Graham Redgrave, M.D.
The teenage girl had experienced abdominal pain, dizziness, fatigue and nausea. Her initial labs from an outside hospital showed signs of metabolic alkalosis, specifically increased pH, likely triggered by low levels of hydrochloric acid, which can result from vomiting. That, along with the teen’s rapid and sudden decline in her growth chart over the previous two years – from the 75th to the 10th percentile in weight – and her inability to recall her last period, pointed to the underlying problem when she was transferred to Hopkins Children’s for management of electrolyte abnormalities.
“We were thinking eating disorder early on when we saw the amount of weight loss and the lack of menses,” reported pediatric resident Meghan Bernier at a recent Hopkins Children’s case conference. “Anyone who is purging themselves with vomiting can induce a number of electrolyte problems that can cause problems in the heart, and that’s what we were most worried about.”
The patient was treated successfully with hydration and nasogastric feeds, but such therapies would only be Band Aids without addressing the eating disorder itself. What should community pediatricians be aware of and screen for? What kind of eating disorder does the patient have? What are the origins of eating disorders, how do they present, and how do you manage them?
Psychiatrist Graham Redgrave, assistant director of the Eating Disorders Program at Johns Hopkins, likened an eating disorder patient to Odysseus facing the choice between Scylla and Charybdis. Scylla, according to Greek mythology, was a six-headed sea monster on one side of the Strait of Messina, and Charybdis a whirlpool on the other, and both swallowed sailors and ships whole. Avoid one and you face the other. In our culture, Redgrave explained, Scylla is the pervasively perceived thin ideal of a woman and Charybdis the toxic food environment of our times.
“We’ve had these increasing unhealthy models for what women are supposed to look like at the same time we’ve had increasing access to very cheap and highly caloric dense food,” said Redgrave, noting that the average weight of Playboy models and Miss Americas is close to the weight cutoff for anorexia nervosa.
The thin ideal, he added, becomes an overvalued idea that feeds a fear of fatness and drives dietary restriction and behaviors like excessive exercise, laxative abuse and forced vomiting. “The concept of ‘You can’t be too rich or too thin,’ underlies these diagnoses,” Redgrave said. “The problem is the intensity with which the problem is held. It’s not a delusion but a very strongly held idea."
Redgrave explained that for patients with eating disorders, behaviors like restricting diets and purging are not unlike scratching the itch left by a mosquito bite – it feels better when you scratch it. But the reward is only temporary. When you stop scratching the itch comes back stronger. Pediatricians, he cautioned, cannot fix the overvalued idea of thinness, though they can interrupt the behavior.
“You stop the scratching and when the itch gets worse, you support the patient through that, and then the over-valued idea tends to ease off,” Redgrave said. “We’re not very good at predicting who will do well, but we do know that people do better when we catch it early, which is why it’s very important for pediatricians to know about these conditions.”
Those conditions include anorexia, the criteria of which includes less than 85 percent of ideal body weight, a BMI (body mass index) of 17.5 or below, a fear of fatness or body image disturbance, amenorrhea of three or more months, and binging (eating a large amount of food in a discreet period of time) and purging behaviors. Bulimia nervosa includes the same fear of fatness, along with cyclical binging, purging and other compensatory behaviors like excessive exercise, though patients may appear at normal or near-normal weight. Women represent 90 percent of patients with eating disorders, with the peak onset under 20 years of age. Anorexia afflicts 0.1 to 2 percent of women in this country, bulimia up to 13 percent of college women.
“College kids come to us saying they can’t concentrate on their studies anymore because they’re burdened by constant thoughts about food, weight and shape,” Redgrave said. “What started out as a fairly normal dieting project has now blossomed into something they’ve lost control of.”
So, what raises suspicion of an eating disorder? Functional gastrointestinal disorders, pre-syncope or syncope, hyperglycemia, unexplained hypokalemia, and a BMI below 17.5. Also, pediatricians should be wary of any dramatic changes in growth charts, signs of food restriction, problems with body image, or indications of abuse, anxiety or depression. History is important, said Bernier, noting that what’s eating away at the patient will likely provide clues to the patient’s eating disorder.
“You really have to gain the patient’s trust to be able to discuss these issues,” said Bernier. “You just don’t want the information, you need the information to be able to help them.”
Also, don’t be fooled by the labs. They can be normal for a patient who is purging only once a day.
“We could have easily corrected our patient’s metabolic problems and then discharged her home if we hadn’t know what she was going through,” said Bernier. “It did take a couple of days for her to open up to us.”
For screening patients, Redgrave recommended a British questionnaire called SCOFF:
- Do you make yourself Sick (vomit) because you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you lost more than One stone ( 14 lbs) over the last 3 months?
- Do you believe yourself to be Fat when others say you are thin?
- Would you say that Food dominates your life?
Other questions include –
- Are you satisfied with your eating patterns?
- Do you ever eat in secret?
- Does your weight affect the way you feel about yourself?
- Have any of your family members suffered with an eating disorder?
- What weight would you like to be?
- What did you eat yesterday?
- How much time do you spend thinking about food, your weight and shape?
- Have you recently become vegetarian?
Pediatricians need to anticipate the typical reactions of a diagnosis, including anger, denial, rejection and rationalization. But if you believe the patient has an eating disorder, Redgrave said, inform the patient and family and make the diagnosis.
“Time and time again I hear from patients, ‘I never heard anything from my pediatrician,’” Redgrave said. “Not to knock pediatricians because we also hear this about internists and family doctors. Physicians are not making the diagnosis.”
So, how do you treat eating disorders? It’s not easy, Redgrave noted, even for patients who want help because the behaviors are rewarding. Pediatricians need to cut through the patient’s ambivalence through techniques like role induction, in which the physician acknowledges and summarizes the costs of the patient’s behaviors.
“Say to the patient, ‘You know it feels good to restrict your intake but your boyfriend broke up with you, your grades are dropping and you can’t think about anything else,’” Redgrave said.
Noting that patients tend to feel hopeless and depressed, and that anorexia is the most lethal psychiatric condition next to schizophrenia, Redgrave stressed the goal is not to blame patients and parents but to normalize the patient’s ambivalence. Stigmatize the behavior, he said, not the patient: “You can say, ‘We can’t wait for you to feel like you want to get well because things will just get worse. The longer this goes on the harder it becomes to treat.’”
Family support and modeling is critical, Redgrave noted, especially in divorced families.
“For teenagers we work with, this is probably the single biggest challenge,” Redgrave said. “A parent who is on the outs may see this as an opportunity to get back in good graces by being easy on the child.”
Management includes setting goals for normalizing weight and behaviors, and monitoring progress. Redgrave recommended a goal of gaining one to two lbs. a week until reaching a BMI of 21, and reducing binging and purging behaviors by 50 percent in the first month.
“It’s not like flicking a light switch,” Redgrave said. “You have to explain to the parents that it won’t stop overnight, but the behavior will be extinguished in a couple of months.”
Also, as disorders like anorexia and bulimia are associated with mental health conditions like anxiety and depression, reach out to a behavioral specialist. Pediatricians should refer to an inpatient eating disorders unit when the patient is below 60 percent of his or her ideal weight, a BMI below 14, or if the patient is medically unstable or suicidal.
“I don’t think any general pediatrician would try to tackle a patient like this on their own,” Bernier said. “It’s definitely a partnership between pediatrician, psychiatrist, therapist, nutritionist, and especially the family.”
For more information, call 410-955-3863, or visit the Eating Disorders Program website.