During that time I also had times of deep sadness as I watched hundreds of women with eating disorders relapse repeatedly. Treatment teams are frequently dismayed, families are in debt for thousands of dollars, and patients themselves feel as if they’ve failed yet one more time.

I became aware early on as an eating disorder therapist that the medical model of treatment, which is cognitive-behavioral therapy and nutritional education with some equine therapy tossed in occasionally, simply doesn’t work. Stuart Agras (1993) stated that only 32% of all people who have had eating disorder treatment are eating disorder free after a year. This is simply not good enough!

It was when I was studying for my PhD at Saybrook in San Francisco that I finally figured out what was missing. Attention to what I call my holy trinity – mind, body, spirit was missing. In the medical model of eating disorder treatment, the body and the spirit were left out!
Treating eating disorders is serious. Eating disorders affect a significant number of Americans, an estimated 5 million every year (Kreipe, Golden, Katzman, Fisher, Rees, Tonkin, et al., 1995). These disorders include anorexia nervosa, bulimia nervosa, binge-eating disorders and several other variants. Although these disorders are more common in adolescent girls or young women, approximately 7 million girls and adult women struggle with eating disorders and approximately 1 million boys and men will struggle with eating disorders this year (Katz, 2003). 10%-25% of all those battling anorexia will die as a direct result of the eating disorder. Anorexia nervosa has the highest mortality rate of any DSM diagnoses.

We often say that there’s no such thing as a client with JUST an eating disorder. Nearly all eating disorder clients present with a host of issues that may include anorexia, bulimia and compulsive eating, but also attention deficit disorder, anxiety, depression, trauma, substance abuse, obsessive compulsive disorders, sleep disorders, and a host of other conditions. Almost all eating disordered patients have a dual diagnosis.
Given the complexity of eating disorders, holistic treatment is the one of the few ways to successfully treat eating disorders and their co-occurring conditions.

Holistic eating disorder treatment takes into account the whole person (body, mind, spirit), including all aspects of lifestyle. It makes use of all therapies, both conventional and alternative.

Integrative medicine and holistic eating disorder treatment are partners in treating the whole person, knowing that one part of a person cannot become either ill or well without all of the other parts being affected. Holistic eating disorder treatment depends on a partnership between the patient, therapist, the doctor, and all of the practitioners where the goal is to treat the mind, body, and spirit, all at the same time. While some of the therapies used might be considered unconventional, a guiding principle within holistic and integrative medicine is to use therapies that have some high-quality evidence to support them, such as some therapies used in holistic eating disorder treatment as well.

In a holistic eating disorder treatment center, a multidisciplinary treatment team consists of practitioners from traditional psychiatry, psychotherapy, and medicine who work closely with complementary medicine practitioners. Every member of the staff needs to be an experienced, caring professional who is certified and/or licensed in his or her area of practice and is knowledgeable in the field of eating disorders.

In holistic eating disorder treatment, many types of experiential therapies are used. Clients who have had various traumatic events in their lives are treated through the use of experiential therapies. These therapies include Eye Movement Desensitization and Reprocessing (EMDR), cognitive-behavioral interventions, Gestalt Therapy, Traumatic Incident Reduction (TIR), Emotional Freedom Techniques (EFT) and Neural-Linguistic Programming (NLP). Trauma, Post-Traumatic Stress Disorder and sexual abuse issues are addressed in a professional, respectful, and gentle manner.

Clients in holistic eating disorder treatment are treated as individuals with the utmost dignity and respect.

Holistic eating disorder treatment covers quite a wide range of options for treatment. One eating disorder expert said it like this, “We’re going to knock on a lot of little doors with and for a patient. Some of those doors will open with CBT, others with acupuncture, bodywork, or neurofeedback. But we at least have such a wide variety of little doors that we’ll find whatever it is that will be the way that will take an individual towards healing, health, and wellness.”

This is the first of a series of articles where I will explain the types of alternative therapies that are used in the holistic treatment of eating disorders, why they’re used and, their effectiveness.

Part Used: The dried rhizome and root.

Constituents: The whole complex of primary plant constituents and a characteristic array of secondary plant constituents are present. Pharmacologically important constituents include iridoids, xanthones andalkaloids.

Actions: Bitter, sialagogue, hepatic, cholagogue, anthelmintic, emmenagogue.

Indications: Gentian is an excellent bitter which stimulates appetite and digestion through a general stimulation of the digestive juices, increasing the production of saliva, gastric juices and bile. It also accelerates the emptying of the stomach. It is indicated wherever there is a lack of appetite, dyspepsia or flatulence. The general toning effect of bitters give this herb a role to play in treating debility, anorexia and exhaustion.

Preparations & Dosage: Decoction: Put l/2 a teaspoonful of the shredded root in a cup of water and boil for 5 minutes. Drink warm l5-30 minutes before meals, or at any time when stomach pains result from a feeling of fullness. Tincture: take l-2 ml of the tincture three times a day .

Umbelliferae

Names : European angelica.

Collection : The root is collected in the autumn of its first year. If it is very thick it can be cut longitudinally to speed its drying. The leaves should be collected in June.

Part Used : Roots and leaves are used medicinally, the stems and seeds are used in confectionery.

Constituents :

• Volatile oils obtained mainly from the root and seeds, have a similar composition consisting of a range of terpenes, mainly[[beta]]-phellandrene, with [[beta]]-bisabolene,
  
  [[beta]]-caryophyllene, [[alpha]]-phellandrene, [[alpha]]- and [[beta]]-pinene, limonene, linalool, borneol, acetaldehyde, menthadienes and nitromenthadienes.

• Macrocyclic lactones including tridecanolide, l2-methyl tridecanolide, pentadecanolide.

• Phthalates such as hexamethylphthalate.

• Coumarins, especially furocoumarin glycosides such as marmesin and apterin.

• Angelicin and byakangelicin derivatives, osthol, umbelliferone, psoralen, bergapten, imperatoren, xanthotoxol, xanthotoxin, oxypeucedanin and more.

• Misc. sugars, plant acids, flavonoids and sterols.
  

Actions : Astringent, tonic, diuretic, vulnerary, cholagogue, anti-inflammatory.

Indications : This herb is a useful expectorant for coughs, bronchitis and pleurisy, especially when they are accompanied byfever, colds or influenza. The leaf can be used as a compress in inflammations of the chest. It content of carminative essential oil explains its use easing intestinal colic and flatulence. As a digestive agent it stimulates appetite and may be used in anorexianervosa. It has been shown to help ease rheumatic inflammations. Incystitis it acts as a urinary antiseptic. Angelica is used frequently as a flavoring; in liqueurs such as chartreuse and benedictine, in gin and vermouth; the leaves as a garnish or in salads; and the candied stalks in cakes and pudding.

Combinations : For bronchial problems it combines well with Coltsfoot and White Horehound; for indigestion, flatulence and loss of appetite with Chamomile. In Musculo-skeletal problems it may be used with herbs such as Black Cohosh, Willow Bark and Bogbean.

Preparations & Dosage : Decoction: put a teaspoonful of the cut root in a cup of water, bring it to the boil and simmer for two minutes. Take it off the heat and let it stand for l5 minutes. Take one cup three times a day. Tincture: Take 2-5 ml of the tincture three times a day.

Citations from the Medline database for the genus Angelica

Angelica, Dong QuoiFeng Y Lian NJ Jia ZL [Clinical observations on the treatment of sudden deafness with concentrated Angelica injection]

Chung Hsi I Chieh Ho Tsa Chih 1986 Sep;6(9):536-7, 516 ((Published in Chinese))Guo TL Zhou XW [Clinical observations on the treatment of the gestational hypertension syndrome with Angelica and Paeonia powder]

Chung Hsi I Chieh Ho Tsa Chih 1986 Dec;6(12):714-6, 707 ((Published in Chinese))Harada M Suzuki M Ozaki Y Effect of Japanese Angelica root and peony root on uterine contraction inthe rabbit in situ.

J Pharmacobiodyn 1984 May;7(5):304-11He ZP Wang DZ Shi LY Wang ZQ Treating amenorrhea in vital energy-deficient patients with angelica sinensis-astragalus membranaceus menstruation-regulating decoction.

J Tradit Chin Med 1986 Sep;6(3):187-90

Here are some common causes of nausea and vomiting:

• Viruses in the intestines (Your child can get diarrhea, too.)
  Morning sickness in pregnant teens
  
• Motion sickness (getting “car sick” or “seasick” from travelling)
  
• Some medicines
  
• Spoiled food
  
• Eating or drinking too much

Some serious problems cause vomiting, too. Here are some of them:

• Appendicitis – when your child’s appendix is infected
  
• Brain tumors
  
• Meningitis
  
• Stomach ulcers

Watch your child very closely if he or she is vomiting. Babies and small children can get dehydrated very fast. Dehydration is when your body doesn’t have enough water.

Your older child or teen may make themselves throw up. They may stick a finger down their throat or take ipecac syrup. This could be a sign of an eating problem like anorexia nervosa or bulimia.

Does your child have any of these problems along with the vomiting? Stiff neck and headache Black or bloody vomit Very bad pain in and around one eye Blurry eyesight A head injury that happened a short time ago
Dehydration is when your body loses too much water. Does your child have two or more of these signs of dehydration? Feeling confused Dry diaper for more than 3 hours in a baby No urine for 6 or more hours in a child Sunken eyes Crying with no tears Dry skin and dry mouth
Does your child have very bad stomach pain? Does it last for more than 3 hours? Does it keep hurting even after your child throws up? Or is the vomit greenish-yellow?
Does your child have 2 or more of these problems? Fever Pain below the waist Passing urine very often or wetting the bed (if he or she didn’t before) Pain when passing urine Bad-smelling urine
Does the vomiting come after bad coughing?
Is your child’s urine very dark? Is your child’s stool (solid waste) white?
Is your older child or teen making him or herself throw up over and over? Has someone else told you that your child is doing this?
Has your child been throwing up for more than 12 hours without getting better? In a small child, has the vomiting lasted 6 hours?
Is your child taking any medicine that doesn’t work if they throw up?

• Be calm and loving. Throwing up can scare a child.
  
• Keep a bowl or basin near your child. Hold your hand against their forehead when they vomit.
  
• Give your child water to rinse their mouth out after they throw up. Sponge his or her face.
  
• Take away dirty clothes or bedding. Change to clean ones.
  
• Don’t smoke near your child.
  
• Don’t feed your child solid food until they stop throwing up.
  
• Give your child clear liquids at room temperature (not too cold or too hot). Here are some examples:
  
  • Water (This is best.)
    
  • Pedialyte, Lytren or other mixtures for babies
    
  • Lemon-lime soda or ginger-ale for older children. Warm the soda on the stove or in microwave until the fizz is gone. Then cool it or, just stir it until the fizz is gone.
  
  
• Start with 1 teaspoon to 1 tablespoon of liquid every 10 minutes for babies. Start with 1 to 2 ounces every 15 minutes for children. Give twice as much each hour after the vomiting stops. If your child is still vomiting, give small amounts every hour.
  
• Slowly give your child more and more clear liquids. Don’t make your child drink when he or she doesn’t want anything.
  
• If you are breastfeeding:
  
  • Give your baby Pedialyte, Lytren, or some other baby mixture if the baby throws up 3 or more times.
    
  • Go back to nursing when your baby has gone 4 hours without vomiting. But feed less. Do only one side, and only for about 10 minutes.
    
  • Go back to nursing on both sides after 8 hours of no vomiting. But feed your baby less than usual for about 8 hours.
  
  
• After your child stops throwing up, you can go from clear liquid foods like Jell-O (any color but red) and broth to liquids like milk. Try soft foods after that. Get them back on their usual food within 24 hours.
  
• Don’t give your child over-the-counter medicine unless the doctor tells you to.

Call the doctor if your child doesn’t get better, or if the vomiting comes back.

A common cause of fainting is a sudden reduction of blood flow to the brain which results from a temporary drop in blood pressure and pulse rate. These lead to a brief loss of consciousness. A fainting victim may pass out for several seconds or up to ½ hour.

There are many reasons why women faint. Medical reasons include:

• Low blood sugar (hypoglycemia) which is common in early pregnancy.
  
• Anemia.
  
• Any condition in which there is a rapid loss of blood. This can be from internal bleeding such as with a peptic ulcer, a tubal pregnancy or a ruptured cyst.
  
• Heart and circulatory problems such as abnormal heart rhythm, heart attack or stroke.
  
• Eating disorders such as anorexia, bulimia.
  
• Toxic shock syndrome.

Other things that can lead to feeling faint or fainting include:

• Any procedure that stretches the cervix such as having an IUD inserted, especially in women who have never been pregnant.
  
• Extreme pain.
  
• A sudden change in body position like standing up too quickly (postural hypotension).
  
• Sudden emotional stress or fright.
  
• Taking some prescription drugs. Examples are: Some that lower high blood pressure, tranquilizers, antidepressants, or even some over-the-counter drugs such as antihistamines, when taken in excessive amounts.
  
• Know, also, that the risk for fainting increases if you are in hot, humid weather, are in a stuffy room or have consumed excessive amounts of alcohol.

Here are some dos and don’ts to remember if someone faints:

Dos:

• Catch the person before he or she falls.
  
• Place the person in a horizontal position with the head below the level of the heart and the legs raised to promote blood flow to the brain. If a potential fainting victim can lie down right away, he or she may not lose consciousness.
  
• Turn the victim’s head to the side so the tongue doesn’t fall back into the throat.
  
• Loosen any tight clothing.
  
• Apply moist towels to the person’s face and neck.
  
• Keep the victim warm, especially if the surroundings are chilly.

Don’ts:

• Don’t slap or shake anyone who’s just fainted.
  
• Don’t try to give the person anything to eat or drink, not even water, until they are fully conscious.
  
• Don’t allow the person who’s fainted to get up until the sense of physical weakness passes and then be watchful for a few minutes to be sure he or she doesn’t faint again.

Is the person who fainted not breathing and does he/she not have a pulse?
Are signs of a heart attack also present with the fainting? Chest pain or pressure. Pain that spreads to the arm, neck or jaw. Shortness of breath or difficulty breathing. Nausea and/or vomiting. Sweating. Rapid, slow or irregular heartbeat. Anxiety.
Are signs of a stroke also present with the fainting? Numbness or weakness in the face, arm or leg. Temporary loss of vision or speech, double vision. Sudden, severe headache.
Did the fainting come after an injury to the head.
Do you have any of these with the fainting? Pelvic pain? Black stools?
Have you fainted more than once?
Are you taking high blood pressure drugs or have you recently taken a new or increased dose of prescription medicine?

Do these things when you feel faint:

• Lie down and elevate both legs.
  
• Sit down, bend forward and put your head between your knees.
  

  If you faint easily:
  

• Get up slowly from bed or from a sitting position.
  
• Follow your doctor’s advice to treat any medical condition which may lead to fainting. Take medicines as prescribed but let your doctor know about any side effects, so he/she can monitor your condition.
  
• Don’t wear tight-fitting clothing around your neck.
  
• Avoid turning your head suddenly.
  
• Stay out of stuffy rooms and hot, humid places. If you can’t, use a fan.
  
• Avoid activities that can put your life in danger if you have frequent fainting spells, such as driving a motor vehicle and climbing to high places.
  
• Drink alcoholic beverages in moderation.
  

  When pregnant:
  

• Get out of bed slowly.
  
• Keep crackers at your bedside and eat a few before getting out of bed. Try other foods such as dry toast, graham crackers, bananas, etc.
  
• Eat small, frequent meals instead of a few large. Have a good food source of protein, such as lean meat, low-fat cheese, milk, etc., with each meal. Avoid sweets. Don’t skip meals or go for a long time without eating.
  
• Don’t sit for long periods of time.
  
• Keep your legs elevated when you sit.
  
• When you stand, as in a line, don’t stand still. Move your legs to pump blood up to your heart.
  
• Take vitamin and mineral supplements as your doctor prescribes.
  
• Never lay on your back during the 3rd trimester. It is best to lay on your left side. If you can’t, lay on your right side

They share other common traits, as well, that reflect the mental/physical health of the sufferer:

• Depression.
  
• Low self-esteem, poor body image.
  
• Self-destructive outlook, self-punishment for some imaginary wrong.
  
• Disturbed family relationships.
  
• Abnormal pre-occupation with food and feeling out of control.
  
• Increased rate of illness due to low weight, frequent weight gain/loss and/or poor nutrition.
  

In addition, anorexia and bulimia have factors specific to each:

• Anorexia Nervosa sufferers tend to:
  
  
  
  • Be female, pre-teen or teenage.
    
  • Grow up in over-achieving families who establish unusually high expectations for their children.
    
  • Place exaggerated emphasis on body image and perfection.
    
  • Have parents who are very busy and involved in their own lives. The anorexic may feel the need to be perfect to gain their parents’ attention.
    
  • Have marked physical effects – loss of head hair, stoppage of ovulation/menstruation, slowed heart rate, low blood pressure, cold intolerance.
    
  • Have depression more extreme than in bulimia patients.
    
  • Develop osteoporosis later in life due to lack of calcium and decreased production of estrogen if menstruation stops. Excessive exercise can contribute to this as well.
    
  • Have severe damage to heart and vital organs if weight drops sufficiently.
    
  • Approximately 1% of American females have anorexia.
    
  
  
• Bulimia sufferers:
  
  
  
  • Can be overweight, underweight or normal weight.
    
  • Are mostly female, older teen or young adult.
    
  • Are characterized by binge eating and then vomiting (purging) and/or taking laxatives and/or water pills (diuretics) to undo the binge.
    
  • Have severe health problems that arise from binge-purge cycle of eating. These include stomach lining tears, ruptures, irregular heartbeat, kidney damage from low potassium levels, damage to tooth enamel from acids produced in vomiting and menstrual stoppage.
    
  • Repress anger from inability to express emotions in an assertive way. They fear upsetting important people in their lives.
    

Approximately 2% of college students and 1% of U.S. women overall have bulimia. Bulimia can follow anorexia and vice versa.

There is no one cause for these eating disorders. Many factors contribute to them:

• A possible genetic predisposition.
  
• Metabolic and biochemical problems or abnormalities.
  
• Societal pressure to be thin.
  
• Personal or family pressures.
  

Treatment for anorexia and/or bulimia includes:

• Medical diagnosis and care, the earlier the better.
  
• Psychotherapy, individual, family or and/or group.
  
• Behavior therapy.
  
• Medication. Antidepressant medicine is sometimes used.
  
• Nutrition therapy, including vitamin and mineral supplements.
  
• Hospitalization, if necessary, especially in anorexia, if weight has dropped about 25% or more below normal weight and/or has affected vital functions.
  

Have you gotten to a weight that is over 15% less than what is standard for your age and height by intentionally dieting and exercising (not due to any known illness)?
Are you aware that your eating pattern is not normal and are you afraid that you will not be able to stop binge eating? Are you depressed after binging on food?
Do you have any of these problems? Irregular heartbeat. Slow pulse, low blood pressure. Low body temperature, cold hands and feet. Thin hair (or hair loss) on the head, baby-like hair on the body (lanugo). Dry skin, fingernails that split, peel or crack. Problems with digestion, bloating, constipation. Three or more missed periods (in a row), delayed onset of menstruation, infertility. Sometimes depression and lethargy, sometimes euphoria and hyperactivity. Tiredness, weakness, mus-cle cramps, tremors. Lack of concentration.
Do you have an intense fear of gaining weight or of getting fat or see yourself as fat even though you are of normal weight or are underweight? Do you continue to diet and exercise excessively even though you have reached your goal weight?
Do you: Hoard food? Leave the table right after meals to “go to the bathroom” to induce vomiting and/or spend long periods of time in the bathroom as a result of taking laxatives and/or water pills?
Do you have recurrent episodes when you eat a large amount of food in less than two hours time, at a very fast pace, and do you do at least three of these? Eat a high calorie, easily eaten food during a binge. Binge eat with no one watching. Stop the binge eating when you get abdominal pain, go to sleep, interact socially or induce vomiting. Attempt to lose weight repeatedly with severe diets, self-induced vomiting and/or laxatives or water pills. Have weight changes of more than 10 pounds due to binging and fasting.

Self-Care Procedures

Eating disorders are too complicated and physically hazardous to be treated with self-care procedures. Experts agree that experienced professionals should treat people who have eating disorders.
But, to avoid succumbing to an eating disorder, follow these suggestions:

• Accept yourself and your body. You don’t need to be or look like anyone else. Spend time with people who accept you as you are, not people who focus on “thinness”.
  
• Eat a wholesome nutritious diet. Focus on complex carbohydrates (whole grains, beans, etc.), fresh fruits and vegetables, low-fat dairy foods and low-fat meats.
  
• Eat at regular times during the day. Don’t skip meals. If you do so, you are more likely to binge when you do eat.
  
• Avoid refined foods such as white flour and sugar and “junk” food high in calories such as cakes, cookies or pastry, which have fat and sugar. Bulimics tend to binge on junk food. The more they eat, the more they want.
  
• Get regular moderate exercise. If you find that you are exercising excessively, make an effort to get involved in non-exercise activities with friends and family.
  
• Find success in things that you do. Your work, hobbies and volunteer activities will promote self-esteem.
  
• Educate yourself. Learn as much as you can about eating disorders from books and organizations that deal with them.
  

Parents who want to help daughters avoid eating disorders, should promote a balance between their daughters’ competing needs for both independence and family involvement.

The actual causes of osteoporosis are unknown. Certain risk factors, however, increase the likelihood of developing osteoporosis:

• Being female – women are four times more likely to develop osteoporosis than men. The reasons are:
  
  • Their bones are generally thinner and lighter.
    
  • They live longer than men.
    
  • They have rapid bone loss at menopause due to a sharp decline of estrogen. The risk increases for women who have:
• Natural menopause before age 40; a hysterectomy which includes removal of both ovaries with no hormone replacement therapy (HRT); a lack of/or irregular menstrual flow.
  
• Having a thin, small framed body.
  
• Race – Caucasians and Asians are at a higher risk than African Americans.
  
• Having red or blond hair or freckles may also increase the risk.
  
• Lack of physical activity especially activities such as walking, running, tennis and other weight-bearing exercises.
  
• Lack of calcium and vitamin D – adequate intake of these nutrients throughout life helps to insure that calcium deficiency does not contribute to a weakening of bone mass.
  
• Heredity – the risk increases if there is a history of osteoporosis and/or bone fractures in your family.
  
• Cigarette smoking.
  
• Alcohol – regularly consuming alcoholic beverages, even as little as two to three ounces per day, may damage bones. Heavy drinkers often have poor nutrition and may be more prone to fractures from their predisposition to falls.
  
• Taking certain medicines such as corticosteroids (anti-inflammatory drugs used to treat a variety of conditions such as asthma, arthritis, lupus, etc.) and aluminum containing antacids like Rolaids or Di-Gel.
  
• Some anti-seizure drugs and inappropriate overuse of thyroid hormones may also increase the risk.
  
• Other disorders such as hyperthyroidism, hyperparathyroidism, certain forms of bone cancer, anorexia nervosa, scoliosis and gastrointestinal disease can also increase the risk.

Osteoporosis is a silent disease because it can progress without any noticeable signs or symptoms. The first sign is usually when a bone fracture occurs. Symptoms include:

• Osteoporosis, continued
  
• A gradual loss of height.
  
• A rounding of the shoulders.
  
• Gum inflammation and loosening of the teeth.
  
• Acute lower backache.
  
• Swelling of a wrist after a minor fall or injury.

Osteoporosis can only be prevented. (See self-care/prevention procedures on page 47). Reversing the disease is rarely possible.

Medical tests, such as the dual-energy X-ray absorptiometry (DEXA) and densitometry, can measure bone mass in various sites of the body. They are safe and painless. These tests can help doctors decide if and what kind of treatment is needed.

Treatment for osteoporosis includes:

• Medical management. Check with your doctor, especially if you are at a high risk of getting the disorder. He or she may prescribe hormone replacement therapy (HRT) and/or calcium. These can prevent fractures from osteoporosis if taken during or soon after the start of menopause and then on a continual basis. HRT does not rebuild bone, but it does prevent further bone loss.
• There are risks with HRT though, so you need to check with your doctor to see how they apply to you.
  
• Surgery, such as hip replacement, if necessary.
  
• Dietary and lifestyle measures. (See self-care/prevention procedures on page 47).

Do you have any of these problems? A broken bone, wrist or hip or swelling of a joint after a minor fall or slight injury.
Do you have curving of the spine that brings with it loss of height and/or a rounding of the shoulders or hump on your back.
Are you going through or have you gone through menopause and have any of these. A family history of bone fractures and/or osteo-porosis? A history of: Taking cortisone-like drugs; high doses of thyroid hormones; an over-active thyroid; excessive use of alcohol; smoking; or a lack of exercise.
Do you want to know your chances for having or getting osteoporosis or the status of your bone density?
If you have osteoporosis and take medicine for it, are you having side effects from the medicine?

To prevent or slow osteoporosis, take these steps now:

• Plan to get enough calcium every day: The Recommended Dietary Allowance (RDA) for females aged 11-24 is 1,200 milligrams (mg)/day. For women 25 years and older, the RDA is 800 mg/day. The National Osteo-porosis Foundation recommends 1000 milligrams a day for adult women and 1,500 milligrams a day for post-menopausal women not on hormone replacement therapy.
  
• Choose high calcium foods daily:
  
  • Skim and low-fat milks, yogurts and cheeses.
    

    [Note: If you are lactose intolerant, you may need to use dairy products that are treated with the enzyme lactase or you can add this enzyme with over-the-counter drops or tablets].
    

  • Soft-boned fish and shellfish, such as salmon with the bones, sardines and shrimp.
    
  • Vegetables, especially broccoli, kale, collards.
    
  • Beans and bean sprouts as well as tofu (soy bean curd, if processed with calcium).
    
  • Calcium-fortified foods such as some orange juices, apple juices and ready-to-eat cereals and breads.
  
  
• Get adequate vitamin D. You can get vitamin D from exposure to sunlight and from foods such as vitamin D-fortified milks; salmon, tuna and shrimp. The RDA for vitamin D ranges form 250 to 500 IU (Internations Units) per day for females. Vitamin D helps your body absorb calcium.
  
• Check with your doctor about taking calcium and vitamin D supplements.
  
• Follow a program of regular, weight-bearing exercise at least three or four times a week. Examples include: Walking, jogging, low-impact or non-impact aerobics.
  
• Do not smoke. Smoking makes osteoporosis worse and may negate the beneficial effects of estrogen replacement therapy (ERT).
  
• Limit alcohol consumption.
  
• Pay attention to your posture. Keep your back straight when you sit, stand and walk.
  
• Take measures to prevent falls and injury to your bones.
  
  • Use grab bars and safety mats or non-skid tape on your tub or shower.
    
  • Use handrails on stairways.
    
  • Stay off icy sidewalks and wet or waxed floors.
    
  • Don’t stoop to pick up things. Pick things up by bending your knees and keeping your back straight.
    
  • Wear flat, sturdy, non-skid shoes.
    
  • If you use throw rugs, make sure they have non-skid backs.
    
  • Use a cane or walker if necessary.
    
  • See that halls, stairways and entrances are well lit. Put a night light in your bathroom.
    
  • Avoid taking sedatives or tranquilizers or be careful when you take them as prescribed. They can increase the risk of falls.

RMR has been operationally defined as the calories expended per unit time by a relaxed person who is in a thermoneutral environment and who has been fasting for 12 to 18 hours. The RMR defines that energy which is necessary for the basic maintenance of the body. This includes energy utilized for the movement of the heart and respiratory muscles, for maintenance of ionic gradients between cells and the body fluids, for synthesis of new protein, and for the maintenance of body temperature. The TEF is defined as the elevation of metabolic rate occurring after food ingestion. It includes the cost of the absorption, metabolism, and storage of the food within the body. The TEA is the energy expended with activity and exercise.

Obesity

The increase of caloric intake over expenditure leads to the accretion of fat and an increase in weight. The increase in fat is accompanied by a proportional increase in lean body mass. Thus, for every pound of excess weight added to the body, about two-thirds is fat and one-third is lean. Although the predominant increase in fat-free mass (FFM) is in muscle, other organs are also involved. It has been shown that the RMR is related to the FFM. As a result, as individuals gain weight, they increase their RMR.

On the other hand, what happens to the TEF is more complex. Some studies in obese persons have shown a decrease in TEF whereas others have not. This is most likely related to the insulin sensitivity of the subjects. The more insulin resistant an obese individual is, the more trouble he/she will have in glucose oxidation and disposal, so that postprandial thermogenesis will be decreased. Obese individuals with normal glucose tolerance will have normal TEF, whereas those with impaired glucose tolerance will tend to have decreased TEF.

The TEA is increased in obese individuals per unit of activity. That is, for a given activity, obese persons expend more energy because they are carrying around a greater weight. However, obese persons tend to be very sedentary, so that they actually are likely to spend fewer minutes per day in any type of activity.

Overall, in either room calorimeters or using doubly labeled water in the free-living state, obese persons expend more total 24-hour energy than age- and sex-matched nonathletic normal weight persons.

Starvation

The best known study of metabolism during starvation was conducted by Ancel Keys and his coworkers at the University of Minnesota in the late 1940’s. They studied 32 young male volunteers, who were placed on a diet that provided about two-thirds of their usual calories for 24 weeks. The young men lost more than 70 percent of their fat and about 24 percent of their FFM. The RMR of these volunteers decreased by 40 percent after the 24 weeks of starvation. This decreased RMR can be ascribed primarily to the decrease in lean body mass (LBM). However, the RMR also decreased if expressed per unit of remaining lean tissue, suggesting that other hormonal changes had an important impact. The TEF also decreased, partly because smaller meals were being eaten by the subjects, although the influence of hormonal changes could also have played a role. In addition, TEA decreased, both because the men moved about much less and were moving a much lighter total body, requiring less work and caloric output.

This study has been replicated (less elegantly) in many other studies around the world on undernourished populations. A great deal of information also exists on obese individuals placed on hypocaloric diets for weight loss. Even at weights that are above the normal, hypocaloric diets will induce a drop in RMR. This seems to be in proportion to the loss in LBM. In addition, there is an important drop in nonresting energy expenditure.

Cancer

One of the first manifestations of cancer is loss of weight. This has been primarily ascribed to a loss of appetite and decreased food intake. The net effect of such a hypocaloric diet is to lower energy expenditure. Despite the decreased energy expenditure, energy balance is not maintained. As the imbalance continues or exacerbates, severe undernutrition, called cancer cachexia, can result. Some studies have suggested that cancer patients have an increased RMR. These studies have often expressed RMR as kcal/kg of weight and compared the cancer patients with normal weight patients. Clearly, however, as already mentioned above in the Minnesota study, as one loses weight, one loses more fat than LBM. Since the kcal/kg of fat are much lower than the kcal/kg of LBM, losing proportionally greater fat will leave an individual with a higher kcal/kg of total weight. Overall, the available evidence suggests that an increased RMR contributes very little to the loss of weight in cancer patients, whereas decrease in food intake is key.

Infection

Infections are often manifested by fever. Fever is an elevation of body temperature above normal to more than 37.5°C and is a marker of inflammation. The infection may be obvious, with pain, redness, and inflammation at a site, or it may be a fever of unknown origin, such as bacterial endocarditis. In humans, for each temperature increment of 0.6°C (1°F), RMR increases by approximately 10 percent. Thus, a considerable increase of energy expenditure can occur with even a mild elevation of temperature. Cytokines such as tumor necrosis factor, IL-6, and IL-1 have been implicated in this process, probably working through prostaglandins, and re-setting the hypothalamic thermoregulatory center.

AIDS

There have been a number of studies suggesting that RMR is elevated in patients with AIDS, and that this may contribute to their weight loss and eventual demise. The issue is complicated, as with cancer, in that appetite is also decreased. Also, gastrointestinal symptoms are very prominent in many patients. Studies to date have generally observed an increase of about 10 percent in RMR in relation to the LBM, with a great deal of variation. This is probably explained as an infection effect, discussed above. However, studies of total energy expenditure using doubly labeled water suggest that 24-hour energy expenditure is decreased, related to the fact that these patients feel very ill and as a result are very inactive.

Anorexia Nervosa

The weight loss that occurs in anorexia nervosa because of the patients’ unwillingness to eat appropriate amounts of calories leads to a decrease in RMR, similar to that which occurs in any other starved individual. However, anorexia nervosa patients are generally overactive, so that their 24-hour energy expenditure tends to be higher than one would predict on the basis of their RMR.

Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory disease in which cytokine production is increased. A recent study has reported that RMR is 12 percent higher in this disease than would be predicted. This is probably modulated by increased levels of IL-I beta and TNF-alpha. In contrast, TEA is much lower because general activity and certainly exercise is greatly decreased in patients with the disease.

Surgery and Trauma

Energy expenditure is increased in response to surgery and trauma. The stress that occurs leads to increased levels of catecholamines, cortisol, and glucagon. These, particularly catecholamines, are thermogenic hormones. Also, some cytokine effects lead to fever and anorexia. Energy expenditure tends to be increased proportionate to the degree of injury. A catabolic response occurs that can rapidly deplete muscle mass, again mediated by hormonal response to injury.

Pulmonary Disease

Patients with chronic obstructive pulmonary disease and emphysema tend to be very thin. Studies that have been published on their RMR suggest that it is elevated. This has been ascribed to the increased energy cost of breathing. TEA is decreased in these patients because of their difficulty breathing. Therefore, generally, their total 24-hour energy expenditure may be low, normal, or high, depending on the balance between these two conditions.

Diabetes Mellitus

When diabetes is out of control, with high fasting and postprandial blood glucose levels, energy expenditure is increased above the predicted level for the individual because of an increased RMR. Such an increased RMR has been ascribed primarily to the protein catabolism that occurs in this condition. The protein that is broken down needs to be replaced so that protein synthesis can be increased. This increased protein turnover is metabolically costly and raises the energy expenditure, which returns to normal with diet and drug therapy, as glucose metabolism comes under control.

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2. Golay A, Schutz Y. Meyer HU, Thiebaud D, Curchod B. et al. Glucose induced therrnogenesis in nondiabetic and diabetic obese subjects. Diabetes 1982;11:1023-8.

3. Grunfeld C, Pang M, Shimizu L, Shigenaga JK, Jensen P. Feingold KR. Resting energy expenditure, caloric intake, and short-term change in human immunodeficiency virus infection and the acquired immunodeficiency syndrome. Am J Clin Nutr 1992;55:455-60.

4. Heshka S. Yang MU, Wang J. Burt P. Pi-Sunyer FX. Weight loss and change in resting metabolic rate. Am J Clin Nutr 1990;52:981-6.

5. Kern KA, Norton JA. Cancer cachexia. J Parenter Ent Nutr 1988;12:286-98.

6. Keys A, Brozek J. Henschel A, Mickelsen O. Taylor HL. Human starvation. Minneapolis: University of Minnesota Press, 1951.

7. Knox LS, Crosby LO, Feurer ID, et al. Energy expenditure in malnourished cancer patients. Ann Surg 1983;197:152 61.

8. Macallan DC, Noble C, Baldwin C, Jebb SA, Prentice AM, et al. Energy expenditure and wasting in human immunodeficiency virus infection. N Engl J Med 1995;333:83-8.

9. Ravussin E, LillioJa S. Anderson TE, Christin L, Bogardus C. Determinants of 24-hour energy expenditure in man. J Clin Invest 1986;78: 1568-78.

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Bordetella pertussis, the bacteria that causes pertussis, is contacted by it breathing in after it has been coughed or sneezed out by an infected person, especially during the catarrhal and early paroxysmal stages. Individuals are not infectious after the third week of the paroxysmal coughing. The incubation period averages 7 to 14 days. B. pertussis invades the respiratory mucosa causing increased secretion of mucus, initially thin and later viscid and not easily moved. The disease lasts about 6 weeks and has 3 clear stages:

1. Catarrhal stage. Starts slowly with sneezing, free flowing tears and other signs of the common cold. Anorexia, listlessness and a troublesome, hacking nocturnal cough that gradually becomes diurnal. There is rarely a fever in this stage.
   

2. Paroxysmal stage. Develops after 10-14 days. There are 5 to 15 rapidly consecutive coughs followed by the characteristic whoop, a hurried, deep inspiration. After a few normal breaths another paroxysm may begin. Large quantities of thick viscid mucus may be expelled during the paroxysms. Vomiting following the paroxysms is characteristic.
   

3. Convalescent stage. Usually begins within 4 weeks with the paroxysms becoming less frequent, and the patient looking and feeling better.

Drosera rotundifolia (Sundew)

Thymus vulgaris (Thyme)

Pinguicula vulgaris (Butterbur)

Prunus serotina (Wild Cherry Bark)

Eryngium planum (Sea Holly)

Thymus vulgaris

Drosera rotundifolia

Prunus serotina

Pimpinella anisum — — — equal parts to 100.0g