Update on the medical management of eating disorders in adolescents.

The medical practitioner has an important role to play in the management of adolescents with eating disorders, usually as part of a multidisciplinary team. This article reviews the role of the medical practitioner in the diagnosis and treatment of eating disorders, updating the reader on the changing epidemiology of eating disorders, revised diagnostic criteria, newer methods of assessing degree of malnutrition, more aggressive approaches to refeeding, and current approaches to managing low bone mass.

Anorexia nervosa and bulimia nervosa: brains, bones and breeding.

Recent research has modified both the conceptualization and treatment of eating disorders. New diagnostic criteria reducing the "not otherwise specified" category should facilitate the early recognition and treatment of anorexia nervosa (AN) and bulimia nervosa (BN). Technology-based studies identify AN and BN as "brain circuit" disorders; epidemiologic studies reveal that the narrow racial, ethnic and income profile of individuals no longer holds true for AN. The major organs affected long term-the brain and skeletal system-both respond to improved nutrition, with maintenance of body weight the best predictor of recovery. Twin studies have revealed gene x environment interactions, including both the external (social) and internal (pubertal) environments of boys and of girls. Family-based treatment has the best evidence base for effectiveness for younger patients. Medication plays a limited role in AN, but a major role in BN. Across diagnoses, the most important medicine is food.

Adolescence as a critical stage in the MCH Life Course Model: commentary for the Leadership Education in Adolescent Health (LEAH) interdisciplinary training program projects.

The Life Course Perspective (LCP), or Model, is now a guiding framework in Maternal and Child Health (MCH) activities, including training, supported by the Health Resources and Services Administration's Maternal and Child Health Bureau. As generally applied, the LCP tends to focus on pre- through post-natal stages, infancy and early childhood, with less attention paid to adolescents as either the "maternal" or "child" elements of MCH discourse. Adolescence is a distinct developmental period with unique opportunities for the development of health, competence and capacity and not merely a transitional phase between childhood and adulthood. Adequately addressing adolescents' emergent and ongoing health needs requires well-trained and specialized professionals who recognize the unique role of this developmental period in the LCP.

Beyond picky eating: avoidant/restrictive food intake disorder.

Disorders related to ingesting adequate variety and amounts of food, often dichotomized into feeding or eating disorders, depending on the need for affected individuals to be fed or to eat on their own respectively, include a wide variety of conditions. This paper focuses on disorders that are not also associated with behaviors related to weight-control or self-concept strongly influenced by body weight or shape, as seen in anorexia nervosa or bulimia nervosa. In contrast to eating disorders, there is a relatively sparse body of literature, inconsistent and confusing set of terms and definitions, and conflicting classification schemes applied to feeding/eating disturbances. A new scheme is proposed to improve clinical utility and include individuals who experience morbidities that could benefit from diagnosis and treatment, but are presently excluded from classification. Key research findings are highlighted, and core clinical features regarding diagnosis and treatment are detailed. Two illustrative cases frame the clinical aspects of these conditions.

Calculation of expected body weight in adolescents with eating disorders.

OBJECTIVE: To examine the agreement between three methods to calculate expected body weight (EBW) for adolescents with eating disorders: (1) BMI percentile, (2) McLaren, and (3) Moore methods. METHODS: The authors conducted a cross-sectional analysis of baseline information from adolescents seeking treatment of disordered eating at The University of Chicago. Adolescents (N = 373) aged 12 to 18 years (mean = 15.84, SD = 1.72), with anorexia nervosa (n = 130), bulimia nervosa (n = 59), or eating disorder not otherwise specified (n = 184). Concurrence between the BMI percentile, McLaren, and Moore methods was assessed for agreement above or below arbitrary cut points used in relation to hospitalization (75%), diagnosis (85%), and healthy weight (100%). Patterns of absolute discrepancies were examined by height, age, gender, and menstrual status. Limitations to some of these methods allowed comparison between all 3 methods in only 204 participants. RESULTS: Moderate agreement was seen between the 3 methods (κ values, 0.48-0.74), with pairwise total classification accuracy at each cut point ranging from 84% to 98%. The most discrepant calculations were observed among the tallest (>75th percentile) and shortest (<20th percentile) cases and older ages (>16 years). Many of the most discrepant cases fell above and below 85% EBW when comparing the BMI percentile and Moore methods, indicating disagreement on possible diagnosis of anorexia nervosa. CONCLUSIONS: These methods largely agree on percent EBW in terms of clinically significant cut points. However, the McLaren and Moore methods present with limitations, and a commonly agreed-upon method for EBW calculation such as the BMI percentile method is recommended for clinical and research purposes.

Feeding and eating disorders in childhood.

OBJECTIVE: To review the literature related to the current DSM-IV-TR diagnostic criteria for feeding disorder of infancy or early childhood; pica; rumination disorder; and other childhood presentations that are characterized by avoidance of food or restricted food intake, with the purpose of informing options for DSM-V. METHOD: Articles were identified by computerized and manual searches and reviewed to evaluate the evidence supporting possible options for revision of criteria. RESULTS: The study of childhood feeding and eating disturbances has been hampered by inconsistencies in classification and use of terminology. Greater clarity around subtypes of feeding and eating problems in children would benefit clinicians and patients alike. DISCUSSION: A number of suggestions supported by existing evidence are made that provide clearer descriptions of subtypes to improve clinical utility and to promote research.

Do physicians discuss needed diet and nutrition health topics with adolescents?

PURPOSE: Preventive services guidelines recommend screening all adolescents for diet habits, physical activity and growth, counseling underweight teens about body image and dieting patterns, and counseling overweight or obese teens about dietary habits and exercise. In this study, we assess whether adolescents at risk for overweight or for eating disorders have discussed recommended diet and nutrition topics with their physicians. METHODS: We surveyed 14-18-year-old adolescents who had been seen for well care in primary care pediatric and family medicine practices. Adolescents self-reported their weight, height, body image, dieting habits, and issues they had discussed with their clinicians. Body mass index (BMI) was used to define those "at risk for an eating disorder" (< 5% BMI), "at risk of becoming overweight" (85%-95% BMI), and "overweight" (> 95% BMI). RESULTS: A total of 8384 adolescents completed surveys (72% completion rate). Nearly one-third of adolescents were "at risk" or overweight. Females were less likely to be overweight than males (9.4% vs. 15.7%; p < .001). Although 26.4% were attempting to lose weight, only 12.2% of all teens were actually overweight. Exercise and restricting intake were the preferred methods of weight loss. Physicians routinely discussed adolescents' weight during visits, and were more likely to discuss it with those "at risk" (p < .001). Body image was more often discussed with girls than with boys (52% vs. 44.6%, p < .001) and with those at risk (51.6% vs. 45.5%; p < .001). Discussion of healthy eating and weight loss occurred more often with adolescents "at risk" for becoming overweight (p < .001). CONCLUSIONS: Many adolescents are at risk for being overweight or are currently overweight, confirming the importance of clinicians discussing diet and nutrition health topics with all teens. Many adolescents also misclassify their body image, and hence perceive their body image to be different from their actual BMI; clinicians should discuss body image with all adolescents, not just those at risk for eating disorders. Better interventions are needed to promote healthy nutrition and physical activity to all adolescents.

The biopsychosocial approach to adolescents with somatoform disorders.

Somatoform disorders are presented in the first article in this issue of Adolescent Medicine Clinics because the physical symptoms that cause the adolescent to present for diagnosis and treatment reflect the interaction of the psyche and the soma in ways that are poorly understood. Because of dualistic conceptualizations that are encouraged by technology such as MRI, CT scans and other technologically advanced tools, patients who have these conditions often suffer. As noted by Cassell [35], "suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity." Clinicians who care for adolescents who have somatic complaints also suffer when they are unable to provide relief of an adolescent's suffering. Cassell [36] noted that "physicians are less skilled at what were once thought to be the basic skills of doctors-discovering the history of an illness though questioning and physical examination, and working toward healing the whole person." The biopsychosocial approach offers a means of working toward healing the whole person, and the focus of this article is on practical solutions to difficult challenges that are presented by adolescents and their families.

Macromastia as an etiologic factor in bulimia nervosa: 10-year follow up after treatment with reduction mammaplasty.

Patients with psychologic diagnosis such as eating disorders have been automatically disqualified as candidates for plastic surgery. We have previously reported on a cohort of women with bulimia nervosa who presented with symptomatic macromastia. All patients reported that dysfunctional eating habits where in part the result of breast enlargement. Five patients underwent reduction mammaplasty and postoperatively reported relief of physical symptoms and improvement in psychologic well-being. Symptoms of eating disorders were completely eliminated or greatly reduced. The aim of the current study is to evaluate the degree of long-term postoperative satisfaction and recovery from eating disorders. Patients participating in the original study were contacted for long-term follow-up telephone survey. Data regarding current physical symptoms, body dissatisfaction, and eating attitudes measured by the Eating Attitude Test-26 (EAT-26) questionnaire was obtained. A statistical analysis was performed. Data was obtained from 4 patients. All patients maintained consistent recovery from their eating disorder. A statistically significant improvement in eating attitudes was found when comparing pre- and postoperative data obtained from the EAT-26. Comparing body dissatisfaction, pain, and physical symptoms, we found an overall consistent improvement in subjective scoring. Macromastia can produce a distortion of body image and become a secondary cause of eating disorders. Surgical correction of macromastia can correct physical symptoms, improve body image, and lead to permanent amelioration of associated eating disorders. This could, in part, represent a surgical treatment of a psychologic abnormality. Consequently, the presence of an eating disorder should not automatically exclude a woman from surgical consideration.

The role of the primary care practitioner in the treatment of eating disorders.

This article addresses practical issues facing the primary care practitioner caring for an adolescent with an eating disorder. It is grounded in the four elements of successful treatment noted by Comerci: (1) recognizing the disorder and restoring physiologic stability early in its course, (2) establishing a trusting, therapeutic partnership with the adolescent, (3) involving the family in treatment, and (4) using an interdisciplinary team approach. Although primary care practitioners often have an established relationship with their patients, adolescents with eating disorders present special challenges. These adolescents tend to be bright, strong-willed, and wary of any recommendations to change their weight-control practices for fear that they will lose control. Their families are often distraught by the conflicts that arise as a result of the disordered eating behaviors and the fear that the condition is associated with significant morbidity and mortality. The article provides primary care clinicians with pragmatic ways to diagnose and initiate treatment and engage the patient and parents as active participants and members of the therapeutic team in the early phases of treatment. In addressing these principles, the authors combine the nurturant-authoritative approach described by Levenkron with the biopsychosocial model proposed by Engel.