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norexia has the highest mortality rate of any mental illness. One in five anorexic deaths is by suicide, and it is the third most common chronic illness among adolescents. Over the past decade, the incidence of eating disorders (EDs), anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), has increased among children under 12 and as young as 5, with a hospital admission increase of 119%. The true incidence may be skewed due to under diagnosis, a scarcity of studies, and the new DSM V which includes patients who previously would not have met diagnostic criteria. The general prevalence in adolescents of AN, BN, and BED are 0.3%, 0.9%, and 1.6% respectively, with a mean age of onset of 12.5 years and an overall prevalence of 2.7%. Unfortunately, EDs continue to be under and misdiagnosed by physicians. With a fivefold increase in mortality risk for all EDs, it is imperative that physicians queue into the subtle signs and symptoms of eating disorders in children to diagnose these patients at disease onset maximizing their chance of full recovery. The misdiagnosis of EDs is multifactorial. Patients with EDs are often secretive due to shame or fear and will not disclose their behaviors. Others take pride in their ED and do not see the disorder as problematic.

Additionally, the medical complications of anorexia are often silent and present late in the disease process. Electrocardiogram (EKG) and laboratory values are often normal until a patient is near death. Other symptoms such as constipation, orthostasis, bradycardia, dry skin, hair loss, amenorrhea, fatigue, and inattention mimic other disorders and are sent for subspecialist evaluation, or treated empirically as common childhood ailments. This leads to a litany of diagnoses rather than the unifying diagnosis of an eating disorder. A thorough review of a child’s growth charts should be done at every visit while the patient is present. Any subtle changes in weight, stature, or BMI should lead the physician to question the patient further regarding EDs. Patients with slight changes should be reevaluated within a month and referred for further care with a dietician and mental health provider. Societal norms, cultural bias towards thinness, and genetics all play a role in the masking of eating disorders making an accurate diagnosis more complicated. If a child appears thin and looks like their thin mother who secretly has an ED, healthcare providers may assume a family resemblance and not pursue specific questioning. The parent with the ED will not be forthcoming with eating disordered behaviors, 50% - 80% of the risk for AN is genetic. If there is a family history of an ED, a patient is 7-12 times more likely to develop one. Children diagnosed with chronic illness, such as insulindependent diabetes mellitus or mental illness are also at increased risk. Questioning the family history beyond hypertension, diabetes and cancer is paramount. Physicians should ask about a family history of EDs, mental illness and weight loss. If these are present, physicians should pursue targeted questions about personal and familial exercise habits, diets, food rules and weight standards. Unless a physician asks, dangerous behaviors will persist until a significant medical complication occurs. Physician bias and the previous misconception that EDs are diseases of non-Hispanic white, affluent adolescent girls, gymnasts, wrestlers, and ballerinas puts adolescents at risk for misdiagnosis. Current research demonstrates eating disorder behaviors in all racial and ethnic groups, lower socioeconomic classes and males. There are also increased rates of disordered eating in sexual minority youth with up to 16 times the rate of EDs than their cisgender, heterosexual female peers. The recognition and consideration of EDs in these populations would significantly decrease the morbidity and mortality of EDs. Patients in larger bodies are a unique population that deserves special consideration. These adolescents experience damaging influences through media, adults, and peers resulting in depression, anxiety and poor self-image. Weight stigma results in these patients being overlooked or triggered when health care providers stress weight loss, Initial attempts to lose weight may progress to severe dietary restriction, starvation, self-induced vomiting, diet pill and laxative abuse. Patients with BMIs in the normal to obese range may have significant EDs and are at risk for the same severe medical complications as their underweight peers. A study of adolescents seeking treatment of an ED states that 36.7% had a previous weight greater than the 85th percentile for age and sex. To prevent a delay in diagnosis for these patients, clinicians should offer a sensitive approach that allots appropriate time to address the health concerns of obesity and EDs. Patients in larger bodies or with high BMIs should be referred to registered dieticians trained in EDs who know the science behind weight records, can recommend and monitor weight loss or gain. In combination with mental health therapy, family therapy, and medical management, these patients have improved outcomes. The medical outcome data is clear; early detection, diagnosis, and intervention in EDs leads to better prognosis and even full recovery in adolescent patients. Most medical complications are re - versible, and this population can grow into adulthood without negative sequalae. More advanced cases of ED are not as likely to achieve recovery and face long-term health consequences such as osteoporosis, stunted growth, cognitive dysfunction, chronic gastrointestinal issues, persistent mental illness and frequent relapse. Primary care physicians with high indexes of suspicion and knowledge of eating disorders are key to the diagnosis and play a pivotal role in the treatment of ED patients. Working closely with nutritional experts and mental health professionals to break down the stigma of EDs and provide the best treatment to those affected will improve future outcomes for this underrecognized patient population.

References

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Noel C. Ales, DO is a Board-Certified Internist and the staff physician at Esperanza Eating Disorder Center in San Antonio, Texas. She is a member of the Bexar County Medical Society (BCMS).