Rakel: Textbook of Family Medicine, 7th

ed.
Copyright © 2007 Saunders, An Imprint of Elsevier

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EATING PROBLEMS EATING PROBLEMS
KEY POINTS
•    When entertaining a diagnosis of feeding disorder, consultation with a physician
familiar with growth problems in children should be considered because the
  
differential diagnosis is extensive and includes many metabolic syndromes, child
abuse, and neglect.
•    The long-term mortality rate for anorexia nervosa is 6% to 20%, the highest rate for
  
any psychiatric disorder.
•    The most useful measure to assess for extreme weight loss in adolescents is a body
  
mass index (BMI) adjusted for age that is less than the fifth percentile.
•    For anorexia nervosa, vomiting is a poor prognostic feature; for bulimia nervosa,
  
the use of purgatives is a poor prognostic feature.
•    Patients with eating disorders should be managed by a multidisciplinary team that
  
includes a primary physician, a mental health professional, and a nutritionist.
Background

The eating disorders are included last because the most common and serious ones, anorexia
nervosa and bulimia nervosa, typically have their onset in adolescence. However, several
eating problems are associated with infants and children.

Feeding and Eating Disorders of Infancy and Early Childhood

Feeding difficulties are common in infants and young children. Most are minor and self-
limited and can be addressed through education and reassurance of caregivers. However,
physicians must be alert for specific feeding and eating disorders that can lead to
malnutrition or chronic toxicity from ingested substances. The most important of these is
listed in DSM-IV-TR as “Feeding Disorder of Infancy or Early Childhood.” The diagnosis
has previously been described as psychosocial failure to thrive and as psychosocial
dwarfism. The key feature of the diagnosis is that the child fails to gain weight
appropriately over a prolonged period of time, not fully explained by a gastrointestinal,
endocrinologic, or neurologic condition. Of children admitted to the hospital for failure to
thrive, as many as half have a psychosocial etiology.

The other important consideration in this category is pica, the persistent eating of
nonnutritive substances, such as hair, soil, paint, animal droppings, or sand. Pica can lead to
vitamin deficiencies, lead or other heavy metal intoxication, phytobezoar, and other
complications. The prevalence of pica is not certain but it is probably fairly common in
preschool children and especially so in mentally retarded persons.

Assessment and Management

The most important aspect in assessing feeding difficulties in infants and children is
tracking height and weight with each office visit. Children who are not maintaining
expected gains should be observed more closely, keeping in mind that feeding problems in
a significant percentage of these children have a psychosocial basis. The diagnosis of
feeding disorder is suggested by improvement in feeding and weight gain following a
change in caregivers. When a diagnosis of feeding disorder is entertained, consultation with
a physician familiar with growth problems in children should be considered. This is
because the differential diagnosis for growth problems is extensive and the implications for
a diagnosis of feeding disorder include child abuse and neglect.

The important aspect in assessing for pica is to ask about it. Then, the evaluation and
treatment depend on the specific substance ingested and symptoms the child exhibits, if
any.

Anorexia Nervosa and Bulimia Nervosa

In adolescent girls, eating disorders are the third leading chronic illness, behind obesity and
asthma. The number of young people with eating disorders (anorexia nervosa or bulimia
nervosa) and eating disturbances (some but not all criteria for diagnosis of a disorder) is
increasing. This is due to a combination of improved recognition and reporting as well as
an apparent true increased incidence. About 95% of patients are female, and the prevalence
of eating disorders has been directly correlated to the rates of dieting behavior. High-risk
groups include female athletes and diabetic adolescents.

A person with anorexia nervosa refuses to maintain a minimally normal body weight, is
very fearful of gaining weight, and exhibits a distorted self body image. If she is
postmenarcheal, she is amenorrheic. The long-term mortality rate for anorexia nervosa is
6% to 20%, the highest rate for any psychiatric disorder ( Roerig et al, 2002 ).

Bulimia nervosa is characterized by binge eating and inappropriate compensation attempts

to avoid weight gain, such as self-induced vomiting, misuse of laxatives or diuretics,
fasting, or excessive exercise. The prevalence of bulimia nervosa is 1% to 3% in
adolescents and young women. It is more common but less often fatal than anorexia
nervosa ( APA, 2000 ).

Assessment

A prime objective in assessment is to distinguish normal dieters from persons with eating
disorders. Normal dieters typically tell those around them that they are dieting, seeing it as
something to be proud of. In contrast, patients with eating disorders are usually reluctant to
discuss their diets even when it is obvious to those around them that they are restricting
their intake. When normal dieters achieve their weight loss goal, they want to show off
their new body, often in new and more revealing clothes or situations (e.g., a new swimsuit
or sunbathing). Usually, girls with eating disorders avoid exposing their bodies, often
hiding it with baggy clothing, or they regard their physical dimensions with disgust, no
matter how much weight they lose. Normal dieters regulate their intake by internal cues and
the rules of their diet plan. Those with eating disorders may use external cues, like eating
less than the person at the table who eats the least, to avoid feeling selfish or gluttonous.
Normal dieters exhibit a feeling of accomplishment and a rise in self esteem when they
achieve their planned weight loss. Those with eating disorders tend to become self-critical,
often depressed or irritable, and avoid social occasions. Patients with eating disorders have
a pathological reaction to weight gain. To explore this possibility, a useful question to ask
is, “What would it be like to find you weighed one pound more next week when you get on
the scales?” This can provoke an overly emotional response in a person with an eating
disorder ( Selzer et al, 1995 ).

Another important aspect to evaluation is to exclude certain medical conditions in the

differential diagnosis as the primary cause of the symptoms. Included are such diverse
problems as inflammatory bowel disease, hyperthyroidism, chronic infections, diabetes
mellitus, and Addison's disease. The erythrocyte sedimentation rate (ESR) and serum
albumin tend to remain normal in eating disorders, so an elevated ESR or a reduced
albumin point to an organic cause for weight loss ( Selzer et al, 1995 ).

It is important to assess the acuteness and severity of malnutrition or fluid and electrolyte
abnormalities. Indications for immediate referral include any patient with abnormal
findings on physical exam or lab studies because these indicate severe and entrenched
eating disorders. Laboratory studies should include a complete blood count, electrolytes,
magnesium, calcium, phosphorus, urea nitrogen, creatinine, glucose, albumin, and
electrocardiogram ( Walsh et al, 2000 ).

Extreme weight loss is difficult to define in growing adolescents. The usual criteria of less
than 85% of average body weight (ABW) or a body mass index (BMI) of less than 17.5
kg/m2 used in adults to diagnose anorexia nervosa can be misleading. The most clinically
useful measure is the BMI percentile adjusted for age ( Hebebrand et al, 1996 ). A reading
less than the fifth percentile is considered extreme ( Selzer et al, 1995 ). For anorexia
nervosa, the presence of vomiting is a poor prognostic feature and for bulimia nervosa, the
use of purgatives indicates a poor prognosis ( Wilhelm and Clarke, 1998 ).

Management

Indications for inpatient management include “extremely low weight (<75% of expected
body weight) or rapid weight loss; severe electrolyte imbalances, cardiac disturbances, or
other acute medical disorders; severe or intractable purging; psychosis or a high risk of
suicide; and symptoms refractory to outpatient treatment” ( Becker et al, 1999 ).

Patients with eating disorders should be managed by a multidisciplinary team that includes
a primary physician, a mental health professional, and a nutritionist. Family physicians
should be aware of the resources available in their area and be prepared to refer any
adolescent whom they suspect of an eating disorder or any adolescent with abnormal eating
behavior who does not respond to initial efforts at diet education.

Various antidepressants are effective for treating bulimia nervosa but they have not shown
definite benefit for anorexia nervosa ( Roerig et al, 2002 ). Cognitive-behavioral therapy
has been shown to be the most effective psychological approach to bulimia nervosa ( RCT,
Walsh et al, 2000 ).

Little is known of the effectiveness of primary prevention of eating disorders. For now,
physicians should include questions about risk factors for eating disorders as a standard part
of their evaluation of adolescents. These include eating habits, diet, exercise, menstruation,
sexual activity, body image, drug use, and family relationships.