this population, it may provide benefit. struction in stomach acid. Certain fer- include the following: Many studies have shown a benefit of mented foods contain lactic acid bacteria: omega-3 fatty acid to treat depression and kefir, yogurt, sauerkraut, and kimchi. The ● anorexic girls (aged 13-23) who also suf- . Some epidemiological two most common probiotics are various fer from depression may be at higher studies demonstrated that countries in species of Bifidobacterium and Lactobacil- risk for osteoporosis than those without which there is high consumption of fish lus. depression; the reason for this finding is have a lower incidence of depression and 39 Studies on probiotics that are relevant not known bipolar disorder. Several studies have also to the treatment of eating disorders have ● amenorrhea in anorexic women and reported that (1) a probiotic mixture used shown a decrease of omega-3 fatty acid young girls may indicate the onset of to treat irritable bowel syndrome reduced (Eicosapentaenoic acid [EPA]) in patients estrogen deficiency, which can have a abdominal , distension, flatulence, with depression. In one study, those par- negative effect on bone density and and borborygmi42 ticipants who received supplementation peak bone mass and (2) probiotics used in those suffering from chronic constipa- with one gram of ethyl-EPA achieved a ● undernutrition can affect bone density tion reduced severity of constipation and 50% reduction on the Hamilton Depres- through deficiency of anabolic hor- stool consistency after two weeks.43 sion Rating Scale score, which was supe- mones such as insulinlike growth factor rior to supplementation with either two I; in addition, low weight is also a risk grams or four grams per day.32 Omega-3 factor for lowered bone mass.40 fatty acid supplements can be given along CASE with prescription medications for depres- Other studies have shown that nutri- Maria is a 27-year-old woman hospitalized sion and bipolar disorder. In a four-week, tional factors far outweigh the impact on for (binge-purge type), double-blind study, patients diagnosed bone mass of endocrinologic factors such 41 alcohol dependence, and major depres- with recurrent unipolar depression re- as insulinlike growth factor I. sion. The patient had a history of compul- ceived either ethyl-EPA or placebo. sive overexercise. On admission, her lab Highly significant benefits were found studies showed low potassium and chlo- with the addition of the ethyl-EPA versus IMPROVING AND SUPPORTING ride, elevated cholesterol, HDL, and LDL. placebo to standard antidepressant medi- DIGESTIVE FUNCTION Her electrocardiogram showed bradycar- 33 cation. The 1999 Harvard study on 30 Eating disorder patients commonly have dia. Psychological testing results showed a bipolar patients with a history of at least complaints of constipation, diarrhea, diagnosis of major depressive disorder, al- one relapse in the prior year, of whom all bloating, and other digestive symptoms. cohol abuse, and borderline personality but eight were on medications, used 9.6 These symptoms can pose a significant disorder. The patient admitted at 74% of grams of fish oil capsules, the other half barrier during the refeeding process. her ideal body weight. She complained of received olive oil. The omega-3 fatty acid Probiotics are supplements that contain , loss of interest in normal activi- group stayed in remission significantly beneficial bacteria or yeast that are used to ties, irritability, insomnia, anxiety, and ob- longer—with a decrease in depression ver- replace or enhance the body’s naturally sessive thoughts that her food was rotting

Diet and Nutrition EXPLORE March/April 2007, Vol. 3, No. 2 155 in her stomach. The patient was amenor- thoughts when under stress but was able to 9. O’Neill SK. African American women and rheic for one year. Medications at the time see them as false and no longer became eating disturbances: A meta-analysis. Jour- of admission included Lexapro, 30 mg/ distraught when they appeared. She was nal of Black . 2003;29:3-16. day for depression/anxiety; Klonopin, 1 able to begin a healthy exercise program 10. Lynch WC, Eppers KD, Sherrod JR. Eating attitudes of Native American and white fe- mg twice daily for anxiety; and Ambien, with weight training and was completely male adolescents: a comparison of BMI- 10 mg at bedtime for sleep. The patient abstinent from purging or drinking while and age-matched groups. Ethnicity & presented with the fear of eating specific in treatment. She reported a marked de- Health. 2004;9:253-266. foods; once she developed the thought of crease in bloating, abdominal pain, and 11. Keel PK, Dorer DJ, Eddy KT, et al. Predic- rotting food, she would obsess about it constipation during her current treatment, tors of mortality in eating disorders. Arch of and becoming increasingly distraught un- as opposed to her previous inpatient treat- Gen . 2003;60:179-183. til she forced herself to vomit. Other neg- ment. The patient’s depression scores at 12. Stice E, Burton EM, Shaw H. Prospective ative thoughts stemmed from her eating the time of discharge showed only a min- relations between bulimic pathology, de- disorder, including thoughts about being imal level of depression compared with a pression, and substance abuse: unpacking comorbidity in adolescent girls. J Consult too fat, feeling disgusted with her body, severe level at the time of admission. Her Clin Psychol. 2004;72:62-71. and feeling guilt or shame if she allowed anxiety had decreased significantly despite 13. Sullivan PF. Mortality in anorexia nervosa. herself to eat more than a very small terminating her benzodiazepines, and the Am J Psychiatry. 1995;152:1073-1074. amount of food. Bone density testing patient learned mind-body skill for man- 14. Krieg JC, Pirke KM, Lauer C, Backmund H. showed osteoporosis in both hip and aging anxiety. Endocrine, metabolic, and cranial com- spine. This case demonstrates the importance puted tomographic findings in AN. Biol The patient was started on the following of nutrition and the value of nutritional Psychiatry. 1988;23:377-87. supplement regimen: supplements in the treatment of eating 15. Krieg JC, Lauer C, Pirke KM. Structural disorder patients. brain abnormalities in patients with bu- ● B-complex vitamin for mood and cog- limia nervosa. Psychiatry Research. 1989;27: nitive support 39-48. 16. NEDA. Information for treatment profes- ● omega-3 fatty acids containing EPA and sionals. Available at: http://edap.org/p. REFERENCES docosahexaenoic acid for mood and asp?WebPage_IDϭ293. Accessed March 5, cognitive support 1. American Psychiatric Association Work 2007. ● valerian for sleep, anxiety, and for with- Group on Eating Disorders. Practice guide- 17. Taylor HL, Keys A. Adaptation to caloric drawal symptoms from benzodiaz- line for the treatment of patients with eat- restriction. Science. 1950 Aug 25;112:215- epines ing disorders (revision). Amer J Psych. 2000; 218. 157(1 Suppl):1-39. ● osteoporosis 18. Latner JD, Wilson GT. Binge eating and 2. Bunnell DW, Shenker IR, Nussbaum MP, ● weight-bearing exercise program satiety in bulimia nervosa and binge eating et al. Subclinical versus formal eating disor- disorder: effects of macronutrient intake. ● calcium, magnesium, and vitamin D 3 ders: Differentiating psychological fea- Int J Eat Disord. 2004;36:402-415. tures. Int J Eat Disorder. 1990;9:357-362. 19. Dalvit-McPhillips S. A dietary approach to The patient’s nutrition program includ- 3. Spitzer RL, Yanovski S, Wadden T, et al. bulimia. Physiol Beav. 1984;33:769-775. ed: Binge eating disorder: its further validation 20. Abou-Saleh MT, Coppen A. The biology in a multisite study. International Journal of of folate in depression: implications for nu- ● liquid meal replacement with a 1,200 Eating Disorders. 1993;13:137-153. tritional hypotheses of the psychoses. J Psy- calorie meal plan, gradually increasing 4. National Eating Disorders Association. chiatr Res. 1986;20:91-101. the amount of food and decreasing the Available at: http://www.edap.org/p.asp? 21. Beaumont PJ, Chambers TL, Rouse L, meal replacement WebPage_IDϭ337. Accessed March 2, Abraham SF. The diet composition and 2007. ● a multivitamin with copper nutritional knowledge of patients with an- 5. Eating Disorders in Adolescents: Position orexia nervosa. J Hum Nutr. 1981;35: ● digestive support Paper of the Society for Adolescent Medi- 265-273. ● digestive enzymes before each meal cine. J of Adolescent Health. 2003;33: 22. Rock CL, Vasantharajan S. Vitamin status ● probiotics 496-503. of eating disorder patients: relationship to 6. Shaw H, Ramirez L, Trost A, et al. Body clinical indices and effect of treatment. Int J The patient was involved in group and image and eating disturbances across eth- Eat Disorder. 1995;18:257-262. individual therapy, targeting traumatic nic groups: More similarities than differ- 23. Langan SM, Farrell PM. Vitamin E, vita- childhood experiences and resulting ences. Psych of Addic Behav. 2004;18:12-18. min A and essential fatty acid status of pa- chronic post-traumatic stress disorder. She 7. Cachelin FM, Weiss JW, Garbanati JA. Di- tients hospitalized for anorexia nervosa. was able to be compliant with her meal eting and its relationship to smoking, accul- Am J Clin Nutr. 1985;41:1054-1060. plan and to gain weight, with a discharge turation, and family environment in Asian 24. Thibault L, Roberge AG. The nutritional and Hispanic adolescents. Eating Disorders. status of subjects with anorexia nervosa. Int weight that was 90% of her ideal body 2004;11:51-61. J Vitam Nutr Res. 1987;57:447-452. weight. She was tapered off her benzodi- 8. Sanchez-Johnson L, Dymek M, Alverdy J, 25. Humphries L, Vivian B, Stuart M, McClain azepines and Klonopin and continued on LeGrange D. Binge eating and eating-re- CJ. Zinc deficiency and eating disorders. Lexapro. She was tapered off Ambien and lated cognitions and behavior in ethnically J Clin Psychiatry. 1989;50:456-459. continued on valerian for sleep. The pa- diverse obese women. Obesity Research. 26. Coppen A, Bolander-Gouaille C. Treat- tient continued to have obsessive 2003;11:1002-1009. ment of depression: time to consider folic

156 EXPLORE March/April 2007, Vol. 3, No. 2 Diet and Nutrition acid and vitamin B12. J Psychopharmacol. ication treatment for recurrent unipolar 40. Miller KK. Mechanisms by which nutri- 2005;19:59-65. depressive disorder. Am J Psychiatry. 2002; tional disorders cause reduced bone mass 27. Katz RL, Keen CL, Litt IF, et al. Zinc defi- 159:477-479. in adults. J Womens Health (Larchmt). 2003; ciency in anorexia nervosa. J Adolesc Health 34. Stoll AL, Severus WE, Freeman MP, et al. 12:145-150. Care. 1987;8:400-406. Omega 3 fatty acids in bipolar disorder: a 41. Heer M, Mika C, Grzella I, et al. Changes 28. Birmingham CL, Goldner EM, Bakan R. preliminary double-blind, placebo-con- in bone turnover in patients with anorexia Controlled trial of zinc supplementation in trolled trial. Arch Gen Psychiatry. 1999;56: nervosa during eleven weeks of inpatient anorexia nervosa. Int J Eat Disord. 1994;15: 407-412. dietary treatment. Clin Chem. 2002;48: 251-255. 35. Zanarini MC, Frankenburt FR. Omega-3 754-760. 42. Kajander K, Hatakka K, Poussa T. A probi- 29. Harris WS. N-3 fatty acids and serum li- Fatty Acid treatment of women with bor- otic mixture alleviates symptoms in irrita- poproteins: human studies. Am J Clin Nutr. derline personality disorder: a double- 1997;65:1645S-1654S. ble bowel syndrome patients: a controlled blind, placebo-controlled pilot study. Am J 30. Ebbesson SO, Risica PM, Ebesson LO, et 6-month intervention. Aliment Pharmacol Psychiatry. 2003;160:167-169. al. Omega-3 fatty acids improve glucose Ther. 2005;22:387-394. 36. Dodiuk-Gad RP, Rozen GS, Rennert G, et tolerance and components of the meta- 43. Koebnick C, Wagner I, Leitzmann P, et al. al. Sustained effect of short-term calcium bolic syndrome in Alaskan Eskimos: the Probiotic beverage containing Lactobacil- supplementation on bone mass in adoles- Alaska Siberia project. Int J Circumpolar lus casei Shirota improves gastrointestinal cent girls with low calcium intake. Am J Health. 2005;64:396-408. symptoms in patients with chronic consti- 31. Covington MB. Omega-3 Fatty Acids. Clin Nutr. 2005;81:175-188. pation. Can J Gastroenterol. 2003;Nov17: American Family Physician. 2004;70:133- 37. Specker BL. Evidence for an interaction be- 655-659. 140. tween calcium intake and physical activity on changes in bone mineral density. J Bone 32. Peet M, Horrobin DF. A dose-ranging Carolyn Coker Ross, MD, MPH, is a grad- study of the effects of ethyl-eicosapentano- Miner Res. 1996;11:1539-1544. uate of the residential fellowship at the Univer- ate in patients with ongoing depression de- 38. Calvo MS, Whiting SJ, Barton CN. Vita- spite apparently adequate treatment with min D intake: a global perspective of cur- sity of Arizona Program in Integrative Medi- standard drugs. Arch Gen Psychiatry. 2002; rent status. J Nutr. 2005;135:310-316. cine and is the chief of the Eating Disorders 59:913-919. 39. Konstantynowicz J, Kadziela-Olech H, Program and head of the Integrative Medicine 33. Nemets B, Stahl Z, Belmaker RH. Addition Kaczmarski M, et al. J Clin Endocrinol Department at Sierra Tucson in Tucson, Ari- of omega-3 fatty acid to maintenance med- MEtab. 2005;90:5382-5. Epub 2005 Jun 7. zona.

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