Eating disorders and the practising physician

Eating disorders are becoming increasingly prevalent among adolescents, and even preadolescents. More than 90% of patients with eating disorders are girls and more than 75% of them are adolescents when they first develop their eating disorders. About 0.5% to 1% of teenage girls develop anorexia nervosa (AN); up to 5% of older adolescents and young adults develop bulimia nervosa (BN). Milder forms of eating disorders occur in an additional 5% to 10% of postpubertal girls (1). A recent disturbing development is the increasing prevalence of dieting and eating disorders among children as young as eight years of age. Two recent Canadian studies (2,3) have shown that many Canadian teenagers are dissatisfied with their weights. A study done in British Columbia found that, by the age of 18 years, 80% of girls of normal height and weight reported that they would like to weigh less (2). Disordered eating attitudes and behaviour were present in over 27% of 1739 school girls aged 12 to 18 years who completed a questionnaire in Ontario (3). It is important for paediatricians, family physicians and other health care workers who see children and adolescents to be familiar with the clinical spectrum of eating disorders, including their ability to identify the disorders and to give appropriate treatment or arrange referrals. The present commentary does not review the topic extensively, but gives some guidelines for physicians. Some good reviews are listed at the end of this article (4–6). Two major types of eating disorders are recognized. There is a restrictive form in which food intake is limited severely (AN) or weight is manipulated through excessive exercising. These patients refuse to maintain (or in children, gain) their weights. They also have an intense fear of gaining weight and have disturbances in the ways that they perceive their weights, shapes and sizes. Some may have delayed menarche or develop secondary amenorrhoea. There is a bulimic form in which binge eating episodes are followed by attempts to minimize the effects of overeating through vomiting, catharsis, exercise or fasting (BN). There may be an overlap of AN and BN, or patients may go from one to the other. Both AN and BN are associated with serious biological, psychological and sociological morbidity, and a significant mortality (4). A review of over 100 studies has shown the serious nature of established AN. Only about 50% of patients recover fully, 30% experience partial recovery, and 20% follow a chronic and unremitting course (7). Adolescents may have a better prognosis. In another study, 76% of patients recovered fully, but over a prolonged period (57–79 months) and after very intensive treatment and follow-up (8). During the annual health maintenance examination or if there is suspicion of an eating disorder, a short pertinent history and physical examination usually confirms or excludes an eating disorder. It should be emphasized that a characteristic of these disorders is denial of any problem, and some early cases may be hard to detect. Seeing the patient together with parent(s) or guardian(s) first to obtain some of the basic history is recommended. However, it is important, especially for the adolescent, that the patient be seen alone for further history and the physical examination. This is vital in establishing confidentiality and developing a therapeutic and trusting relationship with the child or adolescent. The essentials of a brief assessment are as follows (9). History: —weight fluctuations, including recent loss or lack of increase with puberty —recent changes in eating behaviour (eg, obsessive calorie counting, restricting food intake, missing meals, becoming vegetarian, binging, purging or vomiting) —guilt and shame about eating and unusual eating habits —distorted body image (ie, a sense of weight gain when there has been none) —secretive vomiting (may leave for the bathroom immediately after a meal) —change in behaviour (more isolated, moody and irritable) —excessive exercising that is not for enjoyment, but for losing weight —menstrual dysfunction (amenorrhea or oligomenorrhea) Physical examination: –recent changes in weight —a fall-off in height percentile in younger patients —pubertal development (Tanner staging) —vital signs, especially bradycardia, hypotension and hypothermia —general examination including calluses on the back of the hands (in BN), hair changes (lanugo, thinning or loss), dental problems or parotid swelling (in BN) Laboratory assessment: —complete blood cell count (leucopenia and low erythrocyte sedimentation rate), electrolytes (especially with BN) and electrocardiogram. The differential diagnosis may necessitate a laboratory workup. It is often necessary to see the patient a few times with her or his family to be sure of the seriousness of the eating disorder and to observe his or her response to the doctor's recommendations. At the end of the assessment, some decisions need to be made. What is the diagnosis? AN, BN or milder forms? Who should manage the patient? —The primary care physician may manage early cases and assess their responses to treatment. —More severe and resistant cases may need to be referred to a multidisciplinary team that is more familiar in dealing with eating disorders. This usually includes a physician, mental health professionals and a nutritionist. —Patients with severe cases (especially with unstable vital signs) may need to be admitted to hospital. A few other pointers for the primary care provider include the following. Take a family history of eating disorders or other psychiatric disorders. Document family dieting or exercising habits. Family weights and heights may be helpful. Emphasize the social aspects of eating and encourage the family to eat together, usually for the evening meal. Healthy eating — patients should be encouraged not to cut out food groups, miss meals or be obsessed by the negativity of fat in the diet. Becoming a vegetarian may be a warning sign of an impending eating disorder. Encourage healthy exercising. It should be enjoyed, not used to lose weight. Do not make a big issue of the slightly overweight prepubertal girl because this is often normal. It is important for the paediatrician or family physician who first sees a child or adolescent with an eating disorder to have some knowledge about these conditions and to make appropriate decisions about their management. A useful resource for patients, families and professionals is the National Eating Disorder Information Centre situated in Toronto, which has publications and names of interested professionals in many parts of Canada (10,11).

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