Pediatric Eating Disorders: Prevention and Early Intervention

Educational Objectives

The goal of this program is to improve identification and management of eating disorders in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Cite changes in classification and criteria of eating disorders in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).
2. List symptoms of orthorexia in patients with eating disorders.
3. Identify commonalities and differences between obsessive-compulsive disorder and anorexia nervosa.
4. Assess the impact of eating disorders on the LGBTQ population.
5. Explain the Maudsley Method used in management of eating disorders.

Summary

Difficulties faced by clinicians involving eating disorders: in speaker’s clinic there is a lack of resources; only one inpatient social worker and speaker trained in interventions for eating disorders; clinicians sometimes wonder whether their obesity counseling has contributed to patients’ eating disorders, but the American Academy of Pediatrics states that appropriate obesity counseling does not cause an eating disorder; basic management in primary care — avoid weighing patients in public spaces (eg, hallways) to avoid embarrassment; avoid a judgmental tone; discuss preferences with parents when developing feedback for family, and determine their feelings around food and weight (eg, guilt, shame); personalize plans and follow-up; do not set goals that are difficult to achieve and that set the patient up for failure and discouragement; when there is an emotional component to eating, overly ambitious goals set patients up for continued overeating or binge eating and canceled appointments; one of speaker’s overweight patients noticed that providers were uncomfortable with her and hesitant to make physical contact (eg, breast examination); this hesitancy was interpreted as judgement, which made her less likely to disclose information and participate in discussions; ask about patients’ comfort level with discussions and components of the examination

Discussing weight loss: do not praise patients for significant weight loss without asking what they did to lose weight and about the timeframe; reinforce and praise healthy weight loss, but make sure that patients are not engaging in unhealthy weight-loss behaviors; weight loss may start with positive intentions, but it can become addictive, with patients engaging in continually more restrictive approaches; patients who lose weight (even when done in a healthy manner) worry about gaining it back and what people will think of them; this can lead to disordered behaviors with the goal of losing even more weight; patients can end up in a cycle of extreme restriction and binging

Adjustments in diagnostic criteria: in the the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5) improvements were made regarding eating disorder not otherwise specified (EDNOS); previously there were so many EDNOS diagnoses it was more difficult to receive insurance reimbursement because “not otherwise specified” was considered subclinical or subthreshold diagnosis; DSM-5 allowed for more inclusion criteria; the criterion of amenorrhea was removed from anorexia (this, according to speaker, is likely because eating disorders may start before menarche); language was altered regarding restriction of energy relative to requirements leading to significantly low body weight (instead of requiring 85% of expected weight); “refusal” to maintain body weight was removed; binge-eating disorder is now a distinct diagnosis; patients eat large amounts of food quickly, lack control over eating, and do not engage in compensatory behaviors; individuals may eat and have very little in front of others (ie, at a restaurant) then binge at home; for bulimia, the number of binge-purge events was reduced to once weekly; anorexia may present with a restriction in energy intake; according to the DSM-5, avoidant restrictive food intake disorder (ARFID) is a new classification; restrictive eating stems from avoidance (eg, fear of choking); children may make excuses for their behavior, delaying help; with a diagnosis of other specified feeding or eating disorder (OSFED), specify which disorder the patient is closest to (patients do not meet full diagnostic criteria); “unspecified” is a catch-all term and may represent behaviors and symptoms of different eating disorders

Orthorexia: not yet an official diagnosis; it is similar to a restrictive eating disorder but individuals use the excuse of “eating healthy”; many athletes engage in this excessive restriction; patients eliminate foods or food groups and risk malnourishment and myocardial infarction (similar to simple caloric restriction), it is not typically associated with body dysmorphia, but patients are practicing misguided eating rules; individuals may bring their own food to gatherings or, avoid social events; it is controversial whether the ARFID diagnosis is appropriate for these patients

Body dysmorphic disorder: may exist without anorexia nervosa (but anorexia cannot exist without body dysmorphia); speaker has observed patients under treatment for this exhibiting body-checking behavior, which is often unconscious and habit-forming; these behaviors (eg, pinching areas of body fat) are enforced by social media; patients have a distorted body image

Loss of control eating: not a diagnosis but is used for children ≤12 yr of age who are too young for a diagnosis of binge eating disorder; with this obsessive approach, individuals are hyperfocused on food; parents say that the child is continuing to eat food after finishing a full meal; children may not be connected to hunger and satiety cues; patients frequently experience psychological distress; it may be associated with internalizing and externalizing disorders; it usually worsens over time; providers should pay attention to disproportionate increases in weight; avoid shaming the child; advise behaviors that are not compatible with eating after meals (eg, take a walk with the family) to break the habit of continuing to eat

Risk factors for disordered eating: type 1 diabetes (high comorbidity with later onset of eating disorders); food allergies (perhaps because of parental anxiety regarding food choices and rigidity in eating patterns); early parental restrictions on eating can lead to subsequent overeating; internalizing disorders; low self-esteem; being teased or ostracized by peers about being overweight; traits that lead to success for students and athletes (ie, “type A” personality) can make them prone to being “good at” a restrictive eating disorder; eg, athletes are able to push themselves past the point of pain, which may allow them to ignore hunger cues; individuals with polycystic ovarian syndrome often have higher body weight and are advised to lose weight; intermittent fasting may provide an excuse to cover eating disorders, and the rigidity and control contribute to disordered eating behaviors; the loss of control felt by many during the pandemic, combined with messages on social media to “improve health” at the beginning of lockdowns, contributed to increases in eating disorders

Overlap between anorexia nervosa and other psychological conditions: an overlap exists between anorexia and addiction in that both conditions cause narrowing of and withdrawal from the social circle; both have negative physical and psychological consequences; as with recovery from substance use, stopping anorexic behaviors causes patients to experience the psychological symptoms they are trying to escape; recovery is difficult because of the significant anxiety patients experience when not allowed to restrict, when restricting is their coping mechanism for anxiety; very few patients are motivated to recover, as it means weight gain; obsessive-compulsive disorder (OCD) and anorexia — compulsive, ritualistic aspects in anorexia, eg, adhering to rigid guidelines, weighing food, and eating only at fixed times; unlike with OCD, the rituals provide comfort and relieve stress for patients with eating disorders; unlike with anorexia, individuals with OCD engage in rituals that reduce acute anxiety but they desire recovery and recognize the irrationality of the behavior; patients externalize anorexia during recovery (eg, referring to it as a “demon”)

Aspects of eating disorders: anorexia — avoidance of feelings; tuning out hunger cues; distracting themselves by focusing on restriction; patients with anorexia think about food constantly; bulimia — patients find tremendous relief in purging emotions, eg, through vomiting; binge-eating disorder — feelings are suppressed (sometimes as self-medication)

Contributing factors and triggers for eating disorders: parental comments about their own weight or modeling self-deprecation; patients often describe a single moment when they began to feel shame about eating or their body; a positive or negative comment about weight can be internalized, and patients begin to have obsessive thoughts and worries about weight gain; gender differences — do not emerge until puberty; expressions of concern around weight — can feed eating disorders; members of the LGBTQ+ community — at high risk for eating disorders, and transgender individuals are at highest risk; speaker has observed attempts to prevent puberty to avoid gender dysphoria; restriction can also be used to gain parental attention

Red flags for practitioners: pay attention to behavior around scales (eg, taking off as much clothing as possible, emotions around the number); ask about behavior and dietary changes (eg, cutting out certain foods) and about constipation or cold sensitivity; get the attention of the parent; there are critical periods where disordered eating habits are reinforced and the fear of gaining weight back (or the desire to continue weight loss) facilitates cognitive changes; irrational thoughts and body dysmorphia increase; early intervention can help prevent this downward spiral; be careful not to reinforce unhealthy weight loss methods

Patient perspectives: a high percentage of patients with eating disorders have a history of being at a higher weight; patients may reach a critical point in adolescence when their body changes and they gravitate toward disordered eating behaviors; pay attention to signs, eg, headaches, dizziness; provide tips for disordered eating and how to hide it

Screening: screen for weight control measures and associated attitudes; there is a gray area where weight loss is medically indicated but patients engage in disordered behaviors to achieve it; emphasize movement over exercise; do not ignore weight loss, even if the patient is still overweight; conversely, do not rely on weight loss as a marker for disordered behaviors; patients, especially those with anorexia, often do not answer questionnaires honestly; ask parents about any changes in behavior or concerning signs, eg, finding empty food wrappers, reports of refusing to eat at school, avoiding gatherings with peers; screen for comorbidities; the Child Eating Disorder Examination (ChEDE) is used for grades 3 through 8; the results (on a Likert scale) are highly correlated with body dissatisfaction and weight management concerns; a tool used in the United Kingdom asks, eg, whether patients have ever made themselves sick, are they worried they do not have control over eating or food, have they lost a significant amount of weight in a short period of time, whether they perceive themselves as fat when others do not think so, do they have a preoccupation with food; ask follow-up questions to elicit red flags — do they know the exact amount of calories in a particular food (indicates preoccupation) or how many calories they burn in a workout; frequent weighing can become obsessive; fluctuations in weight; extreme reactions to being weighed in the clinic; defensiveness; avoidance; preoccupation with cooking for others; rituals around food; upset when siblings take their food; fad diets (often begins with refusing to eat a specific food, eg, gluten, without any medical indication); patients may refuse to eat in front of others because of an eating disorder or because of social anxiety, secretive behavior; loss of pleasure in eating

Signs of eating disorders: patients with anorexia have physiologic hunger without appetite; patients with binge-eating disorder have an appetite without hunger; excessive exercise, with extreme anxiety if told to stop; body checking; delayed puberty; self-induced vomiting or avoiding the calories in toothpaste cause dental issues; it has been thought bulimia may cause a callus on the inner finger; compensating behaviors (eg, purging) may emerge during treatment; monitor for ≥1 hr after meals; speaker’s patient, overachiever, “type A” personality, with 2 sisters who have leukodystrophy and require attention; patient felt “invisible”; she described gastrointestinal complaints to mask not eating; extreme emotional response to benign comments regarding food or weight has been observed (avoid praising weight gain during recovery); deceit (especially when concerns are raised); manipulation of weigh-ins, eg, drinking water beforehand, spitting out food; if patients are not gaining weight, rule out hypermetabolism, ensure that calorie requirements are appropriate, then look for behaviors that sabotage treatment

Treatment: is complicated; wait lists are long for behavioral health experts trained in eating disorders; insurance coverage is also an issue; a physician and dietician should be involved, sometimes with a psychiatrist; patients often refuse medication if weight gain is listed as a side effect; mental health professionals who are not trained in eating disorders can sabotage progress and inadvertently reinforce behaviors; communicate with the entire team about performing blind weights and being aware that the child is trying to access their weight (eg, discharge paperwork, online portals); impose exercise restrictions and obtain support from the school, eg, eating lunch at the nurse’s office or similar monitoring; patients “split” the treatment team (ensure open communication between team members)

Treatment goals: nutritional restoration through regular structured meals and snacks supervised by a trusted adult; stopping the restriction, binge-purge, or binge cycle; engage in mindful eating to bring back appetite and enjoyment of food (there may be guilt and discomfort afterward); regulate eating habits to reduce anticipatory anxiety; reconnect with hunger and satiety cues; treat comorbidities, eg, depression, anxiety, OCD; signs of recovery can be challenging for patients, eg, nausea, feeling too full, and bloating; dietitians can explain that these physiologic reactions are temporary; focus on body strength instead of size; food is fuel, not poison; facilitate more adaptive coping techniques and greater flexibility; address illogical beliefs; avoid commenting on weight (telling patients they look “healthier” is interpreted as looking fat; not commenting when previous comments involved looking “too thin” is interpreted as having gained too much weight); advise parents to avoid praising patients when they finish meals; fear tactics do not work

Maudsley method: most supported evidence-based treatment; it focuses on restoring nutrition and weight; it empowers caregivers to follow through and change their language around food (ie, not referring to foods as “bad”); phase 1 has physician involvement; phase 2 increases the level of patient control; subsequent approach involves addressing comorbidities and triggers

Enhanced cognitive behavior therapy (CBT): focuses on predisposing, precipitating, and perpetuating factors; it anticipates setbacks (recidivism) and prepares the patient and family; it teaches adaptive coping behaviors to replace restriction

Acceptance and commitment therapy: focuses on forgiveness and decreasing shame and guilt; provides hope in anticipating recovery

Dialectical behavior therapy: looks at the intensified conflict in relationships with eating disorders

Medications: there are no FDA-approved medications for anorexia; selective serotonin reuptake inhibitors can be used to treat comorbidities that may perpetuate the behavior; off-label use includes atypical antipsychotic agents, which have been shown to facilitate weight gain in adolescents, theoretically because they increase leptin levels (typically low in anorexia); fluoxetine is approved for bulimia; lisdexamfetamine (Vyvanse) is an appetite suppressant approved for binge-eating disorder, but underlying behaviors must still be addressed; bupropion contraindicated in eating disorders because it can increase the risk for seizures

Prevention: parental education; de-emphasize a superficial focus on weight, size, and beauty; check in with parents between visits; use online support groups; perform periodic screening; encourage parents to monitor social media

Readings

Golden NH, Schneider M, Wood C, COMMITTEE ON NUTRITION, COMMITTEE ON ADOLESCENCE, SECTION ON OBESITY. Preventing obesity and eating disorders in adolescents. Pediatrics. 2016;138(3). doi:10.1542/peds.2016-1649; Heal DJ, Smith SL. Prospects for new drugs to treat binge-eating disorder: Insights from psychopathology and neuropharmacology. J Psychopharmacol. 2022;36(6):680-703. doi:10.1177/02698811211032475; Nationaleatingdisorders.org. Accessed December 15, 2022. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia; Voss MM. Eating disorders & the primary care physician. Mo Med. 2022;119(3):243-249; Ruan VA, Hartz A, Hueck M, et al. Neural mechanisms underlying social recognition and theory of mind in adolescent patients with bulimia nervosa and transdiagnostic comparison with anorexia nervosa. Eur Eat Disord Rev. 2022;30(5):486-500. doi:10.1002/erv.2911; Rosenbaum DL, Bernstein MJ. Evaluating the relationships between sexual orientation, weight-related teasing, weight bias internalization, and binge eating. Psychol Sex Orientat Gend Divers. Published online 2022. doi:10.1037/sgd0000576; Giampaolo GM, Melia DK, Donaldson AA. 159. Eating disorder outpatient clinic outcomes among an LGBTQ-identifying adolescent and young adult sample. J Adolesc Health. 2022;70(4):S83-S84. doi:10.1016/j.jadohealth.2022.01.076; Kass AE, Theim Hurst K, Kolko RP, et al. Psychometric evaluation of the youth eating disorder examination questionnaire in children with overweight or obesity: KASS et al. Int J Eat Disord. 2017;50(7):776-780. doi:10.1002/eat.22693; Presseller EK, Wilkinson ML, Trainor C, et al. Self-regulation deficits moderate treatment outcomes in a clinical trial evaluating just-in-time adaptive interventions as an augmentation to cognitive-behavioral therapy for bulimia-spectrum eating disorders. Int J Eat Disord. 2022;55(5):709-716. doi:10.1002/eat.23695; Thibault I, Pascuzzo K, Pesant C, et al. Anorexia nervosa in adolescence: a comprehensive study of multidimensional factors associated with symptom severity one year following the diagnosis. Research Square. Published online 2022. doi:10.21203/rs.3.rs-2128868/v1; Silén Y, Keski-Rahkonen A. Worldwide prevalence of DSM-5 eating disorders among young people. Curr Opin Psychiatry. 2022;35(6):362-371. doi:10.1097/YCO.0000000000000818; Datta N, Matheson BE, Citron K, et al. Evidence based update on psychosocial treatments for eating disorders in children and adolescents. J Clin Child Adolesc Psychol. Published online 2022:1-12. doi:10.1080/15374416.2022.2109650; Loni SB, Sami W, Elhaleem ZAA, et al. Prevalence of eating disorders among students of health science colleges in Majamaah university, Saudi Arabia. Pakistan Journal of Medical and Health Sciences. 2022;16(2):886-891. doi:10.53350/pjmhs22162886; Muratore AF, Attia E. Psychopharmacologic management of eating disorders. Curr Psychiatry Rep. 2022;24(7):345-351. doi:10.1007/s11920-022-01340-5.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Marcy's lecture includes off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Marcy was recorded at the Aloha Update: Pediatrics 2022, held October 15-21, 2022, on Kauai, HI, and presented by the American Academy of Pediatrics, California Chapter 2, and Children's Hospital Los Angeles Medical Group. For information about CME activities from this presenter, please visit https://www.chla.org/cme-conferences. Audio Digest thanks Dr. Marcy and the American Academy of Pediatrics, California Chapter 2, and Children's Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 2.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 2.00 CE contact hours.

Lecture ID:

PD690801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.