Eating Disorders in Adolescents

Eating disorders are a disturbance in eating that causes physical and/or psychosocial harm. Although anyone may develop an eating disorder, athletes, females, people aged18 to 29 years, and transgender individuals are at increased risk. Eating disorders can affect the physical and mental health of adolescents and adults of all genders.

The main types of eating disorders include:

• Anorexia nervosa (AN): restriction of food intake that leads to being underweight, along with an intense fear of becoming fat or weight gain. Undue influence of body shape or weight on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.

• Binge-eating disorder: weekly episodes of eating large amounts of food past the point of being full and feeling unable to control these episodes, not accompanied by recurrent inappropriate compensatory behaviors. The binge-eating episodes are associated with three or more of the following: (1) eating much more rapidly than normal, (2) eating until feeling uncomfortably full, (3) eating large amounts of food when not feeling physically hungry, (4) eating alone because of feeling embarrassed by how much one is eating, and (5) distress regarding binge eating, feeling disgusted with oneself, depressed, or very guilty afterward.
A diagnosis is made when binge eating occurs, on average, at least once per week for three months. People with binge-eating disorder tend to be overweight or obese.

• Bulimia nervosa: at least weekly episodes of binge eating along with additional behaviors to compensate for the overeating to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. Self-evaluation is unduly influenced by body shape and weight. People with bulimia tend to be normal weight or overweight.

Less common forms of an eating disorder include avoidant/restrictive food intake disorder (apparent lack of interest in eating or food, avoidance based on the sensory characteristics of food, concern about aversive consequences of eating), and atypical anorexia nervosa with weight loss but weight remains in the normal range.

Estimates for the lifetime occurrence of eating disorders range from 0.5% to 3.5% in women and 0.1% to 2.0% in men. These may be underestimations, particularly because the prevalence of eating disorders has risen during the COVID-19 pandemic.

Consequences and complications

Eating disorders have considerable short- and long-term consequences for mental and physical health. Anorexia nervosa is the most severe eating disorder; it has a protracted course of illness and, according to one report, has the highest mortality rate among all psychiatric illnesses. Because of its severe and protracted course, AN represents a high emotional and economic burden for sufferers, carers, and society. The age of onset peaks in middle to late adolescence, which often affects educational and professional development.

Anorexia nervosa is associated with the physical consequences of starvation, including a negative impact on bone density, fractures, reduced bodily growth, and brain maturation, especially in children and adolescents. Many patients are affected by additional psychological problems. Additionally, a common strong ambivalence regarding weight gain and recovery complicates and often slows down the recovery process.

Binge eating disorder is associated with higher rates of obesity and related metabolic disorders than other eating disorders.

Bulimia nervosa is associated with complications due to purging, such as cardiovascular problems (e.g., arrhythmias and cardiac failure), electrolyte disturbances, pancreatitis,
gastric erosions or perforations, dental erosion, and kidney injury.

Eating disorders can be associated with disturbances in cognitive and emotional functioning and psychiatric conditions, such as depression, anxiety, obsessive-compulsive disorder, and substance abuse disorders. Persons with eating disorders have higher mortality rates than the general population, particularly those with anorexia nervosa.

Diagnosis and treatment

Eating disorders are diagnosed by the subject’s history and by measuring height and weight and calculating body mass index (BMI). Additional screening questionnaires are available, such as the Eating Disorder Screen for Primary Care (EDS-PC), the Screen for Disordered Eating (SDE), and the SCOFF questionnaire.

Potential harms of screening for eating disorders include false-positive results that may cause anxiety and stigma and may lead to increased medical referrals. It might also lead to unnecessary treatment with medications that can have side effects.

Because of the potential seriousness of the problem, persons suspected of having an eating disorder are typically referred to specialists for diagnostic evaluations and treatment. Treatment for eating disorders in symptomatic persons generally involves an interdisciplinary approach encompassing psychological/behavioral, medical, and nutritional components.

It often takes years for patients with AN to achieve a first remission or to recover permanently. A quarter of adult patients go on to develop an enduring form of the disorder, and one-third of patients continue to suffer from residual symptoms in the long term. The long-term outcome of adolescent-onset AN is more favorable.

Treatment may vary based on the severity of the disorder. There is some evidence that Family-Based Treatment (FBT is the most efficacious, but other useful psychological approaches include cognitive behavioral therapy, interpersonal psychotherapy, and dialectical behavior therapy. Inpatient treatment is recommended in cases with a BMI <15 kg/m2, rapid or continuing weight loss (>20% over 6 months), high physical risk, severe comorbid conditions, or denial of illness. Other guidelines for inpatient care include criteria, a BMI below the 3rd percentile or an expected body weight below 75%, an abnormally low heart rate or blood pressure, electrolyte disturbances, etc.

Treatment guidelines emphasize the importance of care in managing the risks of refeeding. Medical treatment may be needed for the complications of eating disorders, e.g., cardiac instability, musculoskeletal injury, and endocrine function.

Two medications have US Food and Drug Administration approval for treatment of an eating disorder: lisdexamfetamine for binge eating disorder treatment and fluoxetine for bulimia nervosa treatment.

Other psychotropic medications are used to treat eating disorder symptoms as well as comorbid psychiatric conditions (eg, depression and anxiety) but are not always indicated. Several guidelines suggest caution in the use of antipsychotic medications, and many guidelines emphasize the lack of evidence relating to medication use.
 
Summary:

Eating disorders in children, adolescents, and adults often are a severe disturbance of eating that causes significant physical and/or psychosocial harm. They should not be ignored, and they should be treated by health care providers with expertise in dealing with the condition.

This report presents opinions and ideas and is intended to provide helpful general information. Catalyst for Children is not engaged in rendering advice or services to the individual reader. The ideas, procedures, and suggestions that are presented are not in any way a substitute for the advice and care of the reader's own physician or other medical professional based on the reader's own individual conditions, symptoms, or concerns. If the reader needs personal medical, health, dietary, exercise, or other assistance or advice, the reader should consult a physician and/or other qualified health professionals. Catalyst for Children specifically disclaims all responsibility for any injury, damage, or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this report or participating in any programs described in this report.

References:

Jin J. Screening for Eating Disorders in Adolescents and Adults. JAMA. 2022;327(11):1100. doi:10.1001/jama.2022.2428

Feltner C, Peat C, Reddy S, et al. Screening for Eating Disorders in Adolescents and Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022;327(11):1068–1082. doi:10.1001/jama.2022.1807

US Preventive Services Task Force. Screening for Eating Disorders in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;327(11):1061–1067. doi:10.1001/jama.2022.1806

Attia E, Guarda AS. Prevention and Early Identification of Eating Disorders. JAMA. 2022;327(11):1029–1031. doi:10.1001/jama.2022.2458

Nagata JM, Golden NH. New US Preventive Services Task Force Recommendations on Screening for Eating Disorders. JAMA Intern Med. Published online March 15, 2022. doi:10.1001/jamainternmed.2022.0121

Resmark G, Herpertz S, Herpertz-Dahlmann B, Zeeck A. Treatment of Anorexia Nervosa-New Evidence-Based Guidelines. J Clin Med. 2019;8(2):153. Published 2019 Jan 29. doi:10.3390/jcm8020153

Resmark G, Herpertz S, Herpertz-Dahlmann B, Zeeck A. Treatment of Anorexia Nervosa—New Evidence-Based Guidelines. Journal of Clinical Medicine. 2019; 8(2):153. https://doi.org/10.3390/jcm8020153

Couturier, J., Isserlin, L., Norris, M. et al. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord 8, 4 (2020). https://doi.org/10.1186/s40337-020-0277-8

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