News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
December 1, 2010 — More and more children are developing eating disorders, particularly children younger than 12 years, males, and minority populations, according to a report released today by the American Academy of Pediatrics (AAP).
One reason may be the "increased focus on weight management and dieting related to increased rates of obesity," the report's lead author David S. Rosen, MD, MPH, University of Michigan, Ann Arbor, and the AAP Committee on Adolescence, told Medscape Medical News.
The concern is that some overweight children may take the message to lose weight too far "and with talk about mass [body mass index] screenings in schools, this is a concern,"Rebecka Peebles, MD, an adolescent medicine specialist at The Children's Hospital of Philadelphia, Pennsylvania, who was not involved in the report, noted in an interview with Medscape Medical News.
"What we don't know yet is what makes some kids more predisposed to develop an eating disorder than others. If we could identify those kids, then maybe we could shield them from messages about losing weight that might be too tough or tailor our messages better," Dr. Peebles added.
In counseling about nutrition, Dr. Rosen advises pediatricians to "be mindful not to encourage unhealthy dieting or focus exclusively on weight (risk factors for eating disorders) and instead emphasize healthy eating and physical activity."
New Report Updates Old
"Clinical Report – Identification and Management of Eating Disorders in Children and Adolescents," published in the December issue of Pediatrics, updates a 2007 report from the AAP on eating disorders. "There was enough new information about eating disorders to warrant an update of our previous report," Dr. Rosen said, including the following:
Increasing prevalence of illness;
Increasing prevalence in boys, younger children, and children of color;
Stronger support for a genetic role in etiology;
Importance of screening in primary care;
Better understanding of medical risks associated with eating disorders;
Increasing support for family-based outpatient treatment;
New roles for medication in the management of these disorders; and
Better prognoses than most people (including clinicians) realize.
The increasing prevalence of eating disorders at progressively younger ages is "of particular concern," Dr. Rosen and the committee note in the report. According to a recent analysis by the Agency for Healthcare Research and Quality, from 1999 to 2006, hospital admissions for eating disorders increased most sharply (by 119%) in children younger than 12 years, they point out.
Overall, it is estimated that about 0.5% of adolescent girls in the United States have anorexia nervosa, that about 1% to 2% meet diagnostic criteria for bulimia nervosa, and that up to 5% to 10% of all cases of eating disorders occur in boys.
"With younger patients and boys more frequently affected, pediatricians need to consider eating disorders more often than they did in the past," Dr. Rosen said.
The report also notes that many more children have "partial syndrome eating disorders" or "eating disorders not otherwise specified" than have anorexia nervosa or bulimia nervosa; depending on the definition used, the prevalence of partial syndrome eating disorders is estimated to be between 0.8% and 14%. These patients often experience the same physical and psychological consequences as do those who meet criteria for anorexia nervosa and bulimia nervosa.
Athletes and performers, particularly those who participate in activities that reward leanness, such as gymnastics, running, wrestling, dance, and modeling, may be at particular risk for partial syndrome-eating disorders, the report notes.
True Rise or Better Diagnosis?
"What is challenging is to know whether we are seeing a true rise in the incidence or we are just getting better at diagnosis," Dr. Peebles noted. "I don't think there are great data to tell us either way at this time," she said.
"I think that it's likely that for males especially we are getting better at recognizing them. However, clinically, I do feel that each year I do see more kids at younger ages with eating disorders," Dr. Peebles added.
She noted that, "for males, the diagnosis is often delayed because they are worked up for so many other things before being referred for an eating disorder."
Another problem, said Dr. Peebles, is that many people, both clinicians and the lay public, believe that eating disorders aren't an issue in the average young person. "They think it's only an issue in thin, rich, Caucasian females. That is simply not true from an evidenced-based standpoint," Dr. Peebles said.
In addition, "someone doesn't have to be very thin to have a very significant and serious eating disorder; that's also something that a lot of clinicians and the lay public don't always know," she said.
Call to Action
The growing problem of eating disorders in children makes it "essential for pediatricians to consider these disorders in appropriate clinical settings, to evaluate patients suspected of having these disorders, and to manage (or refer) patients in whom eating disorders are diagnosed," the AAP clinical report reads.
It suggests pediatricians screen for eating disorders at each annual checkup. "Screening questions about eating patterns and body image should be asked of all preteens and adolescents," the report states. Dr. Peebles agrees.
"Population-based studies show that the behaviors of purging, binge-eating, and dieting are exceedingly common in young people, and we probably should be screening for them," she said.
According to AAP, the SCOFF (sick, control, one, fat, food) questionnaire, "although validated only in adults, can provide a framework for screening. Any evidence of excessive weight concern, inappropriate dieting, or a pattern of weight loss requires further attention, as does primary or secondary amenorrhea or a failure to achieve appropriate increases in weight or height in growing children."