The Cribsiders podcast

#108: Restrictive Eating Disorders – From Assessment to Recovery

April 24, 2024 | By

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Summary:

Eating disorders are among the most challenging and consequential mental health diagnoses in pediatric medicine. Join us and Dr. Abigail Donaldson, Medical Director of the Eating Disorders Program at Hasbro Children’s Hospital, as we tackle the complexities of anorexia nervosa and other restrictive eating disorders from a clinical perspective. Tune in as we explore assessment tools, therapeutic approaches, and collaborative strategies for managing these challenging disorders in practice.


Restrictive Eating Disorder Pearls

  1. Eating disorders present across genders, ethnicities, body types, and socioeconomic statuses – beware of biases that lead to missed diagnoses. 
  2. The SCOFF Questionnaire is an easy, five-question screening tool available to help screen for disordered eating.
  3. “Significantly low body weight” may vary based on body type. Rather than focusing solely on BMI, look at change from the patient’s prior healthy body weight.
  4. Eating disorder treatment is a “three legged stool”; successful treatment requires support from medical providers, therapists, and dieticians.
  5. Monitor for bradycardia, orthostasis, and hypotension as initial signs of severe malnutrition.


Restrictive Eating Disorder Notes

Definitions & Epidemiology

  • Eating disorders is a broad class of diagnoses, including anorexia, bulimia nervosa,, unspecified feeding or eating disorder, avoidant restrictive food intake disorder, binge eating disorder, pica, and rumination disorder. Overall, these disorders reflect a change in thought patterns that prompt changes in behavior related to eating.
  • Epidemiology is difficult to obtain, but an estimated 4-8% of adolescents struggle with an eating disorder. 
  • A recent JAMA study found that 22% of children (ages 7-18) internationally had a positive screen for disordered eating.
  • Eating disorders present across genders, ethnicities, body types, and socioeconomic statuses – beware of biases that lead to missed diagnoses. 
  • One study of transgender youth found that more than 50% manipulated their weight using changes in eating and exercise behavior for gender-affirming purposes. 

Screening & Diagnosis

  • The SCOFF Questionnaire is an easy, five-question screening tool designed to help screen for disordered eating (particularly restrictive and purging behaviors). A score >2 warrants further investigation. 
  • Not all weight loss is due to an eating disorder! Consider alternative diagnoses including IBD, celiac disease, etc. It’s also ok to bring patients back to reassess when unsure. 
  • Anorexia nervosa is diagnosed based on the following criteria (from the DSM-V):
    • Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
    • Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
    • Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
  • Expert tip: “Significantly low body weight” may vary based on body type. Some criteria use BMI <17.5, but Dr. Donaldson’s team instead uses <85% of a healthy body weight for that person, where healthy weight is defined as the weight that they were healthy at before they changed their eating behaviors and started losing weight.
  • If a patient doesn’t meet all criteria for anorexia nervosa but has some of the concerning behaviors above, consider a diagnosis of unspecified feeding and eating disorder 

Physical exam

In addition to a basic exam, Dr. Donaldson emphasizes assessing the following: 

  • Orthostatic vital signs
  • Skin findings, including turgor, dryness, and acrocyanosis
  • Capillary refill

Testing

At time of diagnosis, Dr. Donaldson typically orders the following:

  • BMP (assess for critical findings, e.g., hypokalemia, which require escalation of care)
  • TSH (assess for ddx: Thyroid disease)
  • TTG IgA (assess for ddx: Celiac disease)
  • Vitamin D (optimize to protect bone health in setting of malnutrition) 
  • EKG (may defer if physical exam and vitals completely normal)

The following tests may be ordered in select cases:

  • Prolactin (in setting of vomiting to assess for ddx)
  • Amylase
  • Urine pregnancy test (in setting of amenorrhea)
  • DEXA scan (if malnourished >6 months due to risk of osteopenia)

Tips for Communicating about Weight Changes

  • When a weight or BMI loss has occurred, it can be helpful to note this change aloud and ask the patient if they have “any idea what that’s about” or if it was an intentional loss. If the patient vocalizes a change in thinking about their body, ask what changed and when the change started to occur. 
  • Rather than trying to state a diagnosis upfront, it can be helpful to simply state: “I’m worried about you and this is why.” Note changes in blood pressure, heart rate, and other objective findings that suggest malnutrition. Later in the conversation, identify the issue and next steps, (e.g., “I think you might have anorexia nervosa. And here’s how we’re gonna treat this problem.”) 
  • If the patient is resistant to the diagnosis, it is reasonable to say something along the lines of: “You’re right – I might be wrong. But I know you’re malnourished because of XX. And so in any case, you’re gonna need to eat more and you’re gonna need to rest your body so that you can recover.” 

Outpatient Management

  • Eating disorder treatment is multifaceted; successful treatment really requires support from medical providers, therapists, AND dieticians 
  • With regards to therapy, family-based treatment is the gold standard when the family can accommodate the many requirements, including having the parent take on total responsibility for feeding the child. Cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) are effective alternatives. 
  • It is essential to find therapists and dieticians who have some experience with eating disorders – some approaches not tailored to this population can actually be harmful. 
  • The medical provider’s role is primarily to monitor the patient for complications, help to keep them on track with treatment goals, and help them to see a future without the eating disorder. Initial frequency of visits may vary from every week to every 3-4 weeks depending on how stable the patient is. Be transparent with the patient and family about how you see their trajectory and emphasize that recovery can take time.
  • Approach to weighing the patient in clinic varies – it is reasonable to use strategies that limit the patient seeing their weight (e.g., weighing them backwards, removing from the visit summary), although there are therapeutic ways to involve a transparent weighing process. If you do let patients see their weights, ensure there is adequate time to discuss afterwards, and also indicate when it is time to move on from the conversation.
  • Weight gain is not the only sign of progress! Look for changes in thinking about food and exercise and celebrate these. 

Criteria for Hospitalization

  • The Society for Adolescent Health and Medicine position paper provides an excellent overview of indications for hospitalization (below)
  • There are different criteria for medical hospitalization vs psychiatric hospitalization 
  • Many patients with critical malnutrition will continue to have normal labs due to physiologic mechanisms to maintain homeostasis (e.g., metabolism of bones and muscles)
  • The most common reason for admission is critical bradycardia (HR <50 awake / <45 asleep); other frequent indications include orthostasis (HR drop >40 BPM for patient <18 yrs), hypotension, very rapid weight loss, and failure of outpatient treatment.

Inpatient Management

  • Much of the treatment centers around nutrition management. By removing the patient’s control over eating, ultimately patients may find that there is “no room for the disordered eating thoughts,” which allows them to focus on other things. Initially, however, patients may experience increased distress due to lack of control. 
  • Note that medical admission is usually fairly short (<1 week) due to insurance coverage once medically stabilized. 
  • Previously, advancing diet had been slow due to concern for refeeding syndrome. Recent research suggests that starting with a high calorie diet (2000-2500 calories/day) is generally safe and effective. This is then advanced by around 250 calories/day until they reach the patient’s target caloric intake (typically determined by the dietician).

Complications

  • Refeeding syndrome: Dangerous shifts in electrolytes as carbohydrates are reintroduced.
    • Most common in severely malnourished patients (e.g., those at <70% of their appropriate body weight) and/or with rapid weight loss (e.g., loss of >15% of body weight in 3 months). 
    • Lab findings: Hypokalemia, hypophosphatemia, hypomagnesemia, transaminitis (rapid significant increases). Possibly also hypocalcemia and hyponatremia.
    • S/sx: Edema, lung crackles, change in heart sounds
  • Watch out for psychiatric complications as the patient gains weight/stabilizes medically. 

Resources


Goal

Listeners will explain the assessment, diagnosis, management, and complications of restrictive eating disorders. 

Learning objectives

After listening to this episode listeners will…  

  1. Recognize the diagnostic criteria for anorexia nervosa.
  2. Identify screening instruments and patient-centered interview techniques to assess for restrictive eating disorders.
  3. Recall key signs, symptoms, and tests to monitor in patients with a restrictive eating disorder.
  4. Recognize findings warranting inpatient management for patients with an eating disorder. 
  5. Describe refeeding syndrome and recognize signs warranting further evaluation.

Disclosures

Dr. Donaldson reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Engel S, Raymond-Kolker B, Donaldson A, Masur S, Chiu C, Berk J. “#108: Restrictive Eating Disorders – From Assessment to Recovery”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ April 24, 2024. 


 

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Episode Credits

Producer & Writer: Sydney Engel FNP & Bec Raymond-Kolker MD
Showrunner: Sam Masur MD
Infographic: Sydney Engel FNP
Cover Art: Chris Chiu MD
Hosts: Justin Berk MD, Chris Chiu MD, Sydney Engel FNP
Editor: Clair Morgan of nodderly.com
Guest(s): Abigail Donaldson MD

CME Partner

vcuhealth

The Cribsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit cribsiders.vcuhealth.org and search for this episode to claim credit.

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