Anorexia nervosa among children and adolescents

A scoping review of the role of primary care providers and primary care-based interventions in the treatment of pediatric eating disorders

Youth with eating disorders are often cared for by specialized interdisciplinary teams in pediatric tertiary care centers. Enhanced involvement of primary care providers may provide added benefits to patients because it offers improved access, better continuity of care, and possibly less financial burden. This paper aims to synthesize and assess the literature on the role of the primary care provider in treating pediatric eating disorders in order to identify an optimal model of shared care. Sources were identified by entering search terms in 10 databases. Eligible sources were English publications focusing on primary care-based interventions for eating disorders in youth (=<24 years). The search yielded 5,516 unique citations. Of these, 61 were ultimately included. Sources fell into two categories: (1) primary research (n = 3) and (2) reviews with recommendations for primary care providers (n = 58). The primary studies considered the primary care provider conducting behavioral therapy and guided self-help. Review articles suggested providing education, assessing for hospitalization, aiding in weight restoration, managing complications, referring, and coordinating care. Limited evidence exists that can guide effective primary care-based interventions for the treatment of pediatric eating disorders. Further research is needed to develop and evaluate interventions for the treatment of pediatric eating disorders in primary care settings so that best practices can be identified.

The coexistence of psychiatric and gastrointestinal problems in children with restrictive eating in a nationwide Swedish twin study

BACKGROUND

Restrictive eating problems are rare in children but overrepresented in those with neurodevelopmental problems. Comorbidities decrease wellbeing in affected individuals but research in the area is relatively scarce. This study describes phenotypes, regarding psychiatric and gastrointestinal comorbidities, in children with restrictive eating problems.

METHODS

A parental telephone interview was conducted in 9- or 12-year old twins (n = 19,130) in the Child and Adolescent Twin Study in Sweden. Cases of restrictive eating problems and comorbid problems were established using the Autism, Tics-AD/HD and other Comorbidities inventory, parental reports of comorbidity as well as data from a national patient register. In restrictive eating problem cases, presence of psychiatric and gastrointestinal comorbidity was mapped individually in probands and their co-twin. Two-tailed Mann-Whitney U tests were used to test differences in the mean number of coexisting disorders between boys and girls. Odds ratios were used to compare prevalence figures between individuals with or without restrictive eating problems, and Fisher exact test was used to establish significance.

RESULTS

Prevalence of restrictive eating problems was 0.6% (concordant in 15% monozygotic and 3% of dizygotic twins). The presence of restrictive eating problems drastically increased odds of all psychiatric problems, especially autism spectrum disorder in both sexes (odds ratio = 11.9 in boys, odds ratio = 10.1 in girls), obsessive-compulsive disorder in boys (odds ratio = 11.6) and oppositional defiant disorder in girls (odds ratio = 9.22). Comorbid gastrointestinal problems, such as lactose intolerance (odds ratio = 4.43) and constipation (odds ratio = 2.91), were the most frequent in girls. Boy co-twins to a proband with restrictive eating problems generally had more psychiatric problems than girl co-twins and more girl co-twins had neither somatic nor any psychiatric problems at all.

CONCLUSIONS

In children with restrictive eating problems odds of all coexisting psychiatric problems and gastrointestinal problems are significantly increased. The study shows the importance of considering comorbidities in clinical assessment of children with restrictive eating problems.

A family-based eating disorder day treatment program for youth: examining the clinical and statistical significance of short-term treatment outcomes

This article describes an innovative family-based day treatment program (DTP) for youth with moderate to severe eating disorders. A sample of 65 youth completed a battery of psychological measures pre- and post-treatment and 6 months after program completion. Treatment outcomes were assessed in three main domains: (a) medical stabilization, (b) normalization of eating behavior, and (c) improved psychological functioning. Overall, patients demonstrated statistically significant and clinically meaningful improvements on all outcome measures. Findings indicate that a comprehensive DTP can successfully facilitate positive outcomes in youth with eating disorders and that these improvements can be maintained 6 months post-treatment.

Design and implementation of the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study

OBJECTIVE

To provide an overview of the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) design, with particular attention to its quality control procedures. Other important methodological aspects are described in detail throughout this supplement.

DESIGN

Description of the HELENA-CSS sampling and recruitment approaches, standardization and harmonization processes, data collection and analysis strategies and quality control activities.

RESULTS

The HELENA-CSS is a multi-centre collaborative study conducted in European adolescents located in urban settings. The data management systems, quality assurance monitoring activities, standardized manuals of operating procedures and training and study management are addressed in this paper. Various quality controls to ensure collection of valid and reliable data will be discussed in this supplement, as well as quantitative estimates of measurement error.

CONCLUSION

The great advantage of the HELENA-CSS is the strict standardization of the fieldwork and the blood analyses, which precludes to a great extent the kind of immeasurable confounding bias that often interferes when comparing results from isolated studies.

The effect of bed rest on bone turnover in young women hospitalized for anorexia nervosa: a pilot study

CONTEXT

Malnourished adolescents with anorexia nervosa (AN) requiring medical hospitalization are at high risk for skeletal insults. Even short-term bed rest may further disrupt normal patterns of bone turnover.

OBJECTIVE

The objective of the study was to determine the effect of relative immobilization on bone turnover in adolescents hospitalized for AN.

DESIGN

This was a short-term observational study.

SETTING

The study was conducted at a tertiary care pediatric hospital.

STUDY PARTICIPANTS

Twenty-eight adolescents with AN, aged 13-21 yr with a mean body mass index of 15.9 +/- 1.8 kg/m(2), were enrolled prospectively on admission.

INTERVENTION

As per standard care, all subjects were placed on bed rest and graded nutritional therapy.

MAIN OUTCOME MEASURE

Markers of bone formation (bone specific alkaline phosphatase), turnover (osteocalcin), and bone resorption (urinary N-telopeptides NTx) were measured.

RESULTS

During the 5 d of hospitalization, serum osteocalcin increased by 0.24 +/- 0.1 ng/ml . d (P = 0.02). Urine N-telopeptides reached a nadir on d 3, declining -6.9 +/- 2.8 nm bone collagen equivalent per millimole creatinine (P = 0.01) but returned to baseline by d 5 (P > 0.05). Bone-specific alkaline phosphatase exhibited a decline that was strongly age dependent, being highly significant for younger subjects only [age 14 yr: -0.42 +/- 0.11 (P = 0.0002); age 18 yr: -0.03 +/- 0.08 (P = 0.68)]. Age had no effect on other outcome measures.

CONCLUSION

Limitation of physical activity during hospitalization for patients with AN is associated with suppressed bone formation and resorption and an imbalance of bone turnover. Future interventional studies involving mechanical stimulation and/or weight-bearing activity are needed to determine whether medical protocols prescribing strict bed rest are appropriate.

National athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes

OBJECTIVE

To present recommendations for the prevention, detection, and comprehensive management of disordered eating (DE) in athletes.

BACKGROUND

Athletes with DE rarely self-report their symptoms. They tend to deny the condition and are often resistant to referral and treatment. Thus, screenings and interventions must be handled skillfully by knowledgeable professionals to obtain desired outcomes. Certified athletic trainers have the capacity and responsibility to play active roles as integral members of the health care team. Their frequent daily interactions with athletes help to facilitate the level of medical surveillance necessary for early detection, timely referrals, treatment follow-through, and compliance.

RECOMMENDATIONS

These recommendations are intended to provide certified athletic trainers and others participating in the health maintenance and performance enhancement of athletes with specific knowledge and problem-solving skills to better prevent, detect, and manage DE. The individual biological, psychological, sociocultural, and familial factors for each athlete with DE result in widely different responses to intervention strategies, challenging the best that athletics programs have to offer in terms of resources and expertise. The complexity, time intensiveness, and expense of managing DE necessitate an interdisciplinary approach representing medicine, nutrition, mental health, athletic training, and athletics administration in order to facilitate early detection and treatment, make it easier for symptomatic athletes to ask for help, enhance the potential for full recovery, and satisfy medicolegal requirements. Of equal importance is establishing educational initiatives for preventing DE.

Bone cross-sectional geometry in adolescents and young women with anorexia nervosa: a hip structural analysis study

INTRODUCTION

Better characterization of bone geometry in adolescents with anorexia nervosa (AN) may improve understanding of skeletal deficits in this population. Our objective was to determine whether hip cross-sectional geometry and bone strength were altered in adolescents with AN.

METHODS

Measurements of the left total proximal femur and body composition were obtained in 85 adolescents with AN and 61 healthy controls by dual X-ray absorptiometry. The Hip Structural Analysis (HSA) program was used to determine aBMD, cross-sectional area (CSA), and section modulus (Z) at the femoral neck and shaft. Strength indices were calculated and corrected for lean mass.

RESULTS

Femoral neck and shaft aBMD were lower in AN patients than healthy controls (-36% and -29%, p < 0.001). In both regions, bone CSA and Z were lower in AN sufferers (-11 to -35%, p < 0.001). While lean body mass correlated with HSA variables (r = 0.48 to 0.58, p < 0.001), body fat did not. AN sufferers had lower indices of both whole bone strength (-40%, p < 0.001) and relative bone strength (-36%, p < 0.001) than controls.

CONCLUSIONS

Anorexia nervosa sufferers had decreased resistance to axial (CSA) and bending loads (Z) compared with healthy controls. Differences in strength properties were significant even when adjusted for lean mass, suggesting that not only decreased mechanical loading, but also known metabolic differences are likely responsible for deficits in bone strength in these patients.

Hospitalization of children and adolescents for eating disorders in the State of New York

PURPOSE

To examine hospitalization patterns, length of stay, cost and insurance status for children and adolescents with Eating Disorders.

METHODS

A cross-sectional study was conducted of patients with eating disorders aged 9 to 17 years, discharged from hospitals in the State of New York in 1995. All patients discharged in the state were registered by the State Planning and Research Collaborative System (SPARCS). A subset was identified based on coding by the International Classification of Diseases (ICD) for Anorexia Nervosa, Bulimia and Eating Disturbance Not Otherwise Specified. The Statistical Analysis System (SAS) was used for data analysis. The variables selected were gender, ethnicity, insurance status and length of stay.

RESULTS

In one year there were 352 hospitalizations, 312 females (88.6%) and 40 males (11.4%); 279 Caucasians (79.3%), 35 African Americans (9.9%), and 38 Other (10.8%); commercial insurance 246 (69.9%), Medicaid 68 (19.3%), other 38 (10.8%). The diagnostic categories were Anorexia Nervosa 242, Bulimia 59, and Eating Disturbance Not Otherwise Specified 63 (reflecting dual diagnosis in 13). Mean length of stay was 18.43 days, the median was 7 days. The cost per stay ranged between 341.78 dollars and 148,471 dollars; with a median of 3817 dollars and a mean of 10,019 dollars. Length of stay was not influenced by gender, age, or ethnicity; only payor status, availability of insurance, was dominant.

CONCLUSIONS

This is the first statewide report on hospitalization of children and adolescents for eating disorders. The mean cost in 1995 exceeded 10,000 dollars. A correlation was found between length of stay and insurance status. Hospitalizations for eating disorder have a significant public health impact, calling for the formulation of fair and rational strategies to optimize care.