Eating practices and emphasis on weight and body appearance are a major focus of our society today. Obesity rates in children, adolescents and adults have been on the rise over the past several decades and the importance of diet on physical health has become an essential topic for healthcare providers to address with families. At the same time, the prevalence of eating disorders has steadily been increasing.
Prevalence of eating disorders
Currently the lifetime prevalence of anorexia nervosa is .3% in men and .9% in women with a peak age onset of 13 to 18 years old. Anorexia nervosa also has a mortality rate of 5% to 6%, which is the highest of any psychological disorder. Bulimia nervosa has a lifetime prevalence rate of .5% in men and 1.5% in women with a peak age of onset between 16 and 17. Research shows that the bulimia nervosa mortality rate is 1.7% with the risk of suicide and suicide attempts being much higher than other psychological disorders. It is also important to recognize that 5% to 10% of diagnosed eating disorders occur among males, a group that historically has been overlooked when screening for disordered eating attitudes and behavior.
Taken together, these numbers point to the vital role that pediatricians serve in screening for and addressing disordered eating and recognizing eating disorders.
Screening for eating disorders
Eating disorders have a major impact on child and adolescent development and affect every organ system in the body. Therefore, it's important for pediatricians to recognize the psychological and physical impact of disordered eating that can occur at any weight. Eating disorder awareness is especially critical because early identification of eating disorders results in significantly improved outcomes and prognosis. Any patient who presents with weight loss, unexplained growth stunting or pubertal delay, restriction of certain types of food or sudden and/or unexpected allegiance to vegetarianism or vegan diets could have an eating disorder.
Additionally, recurrent vomiting, excessive exercise, trouble gaining weight or body image concerns are all hallmark symptoms of eating disorders. As a starting point, primary care providers should adopt a standard screening process for these symptoms into wellness exams.
The SCOFF is a standardized set of screening questions* that pediatricians should use and includes:
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you recently lost more than One stone (14 lb/6.3 kg) in a three-month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?
* One point for every "yes"; a score of 2 indicates a likely case of anorexia nervosa or bulimia.
Assessing the severity of eating disorders
When you identify a patient as at-risk during screening, you must complete further assessment to determine next steps for treatment. It's important to gather information from multiple data points to determine the severity of symptoms, as a majority of patients presenting with significant eating disordered behavior are likely to deny or rationalize their symptoms. Additionally, family members can unknowingly rationalize eating disorder symptoms or be unaware of the extent of symptom severity. You should interview patients and parents separately and ask about historical and current eating practices, exercise habits, ideal weight beliefs, trauma, substance use and family psychiatric history.
Additionally, reviewing past and current medical and nutritional records can help identify potential problems and may illuminate discrepancies if a patient is denying symptoms. If primary care providers are monitoring symptoms over time, they should have patients complete weight check-ins wearing hospital gowns; some patients will hide objects in their clothing to increase their weight. After additional assessment, patients demonstrating impaired functioning (e.g. academic, relational, adaptive skills) and/or have significant medical concerns should be referred for specialized assessment to determine the appropriate level of care.
Treating eating disorders
When possible, it's best to treat patients on an outpatient basis for eating disorder symptoms. However, sometimes more intensive treatment is necessary. Intensive treatment may include intensive outpatient care, partial hospitalization, inpatient hospitalization or residential treatment. Prioritize programs that utilize family-based treatment (sometimes referred to as the Maudsley method), as this approach has strong empirical support for the successful treatment of eating disorders.
Eating disorder care referrals
The Eating Disorder Treatment Program at Children's Hospital Colorado is a valuable resource for providers in Colorado and the surrounding region. The program has been treating eating disorders for more than 25 years and offers a comprehensive evaluation to determine an appropriate treatment plan based on individual patient needs. The program offers services across all levels of care (outpatient, intensive outpatient, day treatment and inpatient) and utilizes family-based therapy. These services are available for children, adolescents and young adults through age 21.
If providers are concerned that a comprehensive evaluation and treatment plan is needed, they can refer families to schedule an evaluation appointment with the Eating Disorder Program by calling 720-777-6200. Providers and families can also learn more about Children's Colorado's Eating Disorder Treatment Program online.
Eating disorder resources
Additional resources for families: