Eating disorders in adolescents: a background paper

Olfactory deficits in anorexia nervosa

OBJECTIVE

Young patients admitted to the hospital due to anorexia nervosa report reduced pleasure and impaired perception of smell while eating. So far, two studies on odour identification ability in eating disorders did not suggest any significant deficits. Therefore a new and more detailed method of olfactory testing may be needed, in order to determine the subjective impairment of olfaction.

METHOD

By using all three subtests of the recently developed smell test called "Sniffin'Sticks", the olfactory deficits were assessed in more detail and the results of female anorectic patients (n = 17) were compared with those of healthy females (n = 15).

RESULTS

By examining the anorectic patients no deficits in the subtest odour identification were found. On the contrary, in the subtests odour discrimination and odour threshold deficits of the anorectic patients were detected.

CONCLUSION

Reduced olfactory perception might be considered as a common deficit in anorexia nervosa with possible influences and consequences for therapy.

Anorexia nervosa among children and adolescents

This update on anorexia nervosa among children and adolescents focuses on the current diagnostic criteria for the disorder, its history, epidemiology, and etiology. Consideration is given to the required medical evaluation and differential diagnosis. The medical complications, morbidity, and mortality that may ensue are described, and the corresponding pathophysiology explained. The review concludes with information on treatment and prognosis and a proposal on the appropriate role for the pediatrician in the management of anorexia nervosa.

Struggling with recovery: participant perspectives on battling an eating disorder

Recovery from an eating disorder encompasses a complex matrix of mental, physical, and social factors. Although methodological differences affect rates of reported recovery (from 24 to 76%), many women are not experiencing full recoveries from eating disorders. This trend is apparent in persons who discontinue severely destructive behaviors but continue to exhibit psychiatric problems and impairment in social and occupational roles. The purpose of this grounded theory study was to provide an explanatory schema about recovery. Data collection included 17 interviews, a focus group, and participant observation. Findings included repeating wavelike patterns of disease and recovery that seldom returned to a state of normal eating but, instead, remained at a level of atypical eating.

Population at risk for eating disorders in a Spanish region

OBJECTIVE

To estimate the prevalence of adolescent population at risk for eating disorders (EDs), to examine gender differences and their association with non-psychotic mental disorders.

METHODS

Cross-sectional study using an anonymous, self-reported questionnaire in the classroom and measurement of weight and height in a representative sample of 4334 teenagers of both sexes. A definition of population at risk for EDs has been established, that differentiates those with dieting criteria and those with binge-purge eating behaviour criteria. This definition includes a combination of weight, behaviour, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, and Eating Disorder Inventory (EDI) results. The General Health Questionnaire-28 (GHQ-28) was used to assess non-psychotic mental disorders.

RESULTS

The prevalence of population at risk for EDs was 2.2% (95% CI: 1.6-2.8) for men and 15.3% (95% CI: 13.8-16.9) for women. The prevalence rate of combining both ED risk and mental disorder was 0.8% (95% CI: 0.4-1.2) for men and 9.9% (95% CI: 8.6-11.2) for women. Non-psychotic mental disorders were more prevalent in the population at risk for EDs than in the rest of the population.

CONCLUSIONS

A considerable proportion of adolescent females have eating problems and non-psychotic mental disorders. Their male counterparts also suffer from these disorders, however, a different pattern is followed.

Dieting among preadolescent and young adolescent females

We examined the prevalence of dieting and negative eating attitudes among 2279 females (aged 10-14 years) in southern Ontario. Self-report questionnaires revealed that 29.3% of the girls were currently trying to lose weight and 10.5% had scores greater than the clinical threshold for disordered eating (Children's version of the Eating Attitudes Test [ChEAT] score > or = 20). Those with elevated ChEAT scores were more likely than those with lower scores to be engaged in dieting and other extreme weight control methods.

Nutritional rehabilitation of anorexia nervosa. Goals and dangers

Nutritional rehabilitation of adolescents with anorexia nervosa is both a science and an art. The goals are to promote metabolic recovery; restore a healthy body weight; reverse the medical complications of the disorder and to improve eating behaviors and psychological functioning. Most, but not all of the medical complications are reversible with nutritional rehabilitation. Refeeding patients with anorexia nervosa results in deposition of lean body mass initially, followed by restoration of adipose tissue as treatment goal weight is approached. The major danger of nutritional rehabilitation is the refeeding syndrome, characterized by fluid and electrolyte, cardiac, hematological and neurological complications, the most serious of which is sudden unexpected death. The refeeding syndrome is most likely to occur in those who are severely malnourished. In such patients, this complication can be avoided by slow refeeding with careful monitoring of body weight, heart rate and rhythm and serum electrolytes, especially serum phosphorus. This paper reviews our clinical experience.

The outcomes of psychotherapy with adolescents: a practitioner-friendly research review

This article summarizes the outcome findings of psychotherapy with adolescents through an examination of the research literature. In this problem-focused review of the research literature, we consider adolescent treatment of anxiety disorders, depression, eating disorders, disruptive behavior disorders, multiple problems of adolescence, and health risk behaviors. The evidence base for the effectiveness of various psychotherapies for adolescents is mixed. Psychotherapy in general has been a ripe field in which unsupported approaches have grown, and this is certainly true for psychotherapeutic interventions with adolescents. Nonetheless, there is a growing body of evidence to support various types of interventions as effective for different presenting problems. Researchers and clinicians need to recognize the complexity of the diverse characteristics of adolescents, including variations of culture, race, ethnicity, gender, class, physical disability, family definitions and constellation, and sexual orientation. These require sensitivity, responsiveness, and competence by the therapist, but clinical research has not fully examined these considerations.

Refeeding problems in a severe anorexia nervosa case

Anorexia Nervosa (AN) is an eating disorder of puberty or adolescence. It is characterized by self-induced weight loss; various psychological disturbances including distorted body image, fear of obesity, active pursuit of thinness and loss of recognition of a number of body enteroreceptive sensations; and secondary physiological abnormalities. The treatment of AN includes individual psychotherapy, family therapy, and nutritional rehabilitation. Hospital treatment is required when the patient's medical condition is in danger due to hypovolemia or hypotension. If cardiac arrhythmias occur without electrolyte disturbances or if oral therapy fails, nutrition should be repleted by the safest method available. This can be done by nasogastric tube or intravenous hyperalimentation. The management of AN is challenging, because the treatment process and anticipated outcome is in direct conflict with the sufferer's own wishes. A comprehensive treatment plan including both psychiatric and medical approaches is necessary. We report a severe AN case, who has refeeding problems after a three months' hospitalisation period. She was admitted to the child intensive care unit due to deterioration of her vital signs. We tried to solve her problems as a team, and believe that AN has a number of crucial problems thus requiring a multi-faceted treatment approach.

Evidence for a self-esteem approach in the prevention of body image and eating problems among children and adolescents

Early suggestions from the 1980s for a self-esteem approach in the prevention of eating problems have been adopted by researchers, and the results of several interventions show support for the efficacy, safety, and suitability of a predominantly self-esteem and self-acceptance approach. Several recent studies utilizing strong self-esteem components as part of their controlled prevention interventions have produced improvements in body dissatisfaction, dietary restraint, internalization of the thin ideal, and attitudes associated with the eating disorders. This article discusses self-esteem as one of the important risk and protective factors in the development of body image concerns and eating disorders and describes the subsequent use of a self-esteem approach for prevention of eating disorders. Interventions containing strong self-esteem components from around the world are discussed in relation to their impact on the body image and eating behaviors of adolescents. Applications of the self-esteem approach for the prevention of child obesity also are discussed.

An open trial of fluoxetine for adolescents with bulimia nervosa

OBJECTIVE

This open clinical trial examined the feasibility, tolerability, and efficacy of treating adolescents who suffer from bulimia nervosa with fluoxetine.

METHODS

Ten adolescents, ages 12-18 years received 8 weeks of fluoxetine 60 mg/day with supportive psychotherapy. Primary outcome measures included frequencies of binge eating and purging and ratings on the Clinical Global Impressions-Improvement scale (CGI-I). Secondary outcome measures included self-report measures of eating disorder, depression, and anxiety symptoms. Safety and tolerability of this dose of fluoxetine were also assessed.

RESULTS

Average weekly binges decreased significantly from 4.1 +/- 3.8 to 0 (p < 0.01). Average weekly purges decreased significantly from 6.4 +/- 5.2 to 0.4 +/- 0.9 (p < 0.005). All patients improved on the CGI-I scale, with 20% rated as much improved, 50% improved, and 30% slightly improved. All subjects tolerated the 60-mg dose of fluoxetine, and there were no dropouts due to adverse effects from the medication.

DISCUSSION

Fluoxetine is generally well tolerated and may be an effective treatment option for adolescents with bulimia nervosa.

Eating disorders in adolescent boys: a review of the adolescent and young adult literature

Although a number of studies have investigated eating disorders in adolescence and the topic has been thoroughly reviewed, these studies have typically focused on females, only to state that the approach and treatment should be similar in males. Recently, there have been a number of studies that have explored gender differences in eating disorders. In this article, we review the literature pertaining to two DSM-IV-defined disorders (anorexia nervosa and bulimia nervosa), a DSM-IV-defined research disorder (binge eating disorder), and two DSM-PC-defined disorders (dieting/body image and purging/binge-eating behaviors), highlighting those findings that pertain to disordered eating in adolescent boys.

Eating disorders

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified remain a significant cause of morbidity and mortality in girls and young women. Management of eating disorders typically requires a multidisciplinary team approach, often spear-headed by the clinician initially detecting the illness. This article addresses the definitions and prevalence of eating disorders, tips on recognition and management of medical complications, and reproductive health concerns for these young women. Issues surrounding care of the patient with the female athlete triad, or amenorrhea, osteopenia, and eating disorders, are also discussed.

Anorexia nervosa: the cost of long-term disability

This study was performed to estimate the cost of long-term disability in people who have anorexia nervosa (AN) that live in the province of British Columbia (BC), Canada. Canada provides universal socialized health and welfare services, and each of the 10 provinces is responsible for its own funding. As the provincial government of BC does not categorize its disability payments by the cause of the disability, a survey was used to determine the rate of disability from AN. A sensitivity analysis was performed to assess the influence of variations on the yearly cost of disability in BC: the number of patients with AN was varied between 1.0 and 2.0% of the female and 0.05 and 0.1% of the male population; the percentage of patients with AN receiving disability payments was determined by the survey to be 35%; the cost of these payments was varied between the lowest and highest benefits a single person can receive from the BC provincial government; and finally, to allow for possible sampling bias and a possible lower prevalence of AN, the lower limit of the sensitivity analysis was derived by dividing the lowest estimate above by seven. The sensitivity analysis revealed that the total estimated cost of long-term disability in BC could be as low as $2.5 million (Canadian) or as high as $101.7 million per year, which is a cost of up to 30 times the total yearly cost of all tertiary care services for the treatment of eating disorders in BC. In view of this finding, an increase in funding is warranted for primary, secondary and tertiary prevention programs for AN in BC.

An evidence-based eating disorder program

The Children's Hospital of Denver has an internationally renowned outpatient-inpatient treatment program for children, adolescents, and young adults with eating disorders (EDs). A unique feature of this ED program is its inpatient location on a medical unit. The nurses are medically trained, yet their patients with EDs have complex emotional and psychological problems. To address the special needs of these patients, a child life specialist worked in collaboration with other members of an ED health care team to create a program better serving ED pediatric patients. An evidence-based approach was used to drive this program. The child life specialist queried other health care facilities for best practice ideas, searched the literature, and analyzed unit-based ED data to design a program matching the needs of the patients.

Eating disorders in adolescence and their sequelae

Eating disorders are prevalent in adolescents and are associated with significant medical and psychiatric morbidity. Amenorrhoea, one of the cardinal features of anorexia nervosa, is the most likely reason for consulting the gynaecologist. Amenorrhoea in a young woman should alert the gynaecologist to the possibility of an underlying eating disorder. Osteopenia is a potentially irreversible complication of prolonged amenorrhoea and a low oestrogen state. Eating disorders are best managed by a team approach, with the team comprising a physician, nutritionist and therapist. Oestrogen replacement therapy has not been shown to be an effective treatment for osteopenia in anorexia nervosa and the gynaecologist should avoid simply prescribing oestrogen replacement therapy without referring the patient for comprehensive treatment of the eating disorder. Nutritional rehabilitation, weight restoration and resumption of spontaneous menses are the mainstay of medical management. Calcium and vitamin D supplementation and moderate weight-bearing exercise should be prescribed where indicated. Newer therapeutic options for the treatment of osteopenia include DHEA, IGF-1 and alendronate.

Anguish and Despair in Adolescents with Eating Disorders

Summary: Adolescents struggling against anorexia nervosa or bulimia nervosa often experience self-punishing thoughts and behaviors, including self-mutilation, and suicidal ideation and attempts. These arise out of the profound anguish and despair frequently experienced by these young people. This paper outlines four particularly salient clinical themes underlying this despair that have significant implications for treatment. A practice perspective is discussed which emphasizes empathic listening and the development of a strong therapeutic alliance with the adolescent. Treatment recommendations draw from narrative theory and practice, and from feminist perspectives. The paper also draws on cognitive therapy and on recent developments in the areas of spirituality and motivational enhancement. Involving the distressed adolescent's family is also addressed.

Hábitos e comportamentos alimentares de adolescentes com sintomas de anorexia nervosa

Foram avaliados os hábitos e comportamentos alimentares de adolescentes do sexo feminino com sintomas de anorexia nervosa de uma escola particular. Foi identificada a presença de sintomas através do "Teste de Atitudes Alimentares". O recordatório de 24 horas "modificado" foi usado para avaliar os alimentos consumidos e um questionário foi aplicado para investigar as preferências e aversões alimentares. Das 279 alunas estudadas, 21,1% apresentaram sintomas. Os alimentos mais consumidos entre estas estudantes foram frutas, hortaliças, leite desnatado e bala, e os menos consumidos foram refrigerante, chocolate, massa e batata frita. Os alimentos de que "mais gostam" foram, em ordem decrescente: massas, carnes, hortaliças e doces; e os de que "menos gostam" foram: hortaliças, carnes e gorduras. Houve aversão maior por doces nas adolescentes com sintomas de anorexia nervosa. Concluiu-se ter havido um alto número de alunas com sintomas apresentando aversões alimentares semelhantes às de anoréxicas.

School-based peer support groups: a new approach to the prevention of disordered eating

The goal of the present study was to evaluate the effectiveness of a school-based peer support group designed to improve body esteem and global self-esteem and to reduce negative eating attitudes and behaviors. A total of 214 girls in grades 7 and 8, 115 of whom were in the control group, completed self-report questionnaires immediately before and following the intervention, and three months later. The findings revealed that participation in the 10-session group, facilitated by public health nurses, led to increases in weight-related esteem and decreases in dieting. The role of peer support groups in the prevention of disordered eating is discussed.

Identifying and treating eating disorders

Pediatricians are called on to become involved in the identification and management of eating disorders in several settings and at several critical points in the illness. In the primary care pediatrician's practice, early detection, initial evaluation, and ongoing management can play a significant role in preventing the illness from progressing to a more severe or chronic state. In the subspecialty setting, management of medical complications, provision of nutritional rehabilitation, and coordination with the psychosocial and psychiatric aspects of care are often handled by pediatricians, especially those who have experience or expertise in the care of adolescents with eating disorders. In hospital and day program settings, pediatricians are involved in program development, determining appropriate admission and discharge criteria, and provision and coordination of care. Lastly, primary care pediatricians need to be involved at local, state, and national levels in preventive efforts and in providing advocacy for patients and families. The roles of pediatricians in the management of eating disorders in the pediatric practice, subspecialty, hospital, day program, and community settings are reviewed in this statement.

Children and adolescents with eating disorders: the state of the art

BACKGROUND

Eating disorders in children and adolescents remain a serious cause of morbidity and mortality in children, adolescents, and young adults. The working knowledge of pathophysiology, recognition, and management of eating disorders continues to evolve as research in this field continues.

OBJECTIVES

This article builds on previous background and position papers outlining issues relevant to the care of the adolescent patient with an eating disorder.

METHODS

The eating disorder special interest group from the Society for Adolescent Medicine recognized the need to update the state of the art published guidelines for the care of the adolescent patient with an eating disorder. This article was a multidisciplinary, group effort to summarize the current knowledge of best practice in the field.

RESULTS

This article summarizes newer findings on pathogenesis and etiology, prevention and screening, risk factors, nutritional issues, care from the primary care clinician's perspective, appropriate use of a multidisciplinary team, and issues of managed care and reimbursement.

CONCLUSIONS

Primary prevention combined with early recognition and treatment helps decrease morbidity and mortality in adolescents with eating disorders.

A practice guideline for treatment of eating disorders in children and adolescents

Eating disorders are diseases of both the body and the psyche. Early treatment focuses on restoration of nutritional status and somatic health, including psycho-educational counselling and support offered to the patient and his/her family. Diagnosis and treatment require a multidisciplinary approach. Psychological factors related to the condition should be assessed. The most severe weight loss should be reversed before psychotherapeutic treatment. Nutritional counselling is recommended, and the benefits of individual and/or family therapy are considered in accordance with the patient's age, development, symptomatology and comorbid psychiatric disorders. Medication is useful in the treatment of bulimia nervosa and certain comorbid symptoms of anorexia nervosa. Early admission to treatment and active therapy are associated with a more favourable prognosis.

Ethnic/racial differences in weight-related concerns and behaviors among adolescent girls and boys: findings from Project EAT

OBJECTIVE

To compare weight-related concerns and behaviors across ethnicity/race among a population-based sample of adolescent boys and girls.

METHODS

The study population included 4746 adolescents from urban public schools in the state of Minnesota who completed surveys and anthropometric measurements as part of Project EAT (Eating Among Teens), a population-based study focusing on eating patterns and weight concerns among teenagers. Main outcome measures included measured body mass index (BMI), weight-related concerns (perceived weight status, weight disparity, body satisfaction and attitudes about weight control) and weight-related behaviors (general/specific weight control behaviors and binge eating).

RESULTS

In comparison to White girls, African American girls tended to report fewer weight-related concerns/behaviors, while Hispanic, Asian American and Native American girls tended to report similar or more concerns/behaviors. Among boys, weight-related concerns/behaviors were equally or more prevalent among all non-Whites than among Whites. In particular, African American and Asian American boys were at greater risk for potentially harmful weight-related concerns/behaviors than White boys.

CONCLUSIONS

Weight-related concerns and behaviors are prevalent among adolescents, regardless of their ethnic/racial background, indicating a need for prevention and treatment efforts that reach adolescents of different ethnic backgrounds. However, ethnic differences demonstrate a need for ensuring that the specific needs of different groups are addressed in the development of such interventions.

The role of the family physician in eating disorders

The steady increase in Eating Disorders (ED) during the last three decades has raised increasing concern over the early diagnosis and treatment of this disease. Due to the multi-factorial etiology of ED, treatment is complex, prolonged, and demands a team approach. Family physicians are often approached first for consultation following the patient's initial physical complaints. For this reason, the general practitioner can play a critical role in the early diagnosis and treatment of these disorders. By asking the appropriate questions and providing relevant information, the family physician (FP) may be able to refer the patient to treatment necessary for recovery, as well as assist in this process. Because the family physician typically has previous acquaintance with the patient and her family, he or she may be of considerable import to creating a therapeutic liaison and support framework with the professional team. This article will discuss the potential involvement and significance of the family physician in the successful diagnosis, prevention, and treatment of ED. The importance of the FP in the decision for hospitalization, referral, and follow-up is emphasized, as well as the pivotal role of the FP as a multi-disciplinary team coordinator.

Chronic fatigue syndrome and eating disorders: concurrence or coincidence?

In this report we present four patients who were found to have both an eating disorder and the chronic fatigue syndrome (CFS). Two of the patients presented for evaluation of an eating disorder and also had CFS, while two of the patients presented for evaluation of CFS and also had an eating disorder. In all four patients the eating disorder preceded the CFS. We consider the question of whether the occurrence of these two disorders in the same patients is merely a coincidence; whether an eating disorder can act as a precipitant for CFS, perhaps through the exacerbation of an underlying vascular instability; and whether overlapping etiologies may predispose some adolescents to develop both disorders. We also discuss similarities (including diagnostic dilemmas, cultural influences, psychological correlates, demographic similarities, perceptual biases, and cardiovascular effects) encountered in the management of both of these disorders.

A high exercise load is linked to pathological weight control behavior and eating disorders in female fitness instructors

Demographic data, exercise habits, weight control behavior, attitudes towards body shape, eating disorder (ED) experience, and menstrual regularity among female fitness instructors were descriptively assessed. A 60-item questionnaire was sent to 295 female fitness instructors at eight fitness centers. Responders (57%) reported a mean weekly exercise load of 5.5 h week(-1) (SD 2.6), which indicates frequent training, however, less than that of athletes. Overall, 35% reported ED experience (DSM-IV criteria), with an onset at 15-17 years of age. The problems had lasted 5-7 years, and 20% of the entire group reported recovery, however, 11% still had EDs. For the entire group, it was found that a high weekly exercise load was linked to a pathological weight control behavior. Fitness instructors with an active ED exercised more than instructors who never had an ED or who had a past ED. Menstrual irregularity was more common among instructors who did not use contraceptives (14%), compared to those who did (5%). As ED experience and pathological weight control behavior were common in the studied group, the importance of guidelines regarding communication from female fitness instructors about healthy training habits to regular exercisers is discussed in the article.

Adolescents with eating disorders. Primary care screening, identification, and early intervention

The identification and treatment of eating disorders in adolescents is a challenging and time-consuming commitment. Early identification and treatment requires a multi-disciplinary team of health care professionals and provides an improved prognosis for these complex conditions. Nurses in all levels of practice are in ideal positions to influence early detection through careful screening (identification of risk factors, patient history, and physical exam), close follow-up, and prompt specialty referral with disease progression.

Identification of patients with eating disorders. The signs and symptoms of anorexia nervosa and bulimia nervosa

The optimal medical assessment of an eating disorder patient depends on a knowledge of the associated signs and symptoms, many of which are rarely seen in general medicine. Some of these signs are diagnostic of eating disorders. This paper presents a systematic review of the history and physical examination, including the special signs and symptoms in tabular form. In addition, the significance of the signs and symptoms of eating disorders is reviewed.

The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa

INTRODUCTION

Osteopenia is a serious complication of anorexia nervosa (AN). Although in other states of estrogen deficiency, estrogen replacement therapy increases bone mass, its role in AN remains unresolved.

STUDY OBJECTIVE

To study the effect of estrogen-progestin administration on bone mass in AN.

DESIGN, SETTING, AND PARTICIPANTS

A prospective observational study of 50 adolescents with AN (mean age 16.8 +/- 2.3 yrs) was conducted in a tertiary referral center.

MAIN OUTCOME MEASURES

Bone mineral density (BMD) of the lumbar spine and left hip were prospectively measured using dual-energy x-ray absorptiometry at baseline and annually.

INTERVENTIONS

Twenty-two subjects received estrogen-progestin and 28 standard treatment (Rx) alone. Estrogen-progestin was administered daily as an oral contraceptive containing 20-35 mcg ethinyl estradiol. All subjects received calcium supplementation and the same medical, psychological, and nutritional intervention (standard Rx). Mean length of follow-up was 23.1 +/- 11.4 months.

RESULTS

At presentation, patients were malnourished (79.5% +/- 7.6% IBW), hypoestrogenemic (estradiol 24.7 +/- 10.7 pg/mL), and had reduced bone mass (lumbar spine BMD -2.01 +/- 0.69 SD below the young adult reference mean). Ninety-two percent of subjects were osteopenic and 26% met WHO criteria for osteoporosis. Body weight, and no treatment group, was the major determinant of BMD. At one-year follow-up, there were no significant differences in absolute values or in net change of lumbar spine or femoral neck BMD between those who received estrogen-progestin and those who received standard Rx (80% power of finding a 3% difference in BMD at 1 yr). In those followed for 2-3 yrs, osteopenia was persistent and in some cases progressive.

CONCLUSION

In our study population, estrogen-progestin did not significantly increase BMD compared with standard Rx. These results question the common practice of prescribing hormone replacement therapy to increase bone mass in AN.

Half of rural girls aged 8 to 17 years report weight concerns and dietary changes, with both more prevalent with increased age

OBJECTIVE

Determine body image satisfaction, weight concerns and dieting behaviors, Tanner index, and dietary adequacy in young women and girls.

DESIGN

A cross-sectional, self-selected comparative survey was completed.

SUBJECTS/SETTING

Rural white women and girls (N=333) aged 8 to 17 years, completed a weight concerns and dieting behavior questionnaire, a body image assessment, and a self-rating of sexual maturity, and 230 subjects completed 3-day diet diaries. ANALYSES PERFORMED: Correlational analysis identified relationships between variables among age groups (8 to 10 years, 11 to 14 years, and 15 to 17 years). Analysis of variance examined differences among variables. Multiple regression analysis measured the influence of variables on diet quality. A mean adequacy ratio (MAR) was computed to express dietary adequacy.

RESULTS

More than half (52%) of the subjects reported 1 or more weight concerns and dieting behaviors. This pattern increased with age. Friends dieting positively influenced scores (P=.0001) for 8- to 14-year olds, and a dieting family member meant higher scores (P=.04) for all ages studied. Although most wanted to be smaller, there was little body image dissatisfaction. Girls (aged 11 to 17 years) who dieted had greater body dissatisfaction (P=.0001) and significantly lower (P=.002), but adequate diets (MAR=76) compared to those who did not diet (MAR=81). Inverse relationships were found for the 11- to 14-year olds with diet adequacy and the following variables: body image dissatisfaction (-2.7, P<.01) and weight concerns and dieting behaviors (-3.7, P<.001). These variables accounted for 34% (P=.0001) of the variance in the MAR.

APPLICATIONS/CONCLUSIONS

Dietitians, partnering with school and health clinic personnel, need to educate girls younger than age 11 years about attaining the dietary adequacy needed to support expected growth. This age is important because it appears that actual weight and dieting concerns begin earlier, and by age 11 years, negatively affect diet quality.

Childhood and adolescent anorexia nervosa

Eating disorders are common during childhood and adolescence. Early intervention is associated with the best prognosis. Treatment interventions that focus on achieving ideal body weight and use various family therapy approaches are most likely to be effective. Much remains to be learned about the origin of AN, but there are promising recent advances.

Developing and implementing a comprehensive program for children and adolescents with eating disorders

TOPIC

Treatment of eating disorders in children and adolescents across a continuum of care.

PURPOSE

To describe the development and implementation of a comprehensive pilot program for children and adolescents with eating disorders.

SOURCES

Published literature and clinical experience.

CONCLUSIONS

The pilot program to provide comprehensive care to children and adolescents has been successful. As of November 2000, the inpatient modal eating disorder census has been 4 (highest = 10, lowest = 1). With the focus on prevention and early intervention, the multidisciplinary team continues to educate the public and providers.

Eating disorders, fertility, and pregnancy: relationships and complications

Women are becoming heavier with each generation although the ideal female image emphasizes slimness. This focus results in the development of eating disorders in a significant number of women. The most common eating disorders are anorexia nervosa and bulimia nervosa. Eating disorder behaviors during pregnancy are associated with complications such as preterm delivery, low birthweight, intrauterine growth restriction, Caesarean birth, and low Apgar scores. Increasing the understanding of eating disorders assists health care professionals to accurately assess and intervene to improve a woman's nutritional status, monitor eating behaviors that may negatively affect a woman's health and fertility, and promote positive outcomes during pregnancy.

Position of the American Dietetic Association: nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS)

More than 5 million Americans suffer from eating disorders. Five percent of females and 1% of males have anorexia nervosa, bulimia nervosa, or binge eating disorder. It is estimated that 85% of eating disorders have their onset during the adolescent age period. Although Eating Disorders fall under the category of psychiatric diagnoses, there are a number of nutritional and medical problems and issues that require the expertise of a registered dietitian. Because of the complex biopsychosocial aspects of eating disorders, the optimal assessment and ongoing management of these conditions appears to be with an interdisciplinary team consisting of professionals from medical, nursing, nutritional, and mental health disciplines (1). Medical Nutrition Therapy provided by a registered dietitian trained in the area of eating disorders plays a significant role in the treatment and management of eating disorders. The registered dietitian, however, must understand the complexities of eating disorders such as comorbid illness, medical and psychological complications, and boundary issues. The registered dietitian needs to be aware of the specific populations at risk for eating disorders and the special considerations when dealing with these individuals.

Eating disorders in children and adolescents: epidemiology, diagnosis and treatment

Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are increasingly prevalent among children and adolescents. Whereas AN has a peak age of onset in early to mid-adolescence, BN typically presents during or after late adolescence. There is a spectrum of eating disorders that can be categorised by the criteria in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders into AN, BN and 'eating disorder not otherwise specified (ED-NOS)'. The key clinical signs of AN are those of protein calorie malnutrition. In BN, signs of purging are also important. Despite marked physical changes, metabolic decompensation occurs late and when present is an indication for hospital admission. During refeeding, electrolyte disturbances, in particular hypophosphataemia, should be serially monitored. For females with AN, restoration of gonadotropins, oestradiol and resumption of menses is a cardinal indicator of nutritional recovery. Treatment should address the medical, nutritional and psychological needs of children and adolescents with eating disorders. No single professional can be proficient in all spheres. Children and adolescents with eating disorders are best managed by a 'team approach'. Treatment may occur in a variety of inpatient, daypatient or outpatient settings. The aims of medical treatment are to promote bodyweight gain and nutritional recovery. Psychiatric goals address the psychosocial precipitants, treat comorbid mood symptoms and assist the patient to develop alternative coping skills. The crude mortality of AN has decreased to around 6%. For children and adolescents, the morbidity from malnutrition is increased because of the biological changes that are interrupted.

Eating disorders in children and adolescents: pharmacological therapies

Anorexia nervosa and bulimia nervosa do exist in childhood, frequently have their onset in adolescence, and can result in serious medical and psychiatric sequelae that impede physical, emotional, and behavioral development. Although we use the same Diagnostic and Statistical Manual of Mental Disorders-Version 4 [DSM-IV] definitions to diagnose eating disorders in children, adolescents, and adults, these disorders may be expressed somewhat differently in younger populations, requiring assessment and treatment procedures that are tailored to their developmental needs. Significant advances have been made in recent years in our understanding of treatments for eating disorders in adults, and specifically pharmacological treatments for these disorders. Multiple double-blind, placebo-controlled studies have documented the short-term efficacy of antidepressant medications in bulimia nervosa. While the usefulness of pharmacological treatments for the acute treatment of anorexia nervosa is less clear, recent evidence suggests a role for medication in the relapse-prevention stage of the illness. The majority of the medication trials for the eating disorders have been conducted with adults, and the literature on the pharmacological treatment of children and adolescents with these disorders is very limited. This review article summarizes the current literature on the role of medication in the treatment of anorexia nervosa and bulimia nervosa, with particular emphasis on studies conducted in child and adolescent populations.

Differences between adolescents and young adults at presentation to an eating disorders program

OBJECTIVE

To describe differences between adolescents and adults in clinical presentation of eating disorders.

METHODS

Data from the charts of 622 female patients treated for an eating disorder in a division of adolescent medicine between 1980 and 1994 were coded and computerized. General categories included demographic and family factors, weight loss and weight changes, eating-related behaviors, diagnosis and severity, and treatment issues. Differences between the 438 patients who were aged 9-19 years (adolescents) and 184 patients who were aged 20-46 years (adults) were analyzed.

RESULTS

Adolescents were more likely than adults (p <.05) to have a diagnosis of "eating disorder not otherwise specified," lower global severity score, greater denial and less desire for help, weight loss > or = 3 lb/month, lower original and maximum weights, and history of fasting and elimination of junk food from their diets. Adults were more likely than adolescents (p <.05) to have >1 year of weight loss, greater total weight loss, history of binge eating and laxative use, history of diuretic and ipecac use, diagnosis of bulimia nervosa, and prior use of psychiatric medications. Adolescents and adults did not differ (p >.05) in parents' occupational level; height, weight, and percent ideal body weight at presentation; original percent ideal body weight; use of diet pills, elimination of meat and use of a low-fat diet; daily calorie intake; prior eating disorder hospitalizations; and hospitalization during the course of treatment.

CONCLUSIONS

The findings in this study document and confirm that there are important differences between adolescents and adults that must be taken into account in the evaluation and treatment of patients with eating disorders.

Hypophosphatemia secondary to oral refeeding in anorexia nervosa

OBJECTIVE

Hypophosphatemia is a well-known complication of the refeeding syndrome in severe cases of anorexia nervosa, described mostly as a result of refeeding with total parenteral nutrition. Few cases have been reported secondary to either nasogastric or oral refeeding.

METHOD

The authors present three cases in which hypophosphatemia developed secondary to oral refeeding in severe anorexia nervosa.

RESULTS

All 3 patients developed significant hypophosphatemia, to a low of 0.9 mg/dl in two cases and a low of 1. 7 mg/dl in the third. The first patient received close to 3,000 calories per day, along with intravenous fluids, in the hospital; the other 2 patients ate large amounts for several days at home. Caloric restriction and replenishment with phosphorous resulted in a rapid return of phosphorous values to normal levels.

DISCUSSION

Those who treat severely malnourished patients with eating disorders, whether as inpatients or outpatients, need to be vigilant for the development of the refeeding syndrome, even in patients receiving oral refeeding alone.

Eating disorders in adolescents and young adults

Eating disorders are relatively common and frequently result in medical signs and symptoms. Armed with an appreciation of the protean manifestations of these complex health problems as well as an appreciation of the biopsychosocial approach needed to help the adolescent or young adult woman recover, the primary care physician is in an excellent position to have a therapeutic role in the recovery from these chronic conditions. By recognizing the medical aspects of eating disorders, the oversimplified viewpoint of considering them as purely psychiatric disorders can be avoided. Open and consistent communication with patients, with a focus on health rather than dysfunction and mental illness, facilitates the acceptance of a comprehensive approach in which the internist, dietitian, and mental health provider all have a role.

Electrocardiographic findings in adolescents with eating disorders

OBJECTIVES

We sought to determine the prevalence and clinical correlates of electrocardiographic findings in adolescents with eating disorders.

STUDY DESIGN

We undertook matched case-control study of electrocardiographic findings at initial assessment in 62 adolescents with anorexia nervosa, 9 with bulimia nervosa, and 26 with eating disorder not otherwise specified presenting from March 1995 to September 1996.

RESULTS

Mean (+/- 1 standard deviation) age was 15.0 +/- 1.4 years (95% were female). Patients with anorexia nervosa had significantly lower heart rates (mean case-control difference: -20 +/- 17 beats per minute), lower R in V(6) (-2.6 +/- 5.5 mm), longer QRS interval (+.004 +/-.010 seconds), shorter mean QTc (-.0136 +/-.033 seconds) and lesser QTc dispersion (-.010 +/-. 031 seconds). The bulimia nervosa group had slightly longer mean QTc (.019 +/-.020 seconds), with no significant case-control differences in the eating disorder not otherwise specified group.

CONCLUSION

Electrocardiographic findings are abnormal in adolescents with anorexia nervosa but not in adolescents with bulimia nervosa or eating disorder not otherwise specified.

Eating disorders in adolescent girls

Eating disorders are common in contemporary society. New information is emerging on the pathogenesis of anorexia nervosa and bulimia nervosa and includes psychologic, biologic, family, environmental, genetic and social factors. The physician providing care to adolescents is challenged to carry out a careful evaluation and monitor the patient for complications, especially loss of bone mass. Treatment requires a multidisciplinary team.

Eating disorder symptoms in a cohort of 11 to 16-year-old black and white girls: the NHLBI growth and health study

OBJECTIVE

This study sought to provide reference data for the Eating Disorder Inventory (EDI) with use of young adolescent black and white girls. Moreover, the study examined the relationship between race, age, socioeconomic status, and adiposity and each of the eight EDI scales.

METHOD

To achieve these aims, data were used that had been collected in Years 3, 5, and 7 as part of the National Heart, Lung, and Blood Institute Growth and Health Study, a longitudinal cohort study of risk factors for obesity in black and white girls. For the present report, data were available from 2,228 girls in Year 3, 2,056 girls in Year 5, and 1,902 girls in Year 7.

RESULTS

EDI scores were found to vary by race, age, socioeonomic status, and body weight of respondents. Black girls scored different from white girls on all EDI subscales. Scores on all but two subscales (Body Dissatisfaction, Drive for Thinness) decreased significantly with increasing age. Significant inverse associations were found between maximum parental education and all EDI subscales except Body Dissatisfaction and Perfectionism. Elevated body weight was associated significantly with Body Dissatisfaction, Drive for Thinness, Bulimia, Interoceptive Awareness, and Ineffectiveness.

DISCUSSION

Our results illustrate the importance of taking into consideration the potentially confounding role of demographic characteristics and body weight when comparing different race or ethnic groups on the EDI.

[Anorexia nervosa in children and adolescent: new therapeutic approaches]

Classical therapeutic recommendations requires that girls with anorexia nervosa be separated from their parents. Refeeding, and later individual psychodynamic approaches were also emphasized. These guidelines are now broadened towards psychotherapeutic approaches (psychodynamic, familial, cognitive-behavioral) associated with psychoeducational and dietetic strategies. In the Child and Adolescent Psychopathology Unit of Robert-Debre Hospital in Paris, individual therapeutic programs are applied to young anorectic girls and their families. These programs are implemented within an inpatient (full-time, part-time) or outpatient (consultations, weekly day-therapeutic program) framework. In order to forge a therapeutic alliance with parents and restore "parental competences" feelings, we do not separate any longer anorectic girls from their parents during hospitalization, and we have developed an alternative therapeutic model to full-time hospitalization.

Is there an increased clinical severity of patients with eating disorders under managed care?

OBJECTIVES

We sought to examine possible differences in medical status at presentation in 1996, compared to 1991, of adolescents with eating disorders (EDs) at a hospital-based multidisciplinary care program to reflect the increasing market penetration of managed care.

DESIGN

Charts were reviewed for all new patients scheduled in a hospital-based outpatient ED program in 1996 and 1991. The 92-item standardized data extraction form included information on demographics, indicators of illness severity at the first visit, and subsequent hospitalization. The need for primary care referral was verified using billing records. Data were analyzed with Student's t-test, Chi-square, Fisher's exact, and Mann-Whitney U tests using SPSS 7.5.

RESULTS

Of the 153 total patients, 133 kept their intake appointment and 130 (98%) of these had charts available for review. The age, racial/ethnic characteristics, and average length of disordered eating behaviors were not significantly different over the 5-year period. Referral from a primary care clinician was more commonly required in 1996 than 1991 (59% vs. 11%; p < .0001). Eighteen percent of the patients seen in 1996 were admitted from the initial appointment for medical stabilization, compared to 1.5% in 1991 (p = .002). Comparing 1996 to 1991, a similar number of patients had symptoms consistent with anorexia nervosa, whereas fewer patients in 1996 gave a history of bingeing and purging (22% vs. 40%; p = .027). There were no significant differences in indicators of illness severity, treatment by primary care clinician prior to referral, or hospitalization rates for those patients with and without managed care.

CONCLUSIONS

Patients in 1996 were more likely to require referrals, were less likely to have symptoms consistent with bulimia nervosa, and were more likely to be admitted for medical stabilization. There were no differences in patient presentation characteristics or initial hospitalization rates based on their managed care status. Further research is needed to investigate the changes in illness severity at presentation and to assess the role that managed care plays in the treatment of patients with eating disorders.

Development and evaluation of the McKnight Risk Factor Survey for assessing potential risk and protective factors for disordered eating in preadolescent and adolescent girls

OBJECTIVE

To describe the development, test-retest reliability, internal consistency, and convergent validity of the McKnight Risk Factor Survey-III (MRFS-III). The MRFS-III was designed to assess a number of potential risk and protective factors for the development of disordered eating in preadolescent and adolescent girls.

METHOD

Several versions of the MRFS were pilot tested before the MRFS-III was administered to a sample of 651 4th through 12th- grade girls to establish its psychometric properties.

RESULTS

Most of the test-retest reliability coefficients of individual items on the MRFS-III were r > .40. Alpha coefficients for each risk and protective factor domain on the MRFS-III were also computed. The majority of these coefficients were r > .60. High convergent validity coefficients were obtained for specific items on the MRFS-III and measures of self-esteem (Rosenberg Self-Esteem Scale) and weight concerns (Weight Concerns Scale).

CONCLUSIONS

The test-retest reliability, internal consistency, and convergent validity of the MRFS-III suggest that it is a useful new instrument to assess potential risk and protective factors for the development of disordered eating in preadolescent and adolescent girls.