American Academy of Pediatrics: Identifying and Treating Eating Disorders

Written by HealthyPlace.com Staff Writer

Introduction to Identifying and Treating Eating Disorders

Increases in the incidence and prevalence of anorexia and bulimia nervosa in children and adolescents have made it increasingly important that pediatricians be familiar with the early detection and appropriate management of eating disorders. Epidemiologic studies document that the numbers of children and adolescents with eating disorders increased steadily from the 1950s onward. During the past decade, the prevalence of obesity in children and adolescents has increased significantly, accompanied by an unhealthy emphasis on dieting and weight loss among children and adolescents, especially in suburban settings; increasing concerns with weight-related issues in children at progressively younger ages; growing awareness of the presence of eating disorders in males; increases in the prevalence of eating disorders among minority populations in the United States; and the identification of eating disorders in countries that had not previously been experiencing those problems. It is estimated that 0.5% of adolescent females in the United States have anorexia nervosa, that 1% to 5% meet criteria for bulimia nervosa, and that up to 5% to 10% of all cases of eating disorders occur in males.There are also a large number of individuals with milder cases who do not meet all of the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for anorexia or bulimia nervosa but who nonetheless experience the physical and psychologic consequences of having an eating disorder. Long-term follow-up for these patients can help reduce sequelae of the diseases; Healthy People 2010 includes an objective seeking to reduce the relapse rates for persons with eating disorders including anorexia nervosa and bulimia nervosa.

The Role of the Pediatrician in the Identification and Evaluation of Eating Disorders

Primary care pediatricians are in a unique position to detect the onset of eating disorders and stop their progression at the earliest stages of the illness. Primary and secondary prevention is accomplished by screening for eating disorders as part of routine annual health care, providing ongoing monitoring of weight and height, and paying careful attention to the signs and symptoms of an incipient eating disorder. Early detection and management of an eating disorder may prevent the physical and psychologic consequences of malnutrition that allow for progression to a later stage.

Screening questions about eating patterns and satisfaction with body appearance should be asked of all preteens and adolescents as part of routine pediatric health care. Weight and height need to be determined regularly (preferably in a hospital gown, because objects may be hidden in clothing to falsely elevate weight). Ongoing measurements of weight and height should be plotted on pediatric growth charts to evaluate for decreases in both that can occur as a result of restricted nutritional intake. Body mass index (BMI), which compares weight with height, can be a helpful measurement in tracking concerns; BMI is calculated as:

weight in pounds x 700/(height in inches squared)
or
weight in kilograms/(height in meters squared).

Newly developed growth charts are available for plotting changes in weight, height, and BMI over time and for comparing individual measurements with age-appropriate population norms. Any evidence of inappropriate dieting, excessive concern with weight, or a weight loss pattern requires further attention, as does a failure to achieve appropriate increases in weight or height in growing children. In each of these situations, careful assessment for the possibility of an eating disorder and close monitoring at intervals as frequent as every 1 to 2 weeks may be needed until the situation becomes clear.

A number of studies have shown that most adolescent females express concerns about being overweight, and many may diet inappropriately. Most of these children and adolescents do not have an eating disorder. On the other hand, it is known that patients with eating disorders may try to hide their illness, and usually no specific signs or symptoms are detected, so a simple denial by the adolescent does not negate the possibility of an eating disorder. It is wise, therefore, for the pediatrician to be cautious by following weight and nutrition patterns very closely or referring to a specialist experienced in the treatment of eating disorders when suspected. In addition, taking a history from a parent may help identify abnormal eating attitudes or behaviors, although parents may at times be in denial as well. Failure to detect an eating disorder at this early stage can result in an increase in severity of the illness, either further weight loss in cases of anorexia nervosa or increases in bingeing and purging behaviors in cases of bulimia nervosa, which can then make the eating disorder much more difficult to treat. In situations in which an adolescent is referred to the pediatrician because of concerns by parents, friends, or school personnel that he or she is displaying evidence of an eating disorder, it is most likely that the adolescent does have an eating disorder, either incipient or fully established. Pediatricians must, therefore, take these situations very seriously and not be lulled into a false sense of security if the adolescent denies all symptoms. Table 1 outlines questions useful in eliciting a history of eating disorders, and Table 2 delineates possible physical findings in children and adolescents with eating disorders.