Eating disorders in adolescents: a background paper

Self-assessment of sexual maturation in adolescent females with anorexia nervosa

PURPOSE

To evaluate the accuracy of self-assessment of pubertal maturation and to determine the desired stage of pubertal maturity in adolescent females with anorexia nervosa.

METHODS

Standardized figure drawings depicting Tanner's sexual maturation stages were given to a consecutive sample of 40 adolescent females with anorexia nervosa who were instructed to assess current and desired pubertal development. Pubertal development was assessed independently by two investigators. The percent agreement between physician and subject ratings was determined.

RESULTS

Percent agreement between physician and subject ratings was 30% for developmental stage for breasts and 50% for pubic hair. Subjects underestimated breast development 3.4 times as often as they overestimated it and overestimated pubic hair development 1.5 times as often as they underestimated it. Multivariate probit analysis showed that inaccuracy in breast self-assessment was inversely related to a desire for sexual maturity (p < 0.05). Ninety percent of subjects stated that their desired stage of breast development was equal to or more mature than their present stage. Eighty percent stated that their desired stage of pubic hair development was equal to or more mature than their present stage.

CONCLUSIONS

Self-assessment of sexual maturity by adolescents with anorexia nervosa using standardized figure drawings depicting Tanner's stages is not accurate. Patients desiring a sexually immature body were most likely to be inaccurate in their self-assessment of their pubertal stage.

Antioxidant status in anorexia nervosa

OBJECTIVE

The study of the antioxidant status in female adolescents (N = 82) with anorexia nervosa, by the measurement of erythrocyte tocopherol concentration, and the determination of activities of the main antioxidant enzymes: superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase.

METHOD

Tocopherol was measured by high-performance liquid chromatography (HPLC) with ultraviolet (UV) detection, and antioxidant enzyme activities by spectrometric methods using a Cobas Fara automated centrifugal analyzer.

RESULTS

Tocopherol was significantly decreased in the anorexic patients compared to reference values (p < .02). In 21% of patients, tocopherol levels were below the reference interval. Superoxide dismutase activity was significantly decreased (p < .0001), while catalase activity was increased (p < .0001). The activity of the glutathione system enzymes did not show significant differences between patients and controls.

DISCUSSION

The deficient concentration of erythrocyte tocopherol together with the altered antioxidant enzyme activities suggest a certain degree of oxidative damage in anorexia nervosa owing to both factors deficient micronutrient intake and oxidative stress.

Eating disorders

Anorexia nervosa and bulimia nervosa are primarily psychiatric disorders characterized by severe disturbances of eating behaviour. Anorexia nervosa has been well documented in pre-pubertal children. Eating disorders are most prevalent in the Western cultures where food is in abundance and for females attractiveness is equated with thinness. Eating disorders are rare in countries like India. As Western sociocultural ideals become more widespread one may expect to see an increase in number of cases of eating disorders in non-Western societies. Etiological theories suggest a complex interaction among psychological, sociocultural, and biological factors. Patients with anorexia nervosa manifest weight loss, fear of becoming fat, and disturbances in how they experience their body weight and shape. Patients with bulimia nervosa present with recurrent episodes of binge eating and inappropriate methods of weight control such as self-induced vomiting, and abuse of diuretics and laxatives. Major complications of eating disorders include severe fluid and electrolyte disturbances and cardiac arrhythmias. The most common cause of death in anorexia nervosa is suicide. Management requires a team approach in which different professionals work together. Individual and family psychotherapy are effective in patients with anorexia nervosa and cognitive-behavioral therapy is effective in bulimia nervosa. Pharmacotherapy is not universally effective by itself. Patients with eating disorders suffer a chronic course of illness. The pediatrician plays important role in early diagnosis, management of medical complications, and psychological support to the patient and the family.

Treatment of eating disorders in children and adolescents

Anorexia nervosa and bulimia nervosa are expressed differently in children and adolescents than in adults. Consequently, diagnostic procedures and multidisciplinary treatments need to be tailored to the unique developmental, medical, nutritional, and psychological needs of children and adolescents with eating disorders. This paper reviews current research outlining the differences between child, adolescent, and adult eating disorders. Research is then reviewed concerning the effectiveness of hospitalization, partial hospitalization, individual dynamic therapy, cognitive-behavioral therapy, interpersonal therapy, family therapy, and medication for treating anorexia nervosa, bulimia nervosa, and related eating disorders in children and adolescents. Specific recommendations are made for practitioners to tailor these treatments to their eating-disordered child and adolescent patients, following a stepped-care, decision-tree model of intervention that takes into account the effectiveness, cost, and intrusiveness of the interventions.

Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years

OBJECTIVE

To critically review the research in juvenile anorexia nervosa and bulimia nervosa over the past 10 years and highlight recent advances in normal development as it pertains to these disorders and their diagnosis, prevention, and treatment.

METHOD

Computerized search methods were combined with manual searches of the literature. A detailed review of the most salient articles is provided. Preference was given to studies involving children and adolescents that approached the subject from a developmental perspective.

RESULTS

The information from these studies is presented in a developmental framework. Research in eating disorders has progressed, but definitive longitudinal data are still absent from the literature. Research specific to treatment of child and adolescent eating disorders remains rare.

CONCLUSIONS

Data approaching eating disorders from a developmental perspective are available in only a few studies. Research is needed addressing normative data on the development of eating behavior and specific risk and resilience factors for pathology in specific developmental periods. Especially lacking are studies regarding the continuities and discontinuities of eating disturbances across the life span. Best documented are epidemiological studies of prevalence and incidence, long-term outcome in anorexia nervosa, and short-term treatment response in bulimia.

Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa

AIM

To describe the clinical presentation of the refeeding syndrome and highlight the dangers of performing nutritional rehabilitation too rapidly in a severely malnourished patient.

DESIGN

Retrospective case review of adolescents admitted with anorexia nervosa who developed the refeeding syndrome.

RESULTS

Between July 1993 and July 1994, 3 of 48 adolescent females developed the refeeding syndrome. While the cardiac complications occurred in the first week of refeeding, the delirium characteristic of this syndrome occurred later and was more variably related to hypophosphatemia.

OBSERVATIONS

Refeeding malnourished patients with anorexia nervosa can be associated with hypophosphatemia, cardiac arrhythmia and delirium. Refeeding patients with anorexia nervosa who are < 70% of ideal body weight should proceed with caution, and the caloric prescription should be increased gradually. Supplemental phosphorus should be commenced early and serum levels maintained above 3.0 mg/dL. Cardiac and neurologic events associated with refeeding are most likely to occur within the first weeks, justifying close monitoring of electrolyte and cardiac status.

The prevalence of high-level exercise in the eating disorders: etiological implications

There is increasing evidence both from animal experimentation and from clinical field studies that physical activity can play a central role in the pathogenesis of some eating disorders. However, few studies have addressed the issue of prevalence or whether there are different rates of occurrence across diagnostic categories, and the estimates that do exist are not entirely satisfactory. The present study was designed to conduct a detailed examination of the physical activity history in patients with anorexia nervosa (AN) and bulimia nervosa (BN) both during and prior to the onset of their disorder. A sample of adult patients and a second sample of adolescent AN patients took part in the study. A series of chi-square analyses compared diagnostic groups on a number of variables related to sport/exercise behaviors both premorbidly and comorbidly. Data were obtained by means of a detailed structured interview with each patient. We found that a large proportion of eating disorder patients were exercising excessively during an acute phase of the disorder, overexercising is significantly more frequent among those with AN versus BN, and premorbid activity levels significantly predict excessive exercise comorbidity. These findings underscore the centrality of physical activity in the development and maintenance of some eating disorders. They also have important clinical implications in light of the large proportion of individuals who combine dieting and exercise in an attempt to lose weight, and the increasing recognition of the adverse effects of strenuous physical activity in malnourished individuals.

Psychosocial concerns and health-compromising behaviors among overweight and nonoverweight adolescents

OBJECTIVE

To compare weight-specific and global psychosocial concerns and health-compromising behaviors among overweight and nonoverweight youth across gender and ethnicity.

METHODS

A cross-sectional school-based survey of 31,122 adolescents in grades 7 to 12. Based on self-reported heights and weights, respondents were categorized as nonoverweight (body mass index (BMI) < 85th percentile), moderately overweight (85th percentile < BMI < 95th percentile), or severely overweight (BMI > 95th percentile).

RESULTS

Global psychosocial concerns, such as emotional well-being, suicidal ideation, future job concerns, and peer concerns, did not differ greatly between nonoverweight, moderately overweight, and severely overweight adolescents. Substance abuse behaviors were equally or less prevalent among the overweight group. Overweight girls were significantly less likely to consume alcohol, whereas overweight boys were at lower risk for marijuana use. In contrast, overweight youth were more likely to perceive their health as only fair or poor and were more likely to express weight-specific concerns and engage in behaviors such as chronic dieting and binge eating than nonoverweight youth. Overweight American Indian girls perceived their physical health more positively than nonoverweight American Indian girls. Strong associations were found between overweight status and chronic dieting among African American boys and girls.

CONCLUSIONS

Nutritional counseling and educational programs need to address the weight-specific concerns and behaviors of overweight adolescents. However, assumptions regarding global psychosocial concerns and health-compromising behaviors among overweight adolescents of different genders and ethnicities should be avoided. These broad issues need to be explored in more depth at both the research and intervention levels.

The self-schema model: a theoretical approach to the self-concept in eating disorders

Over the last several decades, the self-concept has been implicated as a important determinant of eating disorders (ED). Although considerable progress has been made, questions remain unanswered about the properties of self-concept that distinguish women with an ED from other populations, and mechanisms that link the self-concept to the disordered behaviors. Markus's self-schema model is presented as a theoretical approach to explore the role of the self-concept in ED. To show how the schema model can be integrated with existing work on the self-concept in ED, a framework is proposed that addresses the number, content, and accessibility of the self-schemas. More specifically, it is posited that a limited collection of positive self-schemas available in memory, in combination with a chronically and inflexibly accessible body-weight self-schema, lead to the disordered behaviors associated with anorexia nervosa and bulimia nervosa.

School-based programs for preventing eating disturbances

This paper describes a framework for involving schools in primary and secondary prevention of eating disturbances. The issues of why, what, who, and how are considered. Research on the prevalence and consequences of obesity, anorexia and bulimia nervosa, unhealthy dieting, and behaviors such as binge eating and purging indicates why prevention is necessary. Research on the etiology of eating disturbances also provided a basis for determining what factors need to be addressed. However, research has not adequately addressed the question of who should be targeted for prevention and how the topic of prevention should be approached. While different approaches to school-based prevention programs are possible, a comprehensive school-based program is recommended. Important components of a comprehensive program include staff training, classroom interventions, integration of relevant material into existing curriculum, individual counseling and small group work with high risk students, referral systems, opportunities for healthy eating, modifications within the physical education program, and outreach activities. This type of comprehensive program is based on an ecological model for health promotion and aims at the modification of both individual and environmental determinants of behavior.