How to tell if your patient has an eating disorder

At the 43rd National Conference on Pediatric Health Care for pediatric nurse practitioners in Dallas Texas, 2 clinicians shared their insights on how primary care providers can screen, diagnose, and treat eating disorders in children and adolescents.

"We wanted to both highlight the work we have done together at an eating disorders clinic, and share ways to address what has become a global eating disorder crisis in children," began Elizabeth Silvers, MSN, RN, CPNP-PC, PMHS, who shared the stage with Kimberly Erlich, MSN, RN, MPH, CPNP-PC, PMHS, in their joint presentation, "Don't get eaten up: Managing eating disorders in primary care"

"The rate of eating disorders (EDs) has more than doubled since 2006, and this is the psychiatric disorder with the highest fatality rate," Erlich added. "For these and other reasons, we believe it is crucial for primary care providers to learn behavioral health."

The speakers also noted COVID-19's impact on ED, with an increase in reported eating disorders increasing by more than 15% since the pandemic, and overall higher rates of nutritional restriction and functional impairment. Furthermore, untreated EDs lead to heart failure, osteoporosis, seizures, and suicide.

The role of the primary care provider is to detect, prevent progression of, and manage ED in both a co-medical and co-psychiatric setting, added Erlich. The two most common disorders are anorexia nervosa and binge eating disorder.

Screenings should include growth chart trends, vital sign abnormalities (including orthostatic vitals), and energy intake and substance use. Additionally, practitioners should become familiar with, and utilize, the EAT-26 and ChEAT/cEDE questionnaires. Additionally, primary care providers should ask their patients about body image (In asking about shape, weight or size concerns, Erlich purposely does not use the word "weight" as the first thing to ask about, as weight can be such a highly charged topic.) Patients should also be asked about their relationship with movement (as opposed to using the word exercise).

Other questions asked would be about eating patterns (with 3 meals a day plus 2 snacks being the baseline); family history of eating disorders, depression/anxiety; and "food rules" within the family (no junk food allowed in the house, the family is all-paleo diet, nongluten and/or nondairy, even when there is no medical indication, etc.)

The medical assessment would include taking all vitals, assessing growth charts (BMI does not necessarily tell the story, noted Silvers: instead, she said, look at stark shift of weight trends and weight oscillation over time.) Signs and symptoms of concern include, among others, fatigue, weakness, heart palpitations, easy bruising or bleeding, and menstrual irregularities.

Some pearls during the assessment and diagnostic stage here include noting that an orthostatic change could point to possible tachycardia. If the patient has been purging, do they see any blood in the purge, which could be Mallory-Weiss tears; and finally, look for callouses around the knuckles, often more prominent on one hand, another indication of purging. "Eating disorders affect every single sytem in the body," notes Silvers, "cardiovascular, gastrointestinal, the renal system, hematologic, endocrine, and neurologic."

If you have diagnosed your patient with a particular ED, you next need to set up a team, which should consist of yourself (the primary care provider); a therapist who regularly treats EDs; and a dietician who also specializes in EDs.

With psychiatric complications that include anxiety and depression (malnutrition has an impact on brain function), psychopharmacology intervention is key. Recommended SSRIs include fluoxetine (Prozac) and sertaline hydrochloride (Zoloft), sometimes in combination with olanzapine (Zyprexa).

Working with your team to include medical, nutritional, psychiatric, and pharmacology interventions will be your best chance of success in treating the child or adolescent that has an eating disorder.

Reference
Silvers E, Erlich K. Don't get eaten up: Managing eating disorders in primary care. 43rd National Conference on Pediatric Health Care. March 22, 2022; Dallas, Texas.