DIURETICS

OFFICIAL NAMES: Acetazolamide, amiloride, bendroflumethiazide, benzthiazide, bumetanide, chlorothiazide, chlorthalidone, dichlorphenamide, dorzolamide, ethacrynic acid, flumethiazide, furosemide, glycerin, isosorbide, hydrochlorothiazide (HCT), hydroflumethiazide, mannitol, methyclothiazide, metolazone, polythiazide, quinethazone, spironolactone, torsemide, triamterene, trichlormethiazide

STREET NAMES: Water pills

DRUG CLASSIFICATIONS: Not scheduled

OVERVIEW

Diuretics are a class of drugs that increase urine output. In healthcare, they are used to treat conditions that cause edema, or water retention. They are also prescribed for several chronic conditions, including asthma, heart disease, and hypertension (high blood pressure).

Because diuretics cause an overall water weight loss, they are often abused by individuals with eating disorders such as anorexia and bulimia. They may also be misused (and sometimes abused) by athletes to "make weight" for certain classes of competition (i.e., wrestling).

Diuretic use in sports may also be prompted by the belief that a lower weight will improve athletic performance. However, the side effects experienced from long-term diuretic abuse typically offset any temporary gains in ability. Diuretics are considered a banned substance by the International Olympic Committee (IOC), the United States Anti-Doping Agency (USADA), the World Anti-Doping Agency (WADA), the National Collegiate Athletic Association (NCAA), and a number of other national and international sporting authorities.

The term diuretics comes from the Greek diuresis, meaning "to urinate." In medieval medicine, diuretics were used to restore the body's humors (blood, bile, and phlegm) to balance, along with other "therapeutic" methods such as blood-letting and induced vomiting.

William Withering, an English physician with a strong interest in botany, was the first to introduce the diuretic digitalis (from the foxglove plant Digitalis purpurea) into common medical practice for the treatment of dropsy. Dropsy, a now-obsolete term for edema (fluid retention or swelling), was frequently related to congestive heart failure and was a common cause of death at the time for lack of an effective treatment.

Although there had been accounts of the use of foxglove in medicine since classical times, Withering was the first to standardize its use and establish digitalis as a legitimate medical therapy. He learned of the botanical therapy from local folk medicine, and began treating patients with it. Ten years after Withering began using the drug, he published An Account of the Foxglove and Some of Its Medical Uses; With Practical Remarks on Dropsy and Other Diseases (1785), in which he described his experiences with the drug and experiments with different preparations and dosages. Digitalis remains a treatment for heart failure today.

In the 1920s, researchers discovered the diuretic effects of substances known as organic mercurials that were used to treat a heart disorder related to syphilis. They were quickly employed as a treatment for congestive heart failure (CHF). While they helped edema, their long-term usefulness was limited since they became ineffective with regular use and, more importantly, they could be highly toxic to the heart and nervous system over time.

The antibiotic class of sulfonamides was introduced in 1936. Although not designed as a diuretic, the drug caused increased urinary output in patients who used it. Over a decade later, Dr. William Schwartz tried the drug on three heart patients and found it was effective for lowering blood pressure and relieving the symptoms of congestive heart failure, but also concluded that the drug could not be safely used for any length of time.

In 1957, researchers John Baer, Karl Beyer, James Sprague, and Frederick Novello formulated the drug chlorothiazide, the first of the thiazide diuretics. This groundbreaking discovery marked a new era in medicine as the first safe and effective long-term treatment for chronic hypertension and heart failure.

Loop diuretics, the next class of diuretic drugs to be developed, are also the most potent. Their introduction was a major advance in the treatment of congestive heart failure. Furosemide (Lasix), the first of the loop diuretics, debuted in 1965.

Over-the-counter diuretic formulations became available around this time as well. Pamabrom, a medication that relieves the fluid retention and bloating associated with a woman's menstrual cycle, is still the active ingredient in a number of over-the-counter preparations(e.g., Aqua-Ban, Pamprin).

There are also many drugs and dietary supplements that may have diuretic action as a side effect, but have a different primary purpose. For example, the supplement creatine is an ergogenic (energy-enhancer), but it also promotes fluid loss with regular use.

CHEMICAL/ORGANIC COMPOSITION

Diuretics work by increasing the amount of sodium and fluids excreted by the kidneys. Less fluid means less total blood volume and improved circulation and blood pressure. There are five main classes of the drug: loop diuretics, thiazide diuretics, potassium-sparing diuretics, osmotic diuretics, and carbonic anhydrase inhibitors.

Loop diuretics

The most potent type of diuretic, loop diuretics are named after the loop of Henle, a component of a nephron. The nephrons are the filtering units of the kidney, and are responsible for moving fluids and waste out of the bloodstream, resulting in urine formation. The loop of Henle is a branch within each nephron where sodium and potassium are reabsorbed back into the bloodstream instead of being filtered into the urine. Loop diuretics inhibit this action and promote excretion of the sodium and potassium instead, along with calcium and magnesium. Since excess sodium causes excess fluid build-up, this results in fluid loss. Furosemide (Lasix), bumetanide (Bumex), torsemide (Demadex), and ethacryinic acid (Edecrin) are all loop diuretics.

Thiazide diuretics

Thiazide diuretics such as chlorothiazide (Diuril) and hydrochlorothiazide (HCTZ) work by blocking the action of aldosterone, a hormone that promotes sodium reabsorption by the kidneys. They are potassium-depleting

diuretics, meaning that they cause a loss of potassium, known as hypokalemia.

Potassium-sparing diuretics

Potassium-sparing diuretics include amiloride (Midamor) and triamterene (Dyrenium). They are used in the treatment of cirrhosis and congestive heart failure. They may be used in conjunction with thiazide diuretics to offset the potassium loss associated with those medications.

Osmotic diuretics

As their name suggests, osmotic diuretics such as mannitol (Osmitrol), isosorbide (Ismotic), and glycerin (Osmoglyn) draw fluid from the tissues of the body through principles of osmosis. Osmotic diuretics are typically given to treat or prevent acute renal failure (kidney failure). They may also be used to relieve intracranial pressure (swelling of the brain) in cases of head injury or hydrocephalus.

Carbonic anhydrase inhibitors

Carbonic anhydrase inhibitors such as dorzolamide (Trusopt) and dichlorphenamide (Daranide) are used to treat glaucoma patients and altitude sickness. Acetazolamide (Diamox), a carbonic anhydrase inhibitor, is also used to treat seizures related to epilepsy. CA inhibitors work by promoting the excretion of sodium and bicarbonate.

INGESTION METHODS

Diuretics are most commonly available in pill form. In a hospital setting, they may be administered intravenously or injected. Carbonic anhydrase inhibitors may be administered in eye drop form [dorzolamide (Trusopt)] to glaucoma patients.

THERAPEUTIC USE

Diuretics are prescribed in cases where excess fluids in bodily tissues (edema) cause illness, discomfort, or medical complications.

Medical conditions that may warrant the use of diuretics include:

Hypertension (high blood pressure)

A standard treatment for hypertension, diuretics flush excess water and sodium from the body. They also lower blood pressure by reducing the total volume of fluid in the bloodstream. A reduced total volume of blood means that the heart does not have to work as hard to circulate it through the body.

Often, diuretics are used in combination with other drugs to relieve hypertension. Types of diuretics used to treat hypertension include thiazides, such as chlorothiazide (Diuril) and hydrochlorothiazide (Esidrex); potassium-sparing diuretics, such as spironolactone (Aldactone); and loop diuretics, such as furosemide (Lasix).

Congestive heart failure (CHF)

Congestive heart failure occurs when the pumping ability of the heart is impaired, and the heart itself becomes enlarged. This may be due to coronary artery disease, chronic hypertension, diabetes, arrhythmia (irregular heartbeat), infection, or a heart valve disorder. The result is edema, or swelling caused by fluid retention, a major symptom of congestive heart failure. Patients with CHF experience swollen legs, ankles, feet, and/or fluid in the lungs (pulmonary edema). Sometimes fluid builds up around other organs, such as the liver, as well. Loop diuretics such as furosemide (Lasix) are frequently prescribed to alleviate edema from congestive heart failure. Thiazide and potassium-sparing diuretics may also be prescribed.

Other drugs that may be prescribed in conjunction with diuretics for the treatment of CHF include vasodilators (drugs that dilate blood vessels, such as ACE inhibitors); inotropics (drugs that increase the heart's ability to contract, such as digoxin); and beta blockers (drugs that inhibit the action of epinephrine, such as carvedilol).

Diabetes insipidus

Also known as water diabetes, diabetes insipidus (DI) is a rare chronic disease that causes excessive urination. If not properly treated, it can result in electrolyte imbalance and dehydration. It may be caused by a number of factors, including lithium use (a psychiatric drug used for bipolar disorder), neurological disease, or an inadequate amount of ADH (anti-diuretic hormone, or vasopressin, which is produced by the pituitary gland). DI caused by insufficient ADH is called central diabetes insipidus.

Nephrogenic diabetes insipidus, which occurs less often than central diabetes insipidus, is characterized by the inability of the kidneys to reabsorb water into the bloodstream. Treatment with thiazide or potassium-sparing diuretics can help maintain a fluid and electrolyte balance in some individuals with diabetes insipidus.

Other

Diuretics may also be prescribed for a number of other disorders and conditions that trigger fluid retention, including:

• Nephrotic syndrome. Thiazide or loop diuretics are used in the treatment of this kidney disorder that causes increased protein in the urine.
• Cirrhosis. Potassium-sparing diuretics are frequently prescribed for the patients with this liver disease.
• Renal hypercalciuria (kidney stones). Thiazide diuretics such as metolazone (Zaroxolyn) that increase calcium levels in the body are used in the treatment of kidney stones.
• Water retention related to menstruation. Pamabrom, an ingredient in over-the-counter diuretic preparations, can relieve bloating related to a woman's menstrual cycle.

Several studies have shown that thiazide diuretics prevent calcium loss in bones, which may improve bone density and protect against osteoporosis. Preliminary research also suggests that diuretics are helpful in preventing stroke. Further studies are needed to confirm these findings.

USAGE TRENDS

The U.S. Centers for Disease Control (CDC) and the National Center for Health Statistics (NCHS) report that cardiovascular-renal drugs (including diuretics, beta blockers, and calcium channel blockers) were the most frequently prescribed medications in the United States in 1999 (the most recent year for which data was available). In fact, the loop diuretic Lasix was the second most frequently prescribed medication overall, with more than12.9 million prescriptions written. It was second only to the allergy drug Claritin.

Scope and severity

Statistics on the misuse of diuretic drugs are more difficult to determine. Estimates vary as to the number of people currently suffering from eating disorders, and not all individuals with an eating disorder abuse diuretics. In addition, the sense of shame and emotional turmoil associated with the disease make the unreported incidence of eating disorders high. Federal and institutional estimates put the number at approximately 5–8 million Americans.

Age, ethnic, and gender trends

According to the National Institutes of Mental Health (NIMH), up to 3.7% of females suffer from anorexia, and up to 4.2% of females suffer from bulimia at some point in their lives. Males develop eating disorders much less frequently, representing only 5–15% of all U.S. cases of anorexia or bulimia.

The 1999 text Mental Health: A Report of the Surgeon General, states that the mortality, or death rate, among females age 15–24 with anorexia is an estimated 0.56% per year, approximately 12 times higher than that of girls of the same age in the general population. In addition to medical problems related to eating disorders, anorexia and bulimia are frequently accompanied by other psychiatric disturbances, including mood disorders (depression, anxiety) and substance abuse. Depression is the third leading cause of death for adolescents ages 15–24, and the eleventh leading cause of death for Americans of all ages.

In a Wesleyan University study of binge eating disorder (BED) published in 2000, researchers found that African-American women with the disorder reported laxative and diuretic abuse more frequently than white women. However, BED was considered a significant health problem in both racial groups.

Diuretic use and eating disorders in sports and professional athletics are growing concerns both in the United States and abroad. Sports that require weigh-ins, from wrestling to regatta sailing, can put the pressure on athletes to take extreme measures to lose weight quickly. Often, those measures include diuretic abuse, rubber suits, starvation diets, exposure to high temperatures, and other unsafe practices that can put athletes at risk for severe dehydration and even death.

A 1996 report in the journal Pediatrics that looked at a variety of studies and surveys of athletic weight-control practices reported that up to 52% of female collegiate athletes had engaged in unhealthy weight-control behaviors including diuretic use.

Weight loss in athletes is sometimes encouraged by coaching staff, as well. In sports such as gymnastics, swimming, and track—where "smaller is better"—female athletes in particular often develop eating disorders and unhealthy weight loss practices, including diuretic abuse. A 1999 NCAA-sponsored study of college athletes found that 13% of female athletes surveyed showed signs of bulimia or anorexia, and an additional 36% were considered at risk for developing an eating disorder. In addition, 3.89% of female and 3.65% of male athletes surveyed reported diuretic use for the purpose of purging at least once in their lifetime. In addition, one-fourth of the males surveyed used saunas or steam baths to lose weight at least once a week and 4.4% of females vomited for weight loss. Female athletes who develop eating disorders or eating disordered behavior are at a higher risk for osteoporosis and amenorrhea (interruption of the menstrual cycle).

MENTAL EFFECTS

Diuretics are not a psychoactive drug and have no direct mental effects. However, abuse and misuse of this medication can lead to severe dehydration, which may lead to headaches and mental confusion.

Because they affect sodium, potassium, and chloride levels in the body, diuretics can trigger electrolyte imbalances. An electrolyte imbalance can cause a variety of neurological symptoms, including confusion, fainting, dizziness, and headache.

PHYSIOLOGICAL EFFECTS

Diuretics increase urine and sodium output, and in some cases they may also increase urinary output of potassium, calcium, and magnesium. In large quantities, they can affect electrolyte balance.

Harmful side effects

The main risk of diuretic abuse is severe dehydration. This is of special concern to athletes who might take the drug to make weight for sporting events or to improve performance. Anyone exercising or participating in athletic competition is already at risk for dehydration from the fluids they are losing from sweating; diuretics can accelerate the process.

Anyone who must take diuretics for therapeutic purposes should take the proper precautions when exercising. This includes adequate and regular intake of water, sports drinks, or other non-caffeinated fluids; loose and comfortable clothing; adequate rest periods; and awareness of the signs of heat exhaustion (clammy and cool skin, fatigue, nausea, weakness, confusion, vision disturbances, and a possible loss of consciousness).

Other common side effects of diuretic use may include:

• rash
• nausea
• dizziness
• urinary incontinence
• photosensitivity (a sensitivity to sunlight)
• high blood glucose levels (blood sugars)

Other side effects that have been reported with diuretic use, but are not considered common, include:

• hearing loss
• pancreatitis
• anemia
• leukopenia (depletion of white blood cells)

Potassium-sparing diuretics (e.g., spironolactone, amiloride, triamterene) may cause a dangerous build-up of excessive potassium in the body. Signs of hyperkalemia, or excess potassium, include:

• arrhythmia (irregular heartbeat)
• breathing difficulties
• numbness or tingling sensation in the hands or feet
• fatigue
• weakness
• anxiety and/or difficulty concentrating

The potassium-depleting diuretics (e.g., hydro-chlorothiazide, chlorthalidone, metolazone) cause potassium loss that may be reversed by supplementation and/or dietary adjustments. As previously stated, potassium can be harmful in high amounts, so any supplementation should be recommended and supervised by a doctor.

• fast or irregular heartbeat
• muscle cramps
• nausea and/or vomiting
• dry mouth and persistent thirst
• fatigue
• weakness
• mood swings

Although diuretics may sometimes be given to pregnant women suffering from preeclampsia, in general, diuretic use is usually not recommended in pregnancy because of the potential risk to the developing fetus. In addition, some diuretics may pass through into breast milk and can cause lactation problems. Therefore, women who are pregnant or breastfeeding should always check with their doctor before taking diuretics.

Certain types of diuretics may be contraindicated (not recommended) for use by people with chronic medical conditions, including diabetes, pancreatitis, and lupus erythematosus. Anyone with a known allergy to diuretics or to sulfa drugs should alert their doctor before taking a diuretic.

Long-term health effects

Anyone taking diuretics for longer than six months may experience a folate, or folic acid, deficiency. Folic acid plays a part in the health and reproduction of virtually every cell in the body. It is responsible for protein metabolism, the prevention of neural tube defects in pregnancy, blood cell production, and the synthesis of neurotransmitters. Individuals with folate deficiencies may suffer from anemia, depression and other mood disorders, and may give birth to babies with neural tube defects. Supplementation with folic acid may be useful in reversing these effects.

Individuals on long-term diuretic therapy may also experience elevated levels of homocysteine, an amino acid regulated by folate. High homocysteine levels increase the risk of heart disease. Thiamin, or vitamin B₁, depletion is another possible side effect of loop diuretics. Individuals with thiamin deficiencies are at risk for fatigue, heart enlargement, muscle cramps, heart rate irregularities, and impaired mental function.

Insufficient zinc intake is another possible side effect of diuretic use. Individuals with zinc deficiency may experience hair loss, problems with night vision, slow wound healing, dermatitis, and a predisposition to infection and illness due to lowered immune function.

Because diuretics affect electrolyte balance, they can cause deficiencies in magnesium and calcium as well as the previously mentioned potassium. Magnesium deficiency may occur with chronic use of the loop and thiazide diuretics. Symptoms include nausea and vomiting, muscle cramps and weakness, insomnia, arrhythmia (irregular heartbeat), difficulty sleeping, and a loss of exercise tolerance. Calcium deficiency is a possible side effect of both loop and potassium-sparing diuretics. Signs of insufficient calcium in the body include muscle cramps, low bone density (which may be indicated by bones that break easily), tooth decay, heart palpitations, and difficulty sleeping.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

Although over-the-counter diuretic preparations are available without a prescription, because of the risk for serious and potentially fatal complications and side effects, diuretics should always be taken under the recommendation and guidance of a trained healthcare professional.

Certain medications may impair or enhance the therapeutic effects of diuretic drugs. Anyone prescribed a diuretic should inform their physician of all other drugs and supplements they are taking in case of a possible interaction.

Drugs that are also known to decrease potassium levels, such as glucocorticoids and digoxin, should be avoided by anyone taking potassium-depleting diuretics. If they are prescribed, a physician should closely monitor the potassium levels of the patient. Potassium deficiency, or hypokalemia, can cause serious and potentially dangerous side effects (see Harmful side effects section).

Potassium-sparing diuretics, such as amiloride (Midamor), spironolactone (Aldactone), and triamterene (Dyrenium), impair the ability of the kidneys to filter potassium from the body. This can result in a condition called hyperkalemia, or excessive potassium, a potentially dangerous situation (see Harmful side effects section). Anyone taking potassium-sparing diuretics should avoid excessive dietary intake of foods high in the mineral. Bananas, tomatoes, sweet potatoes, and oranges are some of the foods that are rich in potassium.

Diuretics may also interact with herbs and dietary supplements. Licorice (Glycyrrhiza glabra) can lower potassium levels, and should be avoided with potassium-sparing diuretics. In addition, herbal diuretics can amplify, or increase, the effect of prescription diuretics. Some of the more well-known diuretic herbs include bilberry (Vaccinium myrtillus), celery seed (Apium graveolens), dandelion leaf (Taraxacum officinale), and elder flower (Sambucus nigra, S. canadensis), goldenrod (Solidago virgaurea), horse chestnut seeds (Aesculus hippocastanum), horsetail (Equisetum arvense), juniper (Juniperus communis), parsley (Petroselinum sativum), St. John's wort (Hypericum perforatum), and uva ursi (bearberry; Arctostaphylos uva ursi). Just because a preparation is labeled natural does not mean it cannot cause harmful interactions with other medications and substances. Individuals should always check with their physician or healthcare professional before taking herbal and supplement products with diuretics.

Foods and beverages rich in caffeine, such as coffee, tea, and chocolate, can also have a diuretic effect at high doses, and should not be taken in excess with prescription diuretics. Alcohol has a diuretic effect as well, and should be avoided in individuals taking a diuretic medication.

TREATMENT AND REHABILITATION

Treatment for diuretic abuse starts with addressing the roots of the physical or psychological problems. There are a number of rehabilitation programs available for the treatment of eating disorders such as bulimia, anorexia, and binge eating disorder (BED). Programs are usually residential, or inpatient, meaning that the patient lives in the hospital or other rehabilitation facility for the length of treatment (several weeks to several months).

The first goal of rehabilitation from any eating disorder is to stabilize both weight and self-destructive behavior such as diuretic abuse and binge eating. Patients with anorexia may be severely malnourished, and could have additional related health problems such as impaired kidney function and dehydration that need immediate medical attention. They may also require intravenous feeding.

Patients need to relearn healthy nutrition, meal management, and exercise patterns. Taking regularly scheduled meals, meeting with a registered dietitian, and participating in classes on appropriate nutrition and fitness will help to establish good habits. Overweight individuals being treated for binge eating disorder may also learn new healthy and realistic strategies for weight loss in this environment.

Equally important is the effective treatment of eating disorders and associated diuretic abuse is to address the emotional motives and distorted thinking behind the patient's behavior. Individual or group psychotherapy or cognitive-behavioral therapy can help the patient work through self-esteem and self-image problems. Studies show that cognitive behavioral therapy has a 40-50% success rate with bulimia nervosa and BED patients. Family therapy may also be part of the treatment program.

The goal of cognitive-behavioral therapy (CBT) is to teach the patient new behaviors by exposing the irrational thoughts that trigger the old, self-destructive behaviors of anorexia or bulimia. Once the disordered thinking is changed, the behavior will follow. Learning how to recognize the thoughts and emotions surrounding eating disordered behavior, and rehearsing the new and desirable behaviors (such as avoiding situations and places that trigger the old behavior), is a key part of long-term recovery and relapse prevention with CBT.

If the patient has a pre-existing mood disorder, such as depression or anxiety disorder, antidepressant medication may also be prescribed. Studies have shown that the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) are effective in people with bulimia and anorexia. These medications reduce depression by increasing levels of serotonin, a neurotransmitter.

Eating disorders can be chronic conditions that need life-long vigilance and attention. A 1999 Harvard Medical School study of 246 women with eating disorders found that one-third of patients relapsed, or returned to eating disordered behaviors, following initial full recovery from both bulimia and anorexia.

Athletes who abuse or misuse diuretics for purposes of performance enhancement or making weight face special treatment challenges. Weight loss and an excessively low percentage of body fat may be praised by coaches, trainers, and teammates, making behavioral changes even more difficult. In addition, obsessive exercise and workout routines may be rewarded in sports and competition rather than questioned. A treatment strategy that includes education of not just the athlete, but also the people around him or her, is essential.

PERSONAL AND SOCIAL CONSEQUENCES

Urinary incontinence, or leakage, that may be associated with diuretic use can cause social embarrassment, self-esteem issues, depression, and anxiety. A person suffering from incontinence may stop participating in social activities, sports, and other activities they once enjoyed because of the risk of embarrassing "accidents." Bladder training, biofeedback, pelvic toning exercises, or special urethral or vaginal inserts may help to treat urinary incontinence problems related to diuretics.

While uncomplicated diuretic use itself has little impact on personal and social well-being, the conditions associated with misuse of the medication can have serious consequences. Aside from the physical problems associated with eating disorders, the dysfunctional behavior itself can greatly affect relationships with friends and family and basic social functioning. Individuals with eating disorders may avoid going out with friends to eat or drink socially. Their rigid schedules of bingeing and purging and/or exercise may take over their life to the extent that they withdraw socially.

Competitive athletes who misuse diuretics, either due to an eating disorder or for performance-enhancing purposes, may be suspended or banned from competition. In addition, if diuretic use becomes chronic and spirals into other eating disordered behaviors, athletic performance will ultimately suffer, and the athlete may face added pressures from coaching staff and teammates.

LEGAL CONSEQUENCES

Diuretics are not a controlled substance, and over-the-counter brands are easily and legally accessible in the United States and throughout the world.

Professional athletes who test positive for diuretics in the Olympics are suspended from participation in the games. They may also be stripped of any medals they have won in competition. Testing for banned substances may be conducted in competition or out of competition.

Federal guidelines, regulations, and penalties

The U.S. Food and Drug Administration (FDA) is the federal authority that oversees the regulation of non-controlled drugs such as diuretics. Any legal penalties for trafficking (illegally selling or distributing) prescription diuretics would typically be determined at the state level unless the charges involved theft from a federal facility such as a VA (Veterans Administration) hospital.

See also Caffeine

RESOURCES

Books

Medical Economics Corporation. Physicians' Desk Reference (PDR). 56^th Edition. Montvale, NJ: Medical Economics, 2002.

Otis, Carol and Roger Goldingay. The Athletic Woman's Survival Guide: How to Win the Battle Against Eating Disorders, Amenorrhea, and Osteoporosis. Champaign, IL: Human Kinetics, 2000.

Periodicals

Anderson, Kelli. "Losing to Win." Sports Illustrated for Women 3, no. 3 (May/June 2001): 88+.

Hoel, Donna, and Robert Howard. "Hypertension: Stalking the Silent Killer." Postgraduate Medicine 101, no. 2 (February1997). Available at: <http://www.postgradmed.com/issues/1997/02_97/hoel.htm>. Accessed April 1, 2002.

Other

National Institute of Mental Health. <http://www.nimh.nih.gov/publicat/eatingdisordersmenu.cfm>. Facts About Eating Disorders. Accessed April 1, 2002.

U.S. Anti-Doping Agency (USADA). <http://www.usantidoping.org/>. Accessed April 1, 2002. Drug reference line: 1-800-233-0393.

Organizations

National Eating Disorders Association, 603 Stewart St., Suite 803, Seattle, WA, USA, 98101, (206) 382-3587, [email protected], <http://www.nationaleatingdisorders.org/>.

Paula Anne Ford-Martin