1. Special Issues for Adolescents with HIV: Anorexia Nervosa and Bulimia As a patient population, adolescents are at high risk for bulimia and anorexia nervosa. Primary care practitioners must be aware of these disorders and appropriately screen for them in their patients. It should be noted that eating disorders are not more prevalent in adolescents with HIV than the general adolescent population. The clinician must differentiate an eating disorder from HIV-associated anorexia or other infectious causes of weight loss. Diagnostic Criteria for Anorexia Nervosa Refusal to maintain body weight over a minimum normal weight for age and height (i.e., weight loss leading to body weight 15% below that expected or failure to make expected weight gain during a period of growth). Intense fear of gaining weight or becoming fat even though underweight. Disturbance in the way in which one's body weight, size or shape is experienced, undue influence of body shape and weight on self-evaluation, and/or denial of the seriousness of low body weight. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhoea). Diagnostic Criteria for Bulimia Recurrent episodes of binge eating characterized by: –Eating in a discrete period of time (i.e., a 2 hour period) an amount of food that is definitely larger than most people would eat during a similar period of time in similar circumstances. –A sense of lack of control over eating during the episode (i.e., a feeling that one cannot stop eating or control what or how much one is eating). Recurrent inappropriate compensatory behavior in order to prevent weight gain such as: self induced vomiting, use of laxatives, diuretics or other medications, fasting or excessive exercise. A minimum average of two binge eating and inappropriate compensatory behaviors per week for at least three months. Self evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa.

2. Clinical Resource Guide PrevalenceSignsSymptomsTreatment Long process, requiring team approach (family, primary care provider, nutrition specialist, and mental health professional) Hospitalization required if the blood pressure is low or electrolytes out of normal range Weight gain should be initial focus, but psychological issues must be addressed at the same time Psychotropic medications if depressed or obsessive- compulsive behavior present Education about the disorder Behavioral techniques: monitor food, reward weight gain, involve patient in different activities to alter behavior. Stress coping skills to decrease relapse Condition Depression may be present (see complementary depression tool) Frequent inappropriate references to being overweight or fat Requesting prescriptions for diuretics, laxatives, or “weight loss pills” Generalized lethargy due to malnutrition or electrolyte disturbances Absence of menstruation Weight 15% or greater below expected weight Inappropriate use of laxatives, enemas, or diuretics to loose weight Skeletal muscle atrophy and loss of fatty tissue Low blood pressure Dental cavities secondary to induced vomiting Denial of eating disorder Absence of menstruation Blotchy or yellow skin Scarring on the backs of knuckles may indicate bulimia Adolescent Anorexia Nervosa & Bulimia Signs = “objective” indication(s) of a medical fact or quality that can be detected by a clinician. Symptoms = “subjective” experiences that a patient might report to a clinician. 3% of adolescent and adult women and 1% of men have either bulimia, anorexia nervosa, or a binge eating disorder (Harvard Eating Disorders Center). An adolescent woman with anorexia is twelve times more likely to die as compared to adolescents her own age without anorexia (Harvard Eating Disorders Center). Mortality for anorexia nervosa may be as high as 15%. Approximately 90-95% of those with anorexia nervosa are female and approximately 80% of those with bulimia are female (National Eating Disorders Association).

3. References 1.Diagnostic Criteria for Anorexia Nervosa, www.edauk.com/media/media_sub_diagnostic.htmwww.edauk.com/media/media_sub_diagnostic.htm 2.Diagnostic Criteria for Bulimia, www.edauk.com/media/media_sub_diagnostic.htmwww.edauk.com/media/media_sub_diagnostic.htm 3. Associated Features or Symptoms, www.medicineonline.comwww.medicineonline.com 4.Harvard Eating Disorders Center, http://www.hedc.org http://www.hedc.org 5.National Eating Disorders Association, http://www.edap.org Credits This tool was developed by the Mental Health subset (Chair: Linda Frank, PhD, MSN, ACRN, PA/MA AETC) of the AIDS Education and Training Centers (AETC) National Resource Center, Adolescent HIV/AIDS Workgroup (Chair: Marion Donohoe, RN, MSN, CPNP, St. Jude Children’s Research Hospital, ANAC and Ronald Wilcox, MD,FAAP, Delta Region AETC). Collaborating members include Elizabeth Cabrera, MEd (TX/OK AETC), Verita Ingram, MBA (TX/OK AETC), Elise Johnson, MSW (Bickerstaff Pediatric Family Center), Jennifer Scanlon, FNP (The Children's Hospital, Denver), and Ronald Wilcox. The workgroup efforts were coordinated by the AETC National Resource Center (Managing Editor: Megan Vanneman, MPH).