Journal of General Internal Medicine

, Volume 15, Issue 8, pp 577–590

Detection, evaluation, and treatment of eating disorders

The role of the primary care physician
  • Judith M. E. Walsh
  • Mary E. Wheat
  • Karen Freund
Reviews

Abstract

OBJECTIVE: To describe how primary care clinicians can detect an eating disorder and identify and manage the associated medical complications.

DESIGN: A review of literature from 1994 to 1999 identified by a MEDLINE search on epidemiology, diagnosis, and therapy of eating disorders, including anorexia nervosa and bulimia nervosa.

MEASUREMENTS AND MAIN RESULTS: Detection requires awareness of risk factors for, and symptoms and signs of, anorexia nervosa (e.g., participation in activities valuing thinness, family history of an eating disorder, amenorrhea, lanugo hair) and bulimia nervosa (e.g., unsuccessful attempts at weight loss, history of childhood sexual abuse, family history of depression, erosion of tooth enamel from vomiting, partoid gland swelling, and gastroesophageal reflux). Providers must also remain alert for disordered eating in female athletes (the female athlete triad) and disordered eating in diabetics. Treatment requires a multidisciplinary team including a primary care practitioner, nutritionist, and mental health professional. The role of the primary care practitioner is to help determine the need for hospitalization and to manage medical complications (e.g., arrhythmias, refeeding syndrome, osteoporosis, and electrolyte abnormalities such as hypokalemia).

CONCLUSION: Primary care providers have an important role in detecting and managing eating disorders.

Key words

eating disorders primary care medical complications 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    leGrange D, Telch CF, Tibbs J. Eating attitudes and behaviors in 1,435 South African Caucasian and non-Caucasian college students. Am J Psychiatry. 1998;155:250–4.Google Scholar
  2. 2.
    Field AE, Colditz GZ, Peterson KE. Racial/ethnic and gender differences in concern with weight and in bulimic behaviors among adolescents. Obes Res. 1997;5:447–54.PubMedGoogle Scholar
  3. 3.
    Robinson TN, Killen JD, Litt IF, et al. Ethnicity and body dissatisfaction: are Hispanic and Asian women at increased risk for eating disorders? J Adoles Health. 1996;19:384–93.CrossRefGoogle Scholar
  4. 4.
    American Psychiatric Association. Practice Guidelines for Eating Disorders. Am J Psychiatry. 1993;150:2–28.Google Scholar
  5. 5.
    Halmi KA, Eckert E, Marchi P, Sampugnaro V, Apple R, Cohen J. Comorbidity of psychiatric diagnoses in anorexia nervosa. Arch Gen Psychiatry. 1991;48:712–8.PubMedGoogle Scholar
  6. 6.
    Eckert ED, Halmi KA, Marchi P, Grove W, Crosby R. Ten year follow-up of anorexia nervosa: clinical course and outcome. Psychol Med. 1995;25:143–55.PubMedGoogle Scholar
  7. 7.
    Comerci GD, Graydanus DE. Eating disorders: anorexia nervosa and bulimia. In: Hoffman ED, Graydanus DE, eds. Adolescent Medicine. Stamford, Conn: Appleton and Lange; 1997.Google Scholar
  8. 8.
    Bulik CM, Wullivan PF, Rorty M. Childhood sexual abuse in women with bulimia. J Clin Psych. 1989;50:460–4.Google Scholar
  9. 9.
    Fairburn CG, Agras WS, Wilson GT. The research on the treatment of bulimia nervosa: practical and theoretical implications. In: Anderson GH, Kennedy SH, eds. The Biology of Feast and Famine: Relevance to Eating Disorders. New York, NY: Academic Press; 1995:317–40.Google Scholar
  10. 10.
    Steen SN. The competitive athlete. In: Rickert VI, ed. Adolescent Nutrition: Assessment and Management. New York, NY: Chapman and Hall; 1996:223–47.Google Scholar
  11. 11.
    Tofler IR, Stryer BK, Micheli LJ. Physical and emotional problems of elite female gymnasts. N Engl J Med. 1996;335:281–3.PubMedCrossRefGoogle Scholar
  12. 12.
    Rodin G, Craven J, Littlefield C, Murray M, Daneman D. Eating disorders and intentional insulin undertreatment in adolescent females with diabetes. Psychosomatics. 1991;32:171–6.PubMedGoogle Scholar
  13. 13.
    Steel JM, Young RJ, Lloyd GG, Clarke BF. Clinically apparent eating disorders in young diabetic women: associations with painful neuropathy and other complications. BMJ. 1987;294:859–62.PubMedGoogle Scholar
  14. 14.
    Johnson GL, Humphries LL, Shirley PB, et al. Mitral valve prolapse in patients with anorexia nervosa and bulimia. Arch Intern Med. 1986;146:1525–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Meyers DG, Starke H, Pearson P, Wilken MK. Mitral valve prolapse in anorexia nervosa. Ann Intern Med. 1986;105:384–6.PubMedGoogle Scholar
  16. 16.
    Freund KM, Graham SM, Lesky LG, Moskowitz MA. Detection of bulimia in a primary care setting. J Gen Intern Med. 1993;8:243–8.CrossRefGoogle Scholar
  17. 17.
    Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999;319:1467–8.PubMedGoogle Scholar
  18. 18.
    Sigman G. How has the care of eating disorder patients been altered and upset by payment and insurance issues? Let me count the ways. J Adolesc Health. 1996;19:317.PubMedCrossRefGoogle Scholar
  19. 19.
    Katz RL, Keen CL, Hurley LS, Kellams-Harrison KM, Glader LJ. Zinc deficiency in anorexia nervosa. J Adolesc Health Care. 1987;8:400–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Birmingham CL, Goldner EM, Bakan R. Controlled trial of zinc supplementation in anorexia nervosa. Int J Eating Disord. 1994;15:251–5.Google Scholar
  21. 21.
    Szmuckler GI, Young GP, Miller G, Lichenstein M, Binns DS. A controlled trial of cisapride in anorexia nervosa. Int J Eating Disorders. 1995;17:347–57.CrossRefGoogle Scholar
  22. 22.
    Isner JM, Roberts WC, Heymsfield SB, Yager J. Anorexia nervosa and sudden death. Ann Intern Med. 1985;102:49–52.PubMedGoogle Scholar
  23. 23.
    Bhanji S, Mattingly D. Anorexia nervosa: some observations on “dieters” and “vomiters.” Brit J Psych. 1981;139:238–41.CrossRefGoogle Scholar
  24. 24.
    Rampling D. Acute pancreatitis in anorexia nervosa. Med J Aust. 1980;74:126–32.Google Scholar
  25. 25.
    Saleeh JW, Lebwohol P. Metoclopromide-induced gastric emptying in patients with anorexia nervosa. Amer J Gastroenterol. 1980;74:127–32.Google Scholar
  26. 26.
    Stewart DE, Robinson E, Goldbloom DS, Wright C. Infertility and eating disorders. Am J Obstet Gynecol. 1990;163:1196–9.PubMedGoogle Scholar
  27. 27.
    Sobanski E, Hiltmann WD, Blanz B, Klein M, Schmidt MH. Pelvic ultrasound scanning of the ovaries in adolescent anorectic patients at low weight and after weight recovery. Eur Child Adolesc Psychiatry. 1997;6:207–11.PubMedGoogle Scholar
  28. 28.
    Lai KY, de Bruyn R, Lask B, Bryant-Waugh R, Hankins M. Use of pelvic ultrasound to monitor ovarian and uterine maturity in childhood onset anorexia nervosa. Arch Dis Child. 1994;71:228–31.PubMedGoogle Scholar
  29. 29.
    Treasure JL, Wheeler M, King EA, Gordon PA, Russell GF. Weight gain and reproductive function: ultrasonographic and endocrine features in anorexia nervosa. Clin Endocrinol. 1988;29: 607–16.Google Scholar
  30. 30.
    Croyan MS, Ibbertson HK. Low serum T3 and hypothyroidism in anorexia nervosa. J Clin Endocrinol Metab. 1977;44:167–72.CrossRefGoogle Scholar
  31. 31.
    Gold PW, Gwirtsman H, Avgerinow PC, et al. Abnormal hypothalamic-pituitary-adrenal function in anorexia nervosa: pathophysiologic mechanism in underweight and weight-corrected patients. N Engl J Med. 1986;314:1335–42.PubMedCrossRefGoogle Scholar
  32. 32.
    Nestel PJ. Cholesterol metabolism in anorexia nervosa and hypercholesterolemia. J Clin Endocrinol Metab. 1979;38:325–9.Google Scholar
  33. 33.
    Gold P, Kaye W, Robertson GI, Ebert M. Abnormalities in plasma and CSF arginine vasopressin in patients with anorexia nervosa. N Engl J Med. 1983;308:1112–23.Google Scholar
  34. 34.
    Silverman JA. Anorexia nervosa: clinical observations in a successful treatment plan. J Pediatrics. 1974;84:68–73.CrossRefGoogle Scholar
  35. 35.
    Reiger W, Brady JP, Weisberg E. Hematologic changes in anorexia nervosa. Am J Psychiatry. 1978;135:984–5.Google Scholar
  36. 36.
    Rigotti NA, Nussbaum SR, Herzog DB, Neer RM. Osteoporosis in women with anorexia nervosa. N Engl J Med. 1984;311:1601–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Rencken ML, Chesnut CH, Drinkwater BL. Bone density at multiple skeletal sites in amenorrheic athletes. JAMA. 1996;276:238–40.PubMedCrossRefGoogle Scholar
  38. 38.
    Rigotti NA, Neer RM, Skates SJ, Herzog DB, Nussbaum SR. The clinical course of osteoporosis in anorexia nervosa: a longitudinal study of cortical bone mass. JAMA. 1991;265:1133–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Drinkwater BL, Nilson K, Chestnut CH, Bremner WJ, Shainholtz S, Southworth MB. Bone mineral content of amenorrheic and eumenorrheic athletes. N Engl J Med. 1984;311:277–81.PubMedCrossRefGoogle Scholar
  40. 40.
    Cumming DC. Exercise-associated amenorrhea, low bone density and estrogen replacement therapy. Arch Intern Med. 1996;156:2193–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Recker R, Davies KM, Hinders SM, Heaney RP, Stegman R, Kimmel DB. Bone gain in young adult women. JAMA. 1992;268:2403–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Klibanski A, Biller BMK, Schoenfeld DA, Herzog DB, Saxe VC. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. J Clin Endocrinol Metab. 1995;80:898–904.PubMedCrossRefGoogle Scholar
  43. 43.
    Hergenroeder AC, O’Brian Smith E, Shypailo R, Jones LA, Klish WJ, Ellis K. Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone or placebo over 12 months. Am J Obstet Gynecol. 1997;176:1017–25.PubMedCrossRefGoogle Scholar
  44. 44.
    Black DM, Cummings SR, Karpf DB, et al. Randomized trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet. 1996;348:1535–41.PubMedCrossRefGoogle Scholar
  45. 45.
    Hosking D, Chilvers CED, Christiansen C, et al. Prevention of bone loss with alendronate in postmenopausal women under 60 years of age. N Engl J Med. 1998;338:485–92.PubMedCrossRefGoogle Scholar
  46. 46.
    McClung M, Clemmensen B, Daifotis A, et al. Alendronate prevents postmenopausal bone loss in women without osteoporosis. Ann Intern Med. 1998;128:253–61.PubMedGoogle Scholar
  47. 47.
    Robin AL, Siegel PT, Koepke T, Moye AW, Tice S. Family therapy versus individual therapy for adolescent females with anorexia nervosa. J Dev Behav Pediatr. 1994;15:111–6.PubMedCrossRefGoogle Scholar
  48. 48.
    Eisler I, Dare C, Russell GF, Szmukler G, LeGrange D, Dodge E. Family and individual therapy in anorexia nervosa. A 5-year follow-up. Arch Gen Psychiatry. 1997;54:1025–30.PubMedGoogle Scholar
  49. 49.
    Gowers S, Norton K, Halek C, Crisp AH. Outcome of outpatient psychotherapy in a random allocation treatment study of anorexia nervosa. Int J Eating Disord. 1994;15:165–77.CrossRefGoogle Scholar
  50. 50.
    Treasure J, Todd G, Brolly M, Tiller J, Nehmed A, Denman F. A pilot study of a randomised trial of cognitive analytical therapy vs educational behavioral therapy for adult anorexia nervosa. Behav Res Ther. 1995;33:363–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Fairburn CG, Shafran R, Cooper Z. A cognitive behavioral theory of anorexia nervosa. Behav Res Ther. 1999;37:1–13.PubMedCrossRefGoogle Scholar
  52. 52.
    Halmi KA, Eckert E, LaDu TJ, Cohen J. Anorexia nervosa: treatment efficacy of cyproheptadine and amitriptyline. Arch Gen Psychiatry. 1986;43:177–81.PubMedGoogle Scholar
  53. 53.
    Gwirtsman HE, Guze BH, Yager J, Gainsley B. Fluoxitene treatment of anorexia nervosa: an open clinical trial. J Clin Psychiatry. 1990;51:378–82.PubMedGoogle Scholar
  54. 54.
    Kaye WH, Weltzin TE, Hsu LK, Bulik CM. An open trial of fluoxetine in patients with anorexia nervosa. J Clin Psychiatry. 1991;52:464–71.PubMedGoogle Scholar
  55. 55.
    Attia E, Haiman C, Walsh BT, Flater SR. Does fluoxetine augment the inpatient treatment of anorexia nervosa? Am J Psychiatry. 1998;155:548–51.PubMedGoogle Scholar
  56. 56.
    Garfinkel PE, Garner DM. The Role of Drug Treatments for Eating Disorders. New York, NY: Brunner/Mazel; 1987.Google Scholar
  57. 57.
    Wells LA, Logan KM. Pharmacologic treatment of eating disorders: a review of selected literature and recommendations. Psychosomatic. 1987;28:470–9.Google Scholar
  58. 58.
    House RC, Grisius R. Periomolysis: unveiling the surrepitious vomiter. Oral Surg. 1981;6:152–5.CrossRefGoogle Scholar
  59. 59.
    Clark DC. Oral complications of anorexia nervosa and/or bulimia: with a review of the literature. J Oral Med. 1985;40:134–8.PubMedGoogle Scholar
  60. 60.
    Dawsen J, Jones C. Vomiting induced hypokalemic alkalosis and parotid swelling. Practitioner. 1977;28:267–8.Google Scholar
  61. 61.
    Levin PA, Falko JM, Dixon K, Gallup EM, Saunders B. Benign parotid enlargement in bulimia. Ann Intern Med. 1980;93:827–9.PubMedGoogle Scholar
  62. 62.
    Walsh BT, Croft CB, Katz JL. Anorexia nervosa and salivary gland enlargement. Int J Psychiatry Med. 1981;11:255–61.PubMedCrossRefGoogle Scholar
  63. 63.
    Larsen K, Skov Jensen B, Axelsen F. Perforation and rupture of the esophagus. Scand J Thorac Cardiovas Surg. 1983;17:311–6.Google Scholar
  64. 64.
    Saul SH, Dekker A, Watson CG. Acute gastric dilatation with infarction and perforation. Report of fatal outcome in patient with anorexia nervosa. Gut. 1981;22:978–83.PubMedGoogle Scholar
  65. 65.
    Mitchell JE, Pyle RL, Miner RA. Gastric dilatation as a complication of bulimia. Psychosomatics. 1982;23:96–7.PubMedGoogle Scholar
  66. 66.
    Breslow M, Yates A, Shisslak C. Spontaneous rupture of the stomach: a complication of bulimia. Int J Eating Disorders. 1986;5:137–42.CrossRefGoogle Scholar
  67. 67.
    Mitchell JA, Boutacoff LI. Laxative abuse complicating bulimia: medical and treatment implications. Int J Eating Disorders. 1986;5:325–34.CrossRefGoogle Scholar
  68. 68.
    Cummings JH. Laxative abuse. Gut. 1974;15:758–66.PubMedGoogle Scholar
  69. 69.
    Cooke WT. Laxative abuse. Clin Gastroenterol. 1977;6:659–73.PubMedGoogle Scholar
  70. 70.
    Al-Mufty NS, Bevan DH. A case of subcutaneous emphysema, pneumomediastinum and pneumoretroperitoneum associated with functional anorexia. Brit J Clin Pract. 1977;31:160–1.PubMedGoogle Scholar
  71. 71.
    Donley AJ, Kemple TJ. Spontaneous pneumomediastinum complicating anorexia nervosa. Br J Med. 1978;11:1604–5.Google Scholar
  72. 72.
    Brotman MC, Forbath N, Garfinkel PE, Humphrey JG. Myopathy due to ipecac syrup poisoning in a patient with anorexia nervosa. Can Med Assoc J. 1981;125:453–4.PubMedGoogle Scholar
  73. 73.
    Adler AG, Walinsky P, Krall RA, et al. Death resulting from ipecac syrup poisoning. JAMA. 1983;243:1977–8.Google Scholar
  74. 74.
    Palmer EP, Guay AT. Reversible myopathy secondary to abuse of ipecac in patients with major eating disorders. N Engl J Med. 1986;313:1457–9.CrossRefGoogle Scholar
  75. 75.
    Brotman AW, Rigotti N, Herzog DB. Medical complications of eating disorders: outpatient evaluation and management. Compr Psychiatry. 1985;26:258–72.PubMedCrossRefGoogle Scholar
  76. 76.
    Mitchell JE, Pyle RI, Eckert ED, Hatsukami D, Lentz R. Electrolyte and other physiological abnormalities in patients with bulimia. Psychol Med. 1983;13:273–8.PubMedCrossRefGoogle Scholar
  77. 77.
    Mitchell JE, Seim HC, Colon E, Pomeroy C. Medical complications and medical management of bulimia. Ann Intern Med. 1987;107:71–7.PubMedGoogle Scholar
  78. 78.
    Fairburn CG, Jones R, Peveler RC, Hope RA, O’Connor M. Psychotherapy and bulimia nervosa: the longer-term effects of interpersonal psychotherapy, behavior therapy and cognitive behavior therapy. Arch Gen Psychiatry. 1993;50:419–28.PubMedGoogle Scholar
  79. 79.
    Goldbloom DS, Olmsted M, Davis R, et al. A randomized controlled trial of fluoxetine and cognitive behavioral therapy for bulimia nervosa: short term outcome. Behav Res Ther. 1997;35:803–11.PubMedCrossRefGoogle Scholar
  80. 80.
    Treasure J, Schmidt U, Troop N, Tiller J, Todd G, Turnbull S. Sequential treatment for bulimia nervosa incorporating a self-care manual. Br J Psychiatry. 1996;168:94–8.PubMedGoogle Scholar
  81. 81.
    Lewandowski LM, Gebing TA, Anthony JL, O’Brien WH. Meta-analysis of cognitive-behavioral treatment studies for bulimia. Clin Psychol Rev. 1997;17:703–18.PubMedCrossRefGoogle Scholar
  82. 82.
    Thackwray DE, Smith MC, Bodfish JW, Meyers AW. A comparison of behavioral and cognitive-behavioral interventions for bulimia nervosa. J Consult Clin Psychology. 1993;61:639–45.CrossRefGoogle Scholar
  83. 83.
    Garner DM, Rockert W, Davis R, Garner MV, Olmsted MP, Eagle M. Comparison of cognitive behavioral and supportive expressive therapy for bulimia nervosa. Am J Psychiatry. 1993;150:37–46.PubMedGoogle Scholar
  84. 84.
    Fairburn CG, Norman PA, Welch SL, O’Connor ME, Doll HA, Peveler RC. A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Arch Gen Psychiatry. 1995;52:304–12.PubMedGoogle Scholar
  85. 85.
    Walsh BT, Wilson GT, Loeb KL, et al. Medication and psychotherapy in the treatment of bulimia nervosa. Am J Psychiatry. 1997;154:523–31.PubMedGoogle Scholar
  86. 86.
    Mitchell JE, Pyle RL, Eckert ED, Hatsukami D, Pomeroy C, Zimmerman R. A comparison study of antidepressants and structured group psychotherapy in the treatment of bulimia nervosa. Arch Gen Psychiatry. 1990;47:149–57.PubMedGoogle Scholar
  87. 87.
    Agras WS, Rossiter EM, Arnow B, et al. Pharmacologic and cognitive-behavioral treatment for bulimia nervosa: a controlled comparison. Am J Psychiatry. 1992;149:82–7.PubMedGoogle Scholar
  88. 88.
    Thiels C, Schmidt U, Treasure J, Garthe R, Troop N. Guided self-change for bulimia nervosa incorporating use of a self-care manual. Am J Psychiatry. 1998;155:947–53.PubMedGoogle Scholar
  89. 89.
    Fluoxetine Bulimia Nervosa Collaborative Study Group. Fluoxitene in the treatment of bulimia nervosa: a multi-center placebocontrolled double blind trial. Am J Psychiatry. 1992;49:139–47.Google Scholar
  90. 90.
    Goldstein DJ, Wilson MG, Thompson VL, Potvin JH, Rampey AH, Jr. Long term fluoxetine treatment of bulimia nervosa. Fluoxetine Bulimia Nervosa Research Group. Br J Psychiatry. 1995;166:660–6.PubMedCrossRefGoogle Scholar
  91. 91.
    Fornari VM, Sandberg DE, Lachenmeyer J, Cohen D, Matthews M, Montero G. Seasonal variations in bulimia nervosa. Ann NY Acad Sci. 1989;575:509–11.CrossRefGoogle Scholar
  92. 92.
    Lam RW, Solyom L, Tompkins A. Seasonal mood symptoms in bulimia nervosa and seasonal affective disorder. Compr Psychiatry. 1991;32:552–5.PubMedCrossRefGoogle Scholar
  93. 93.
    Levitan RD, Kaplan AS, Rockert W. Chracterization of the “seasonal” bulimic patient. Int J Eating Dis. 1996;19:187–92.CrossRefGoogle Scholar
  94. 94.
    Lam RW, Goldner EM, Soplyom L, Remick RA. A controlled study of light therapy for bulimia nervosa. Am J Psychiatry. 1994;151:744–9.PubMedGoogle Scholar
  95. 95.
    Blouin AG, Blouin JH, Iversen H, et al. Light therapy in bulimia nervosa: a double-blind, placebo controlled study. Psychiatry Res. 1996;60:1–9.PubMedCrossRefGoogle Scholar
  96. 96.
    Braun D, Sunday S, Fornari V, Halmi K. Bright light therapy decreases winter binge frequency in women with bulimia nervosa: a double-blind, placebo controlled study. Compr Psychiatry. 1999;40:442–8.PubMedCrossRefGoogle Scholar
  97. 97.
    Rodin GM, Johnson LE, Garfinkel PE, Daneman D, Kenshole AB. Eating disorders in female adolescents with insulin-dependent diabetes mellitus. Int J Psychiatry Med. 1986;16:49–57.PubMedCrossRefGoogle Scholar
  98. 98.
    Krowlewski AS, Warram JH, Cristlieb AR, Busick EJ, Kahn CR. Risk of proliferative diabetic retinopathy in juvenile-onset type I diabetes: a 40 year follow-up study. Diabetes Care. 1985;9:443–52.CrossRefGoogle Scholar
  99. 99.
    Rydall AC, Rodin GM, Olmsted MP, Devenyi RG, Daneman D. Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus. N Engl J Med. 1997;336:1849–54.PubMedCrossRefGoogle Scholar
  100. 100.
    American College of Sports Medicine. The female athlete triad: disordered eating, amenorrhea, osteoporosis: call to action. Sports Med Bulletin. 1992;27.Google Scholar
  101. 101.
    Carlat DJ, Camargo CA, Herzog DB. Eating disorders in males: a report on 135 patients. Am J Psychiatry. 1997;154:1127–32.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2000

Authors and Affiliations

  • Judith M. E. Walsh
    • 1
  • Mary E. Wheat
    • 2
  • Karen Freund
    • 3
  1. 1.the Division of General Internal Medicine, Departments of Medicine and Epidemiology and BiostatisticsUniversity of California, San FranciscoSan Francisco
  2. 2.Barnard College Student Health Services, Department of Epidemiology and Social MedicineAlbert Einstein College of MedicineBronx
  3. 3.Women’s Health Unit, Section of General Internal Medicine, Evans Department of MedicineBoston University Medical CenterBoston
  4. 4.UCSF/Mount Zion Division of General Internal MedicineSan Francisco

Personalised recommendations