Estimates for the prevalence of eating disorders (EDs) in pediatric practice is between 0.3 and 1.6% in 2021. The data available suggests that this prevalence is significantly different than the numbers seen in actual treatment for EDs, which could indicate underdiagnosis. With changes to the way eating disorders are categorized and the COVID-19 pandemic resulting in many changes to childrens’ eating habits, stress, and environments, it’s crucial for pediatricians to readdress their efforts, from reviewing the several forms of eating disorders, to connecting families to the resources they need for long term treatment.
The Latest on Eating Disorders
The way pediatricians think about eating or food intake disorders has changed since the publication of the DSM-5 in 2013 to include a broader scope of the disorder and the variety of patient circumstances that can result in the diagnoses related to EDs apart from traditional symptoms, such as weight loss. Understanding the broader scope of how EDs can appear can help improve diagnosis and offer earlier treatment for children and adolescents.
One marked change in the DSM-5 is that amenorrhea and specific weight percentiles have been eliminated from the diagnosis of anorexia nervosa (AN). Another is that more diagnoses have been added to help pediatricians more accurately classify and treat patients. According to a January 2021 study in Pediatrics by Laurie Hornberger et al, “The diagnosis ‘eating disorder not otherwise specified’ has been eliminated, and several diagnoses have been added, including binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID).”
Researchers are also studying the interactions between adolescent obesity and EDs, as well as the effects that the COVID-19 pandemic has had on children’s eating habits and activity levels.
The AAP recommends that pediatricians remain vigilant in screening for eating disorders as children across the country struggle with changes brought on by the COVID-19 pandemic.
“Pediatricians should assess all patients for onset or worsening of obesity, food insecurity, access to fresh food, disordered eating and physical activity.” The AAP’s interim guidance, last updated in December 2020
Identify Disordered Eating in Clinical Practice
Pediatricians now recognize signs of eating disorders across genders, ethnic groups, socioeconomic status, in preadolescents, and in children with perceived normal or increased body size. Understanding that eating disorders can appear in various demographics can help pediatricians better identify EDs in their clinical practice.
The age of onset for an eating disorder in children is 12.5 years old, on average. According to Dr. Neville Golden in a presentation at the AAP’s 2020 National Conference and Exhibition, the difference in prevalence between female and male patients is 9:1, but only for young adults and teens. In children from 9 to 10 years old, the prevalence is 1:1. Eating disorders are also increasingly recognized in male patients and minority populations.
The change of demographics has led to more nuanced signs pediatricians can look for to diagnose eating disorders in their patients. These include but are not limited to:
- Significant and/or rapid weight loss, even if the patient is not clinically underweight
- Premorbidity or comorbidity with depression or anxiety disorders
- Purging, binging, or disordered eating behaviors
- Use of muscle-building supplements
- Adherence to a restrictive dietary plan, even if it is branded as healthy, such as a paleo or ketogenic diet or a dietary “cleanse”
While these signs are indicators of a possible eating disorder, EDs are important to diagnose within the context of the patient’s health and history. For example, EDs are more likely to appear in children who also have a history of substance abuse, who mature more quickly than their peers, who are a sexual minority or who are transgender, or who have a history of a chronic health condition which requires dietary control (such as diabetes, cystic fibrosis, or inflammatory bowel disease).
Disordered eating becomes even harder to identify if the patient disguises their habits or does not display otherwise traditional symptoms of disordered eating. Even diets and habits which are otherwise healthy, such as vegetarianism or training for a sport, can be signs of an eating disorder if the patient is using diet or exercise as a means to unhealthy weight loss.
With such a breadth of demographics and in circumstances, eating disorders can be difficult to diagnose, especially if concealed by the patient. This is why it’s crucial for pediatricians to adjust their expectations as to where ED can occur, and for consistent, thorough screening tools.
Eating Disorder Recovery: Coordinating Care
Annual wellness visits and sports physicals are excellent opportunities to screen for eating disorders. Visit the Bright Futures guidelines for an excellent screening guide. The first step in an eating disorder recovery care plan is a psychosocial and medical review, where the patient’s pediatrician will then decide if outpatient or inpatient care is best. The best outpatient recovery care involves coordinating with a healthcare team, the patient, and the family for the best possible support and guidance.
Depending on your practice’s resources, you may wish to coordinate care for a patient with an ED with a dietician, as well as a mental health professional such as a counselor or psychologist. Families may also find support through organizations such as the National Association of Anorexia Nervosa and Associated Disorders (ANAD), or the Academy for Eating Disorders.
While coordinating care is important, pediatricians can act as a cornerstone of the patient’s care team over their recovery period. Circumstances will vary, but beyond tracking vitals over time, providers could offer supervised care that helps fit the patients needs -- for example, taking blind vitals and weight, or offering longer visits for the patient and their family.
During these crucial conversations, pediatricians can help guide families to provide support by instructing them to avoid critical comments about body image or weight, focus on health instead of weight loss or gain, support the patient’s treatment plan, and discuss ideas about how media and culture can idealize certain body types. Pediatricians can also alert school personnel for signs to watch for, and when the practice should be called.
A renewed look at how your practice screens for eating disorders can help catch signs early, providing treatment and support for patients as soon as possible. Coordinated care takes a great team -- if you’re thinking of integrating care with another professional such as a counselor or pediatric psychiatrist, check out PCC’s ebook to learn how your practice can integrate behavioral healthcare at any budget.