Eating disorders in primary care: a guide to identification and treatment
Douglas G. Kondo, MD; Mae S. Sokol, MD
WEB EXCLUSIVE / NOVEMBER 2003 / POSTGRADUATE MEDICINE
CME learning objectives
- To recognize the types of eating disorders that occur in children and adolescents
- To understand the medical complications of eating disorders
- To become familiar with the major therapeutic methods used to treat eating disorders
The authors have received funding from the Menninger Foundation Child and Family Center, an American Medical Association Foundation seed grant, and the John A. Wiebe, Jr Children’s Healthcare Fund. They disclose unlabeled uses of selective serotonin reuptake inhibitors, antibiotics, and immunomodulatory therapy for anorexia nervosa as well as tricyclic compounds, monoamine oxidase inhibitors, and ondansetron hydrochloride for bulimia nervosa.
Preview: Awareness of the signs and symptoms of eating disorders is essential for primary care physicians who work with children, adolescents, and young adults. In this article, Drs Kondo and Sokol describe the clinical manifestations of eating disorders such as anorexia nervosa, bulimia nervosa, and binge-eating disorder, which usually occur in adolescence and early adulthood, and pica and rumination disorder, which are more characteristic of infancy and early childhood. The authors also discuss risk factors for and medical complications of eating disorders and present current treatment methods.
Kondo DG, Sokol MS. Eating disorders in primary care: a guide to identification and treatment. Postgrad Med 2003;114:Nov (online article)
Primary care physicians have an important role in the detection and management of eating disorders, which affect an estimated 5 million persons in the United States each year (1). As defined in the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (2), eating disorders fall into two categories–those of infancy or early childhood (ie, pica, rumination disorder, and feeding disorder of infancy or early childhood) and those usually observed in adolescence or adulthood (ie, anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified [ED-NOS]). Adolescent and adult eating disorders often result in medical complications and are characterized by excessive concerns about body size and shape that can lead to serious functional deficits. Binge-eating disorder has been proposed as a new diagnosis within eating disorders and is undergoing active research.
Although eating disorders are known to occur in all ethnic, socioeconomic, and age-groups within the United States, females make up more than 90% of patients presenting with classic anorexia nervosa and bulimia nervosa. In addition, more than 95% of the patients are white, and more than 75% are adolescent when they first manifest the eating disorder (3).
Eating disorders of adolescence and adulthood are complex illnesses with multifaceted etiologic factors that include psychologic, familial, cultural, and genetic aspects (4). Risk factors for development of an eating disorder are presented in table 1. Because of the high rates of morbidity and mortality associated with eating disorders, particularly anorexia nervosa, it is important that the diagnosis be made and treatment initiated as early as possible.
|Table 1. Risk factors for development of an eating disorder|
Middle-class or upper-class socioeconomic status
Family history of eating disorder
Participation in activities valuing thinness (eg, sports, dance, modeling)
Unsuccessful attempts at dieting and weight loss
History of sexual abuse
Family issues (eg, separation difficulties, overinvolvement, abandonment)
Psychiatric comorbidity (eg, depression, anxiety, substance abuse)
Type 1 diabetes
Eating disorders of early childhood
Among preschoolers, the most common eating disorders are pica, rumination disorder, and feeding disorder of infancy or early childhood (formerly called nonorganic failure to thrive). Pica, the persistent ingestion of one or more nonnutritive substances, is most commonly associated with iron deficiency anemia. It may also be linked to zinc deficiency, mental retardation, developmental delay, and a family history of pica (5).
Rumination disorder is characterized by repeated regurgitation and rechewing of food after feeding. The age at onset of the disorder is often between 3 and 12 months, and in infants, it frequently remits spontaneously. Reassurance and behavioral therapy are the mainstays of treatment (6).
Feeding disorder of infancy or early childhood is present when a child younger than 6 years displays a persistent failure to eat adequately that results in weight loss or failure of expected weight gain. The diagnosis is applied only after gastrointestinal disease and other medical conditions that could account for the symptoms have been ruled out.
Anorexia nervosa is characterized by a refusal to maintain normal body weight and carries with it a substantial risk of premature death (7). Diagnostic criteria for anorexia nervosa and other eating disorders are listed in table 2. Medical signs, symptoms, and complications associated with eating disorders are presented in table 3.
|Table 2. Diagnostic criteria for eating disorders of adolescence and adulthood|
Body weight <85% of expected weight
Intense fear of weight gain
Inaccurate perception of own body size, weight, or shape
Amenorrhea (in females after menarche)Bulimia nervosa
Recurrent binge eating (at least twice per week for 3 mo)
Recurrent purging, excessive exercise, or fasting (at least twice per week for 3 mo)
Excessive concern about body weight or shape
Absence of anorexia nervosaEating disorder not otherwise specified
Used for disorders of eating that do not meet full criteria for anorexia nervosa or bulimia nervosa but which cause significant distress or impairmentBinge-eating disorder (research criteria set)
Recurrent binge eating (at least twice per week for 6 mo)
Marked distress with at least three of the following:
No recurrent compensatory purging, exercising, or fasting
|Table 3. Medical signs, symptoms, and complications of eating disorders|
Cardiomyopathy (seen in ipecac abuse)
Congestive heart failure (refeeding syndrome)
Electrocardiographic abnormalities: decreased left ventricular forces, prolonged corrected QT interval
Callus formation on knuckles (Russell sign for self-induced vomiting)
Hypercarotenemia, yellowing of skin
LanugoEndocrine and metabolic
Euthyroid sick syndrome
Hyperphosphatemia (bulimia nervosa)
Hypophosphatemia (anorexia nervosa)
Low serum estradiol level
Decreased intestinal motility
Delayed gastric emptying
Diarrhea (from laxative abuse)
Erosion of tooth enamel
Gastric rupture (after bingeing)
Hematemesis (Mallory-Weiss syndrome)
Parotid gland enlargement
Gynecologic and reproductive
The diagnosis of anorexia nervosa should be considered in primary care settings whenever a patient fails to attain age-appropriate weight, height, body composition, or stage of sexual development. Associated physical findings include bradycardia and orthostasis, muscle wasting, regression of secondary sex characteristics, abnormal bowel sounds, pitting edema, and lanugo. At presentation, patients with anorexia nervosa often attempt to hide their condition by wearing baggy or loose-fitting clothing.
Differential diagnostic considerations in weight loss in a child or adolescent includes gastrointestinal disease (eg, achalasia, decreased intestinal motility, pancreatic insufficiency), occult malignancy, occult infection (eg, HIV infection), type 1 diabetes, cystic fibrosis, hyperthyroidism, inflammatory bowel disease, brain tumor, and substance abuse. Although anorexia nervosa is distinguishable from these conditions by the patient’s distorted body image and desire for further weight loss, it is important to remember that anorexia nervosa should be diagnosed only after all medical causes of weight loss have been ruled out.
When a primary care physician suspects the presence of anorexia nervosa, a detailed eating history should be obtained from the patient and, ideally, his or her family members. Important history clues include preoccupation with weight loss, food, calories, and fat grams; food refusal that encompasses entire categories of food (eg, fats, carbohydrates, desserts); development of rituals around food and mealtimes; excessive and rigid adherence to exercise regimens; purging behavior and abuse of laxatives; and withdrawal from friends and activities. Fortunately, when asked by a primary care physician, most patients are willing to talk about these and related issues (8). Along with eating issues, the attentive physician often uncovers depressive and obsessive-compulsive symptoms.
The immediate goals of treatment for patients with anorexia nervosa include weight gain and normalization of eating patterns. Attainment of these goals often requires hospitalization and a multidisciplinary team approach that involves the physician, a registered dietitian and, often, individual, group, and family therapy. Any psychosocial precipitants of the patient’s illness should be identified and explored. Inpatient treatment is mandated in cases involving active suicidal intent, rapid weight loss to less than 75% of expected body weight, severe electrolyte imbalances, intractable purging, psychotic symptoms, or failure of outpatient management. The role of psychopharmacologic interventions to foster weight gain is limited in low-weight patients with anorexia nervosa (9); however, selective serotonin reuptake inhibitors may facilitate weight maintenance in the recovery phase (10).
The prognosis for patients diagnosed as having anorexia nervosa is grave. The illness carries with it a significant risk of suicide, and the mortality rate from all causes for patients with anorexia nervosa is 0.56% per year (5.6% per decade) (11). Although 84% of affected patients with anorexia nervosa achieve a partial recovery at some point in the course of the illness, the rate of sustained full recovery is just 33% (12).
Bulimia nervosa is characterized by recurrent binge eating and compensatory behaviors, which may or may not include vomiting. Fasting, excessive exercise, and use of diuretics, laxatives, or enemas may also be employed as compensation for a binge. In addition, patients with bulimia nervosa overemphasize body shape and weight as a means of self-evaluation. Because most affected patients are of normal weight, the disease is more difficult to diagnose than anorexia nervosa. Comorbid psychiatric conditions may include depression, anxiety disorders, substance abuse, and personality disorders.
Physical findings that may be seen in bulimia nervosa include scarring on the dorsum of the hand (Russell sign), dental caries, swollen cheeks due to enlarged salivary glands, and poor skin turgor. Laboratory testing may reveal electrolyte abnormalities, most commonly hypokalemia. The serum amylase level may also be elevated. This finding commonly signifies the parotid hyperplasia associated with frequent vomiting but may also be evidence of an evolving pancreatitis. Bulimia nervosa is 10 times more common in females than males, affects up to 3% of young women, and often becomes symptomatic between the ages of 13 and 20 years (13).
Controlled trials have established cognitive behavioral therapy as the psychosocial treatment of choice for patients with bulimia nervosa (14). Other treatments to consider are interpersonal therapy, group therapy, behavioral approaches, and nutritional counseling.
Evidenced-based pharmacotherapy for bulimia nervosa has focused on antidepressants. Fluoxetine hydrochloride (Prozac) is the only medication approved for bulimia nervosa by the US Food and Drug Administration, although tricyclic compounds as well as monoamine oxidase inhibitors (MAOIs) have been shown in controlled trials to reduce symptoms. Bupropion hydrochloride (Wellbutrin) is not recommended because of its association with seizures in patients with bulimia nervosa or anorexia nervosa, and MAOIs are potentially dangerous in patients with uncontrolled eating and purging. Preliminary reports are promising with the 5-hydroxytryptamine3 receptor antagonist ondansetron hydrochloride (Zofran), an antiemetic agent used during cancer chemotherapy (15).
The prognosis for patients with bulimia nervosa is much better than for patients with anorexia nervosa. In one study (12), at 7.5 years of follow-up, a full recovery rate of 74% and a partial recovery rate of 99% were observed in patients who sought treatment.
Emerging issues in eating disorders
An important diagnostic category is that of ED-NOS. This diagnosis is given to patients who have significant eating disorder symptoms but do not meet the full criteria and therefore present with subsyndromal cases of anorexia nervosa or bulimia nervosa. The condition is common among adolescents, and ED-NOS is diagnosed in nearly 50% of patients who are admitted to tertiary-care eating disorder programs (14).
Within ED-NOS is the emerging diagnostic subgroup known as binge-eating disorder. This disorder is designated in the DSM-IV-TR as a condition worthy of further study. Persons with binge-eating disorder are often obese, do not engage in the compensatory behaviors found in bulimia nervosa, and represent a substantial portion of patients in weight control programs (16).
Increasing attention has been paid to the problem of eating disorders among males. In the population of patients with binge-eating disorder, for example, the female-male ratio is estimated to be as low as 1.5:1 (2). Experts have also drawn distinctions between the sexes in terms of the motivations that drive eating disorders. Four weight loss goals that are more commonly held by males with anorexia nervosa than by females with the condition are (1) to avoid teasing brought on by being overweight, (2) to improve athletic performance, (3) to avoid a medical illness their father has, and (4) to improve a homosexual relationship (17). Further study is needed to understand the extent and unique features of eating disorders in males.
A recent development is the description of an infection-triggered form of anorexia nervosa that falls into the diagnostic category of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) (18,19). In this variant, children experience either the onset or a dramatic worsening of eating disorder symptoms in association with a documented infection of group A beta-hemolytic streptococcus. Studies are under way to determine whether PANDAS responds to antibiotic and immunomodulatory therapy. At this time, antibiotic treatment of anorexia nervosa should be regarded as experimental and should only be undertaken within referral center research protocols.
Eating disorders are serious chronic illnesses that often display a wide range of medical comorbidity. The diagnosis is made clinically, since there are no pathognomonic test findings. A multidisciplinary approach to treatment is optimal and involves a dietitian and psychotherapist in addition to the patient’s physician.
Familiarity with the signs and symptoms of eating disorders, and comfort in discussing these issues with patients, is essential for primary care physicians who work with children, adolescents, and young adults. (For resources, see the box at the end of this article.) Because early detection is a key prognostic indicator, screening for eating disorders should be a routine part of the medical care of adolescents (20). When an eating disorder is diagnosed, referral to a mental health professional is indicated for treatment as well as a thorough evaluation for comorbid substance abuse and mood, anxiety, or personality disorders. In the population of persons with eating disorders, the rate of comorbidity with other psychiatric illness (89.5%) is extraordinarily high (21).
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- Herzog DB, Greenwood DN, Dorer DJ, et al. Mortality in eating disorders: a descriptive study. Int J Eat Disord 2000;28(1):20-6
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- Kotler LA, Walsh BT. Eating disorders in children and adolescents: pharmacological therapies. Eur Child Adolesc Psychiatry 2000;9(Suppl 1):I108-16
- Kaye WH, Nagata T, Weltzin TE, et al. Double-blind placebo-controlled administration of fluoxetine in restricting- and restricting-purging-type anorexia nervosa. Biol Psychiatry 2001;49(7):644-52
- Sullivan PF. Mortality in anorexia nervosa. Am J Psychiatry 1995;152(7):1073-4
- Herzog DB, Dorer DJ, Keel PK, et al. Recovery and relapse in anorexia and bulimia nervosa: a 7.5-year follow-up study. J Am Acad Child Adolesc Psychiatry 1999;38(7):829-37
- McGilley BM, Pryor TL. Assessment and treatment of bulimia nervosa. Am Fam Physician 1998;57(11):2743-50
- Practice guideline for the treatment of patients with eating disorders (revision). American Psychiatric Association Work Group on Eating Disorders. Am J Psychiatry 2000;157(1 Suppl):1-39
- Faris PL, Kim SW, Meller WH, et al. Effect of decreasing afferent vagal activity with ondansetron on symptoms of bulimia nervosa: a randomised, double-blind trial. Lancet 2000;355(9206):792-7
- de Zwaan M, Mitchell JE, Raymond NC, et al. Binge eating disorder: clinical features and treatment of a new diagnosis. Harv Rev Psychiatry 1994;1(6):310-25
- Anderson A, Cohn L, Holbrook T. Eating disorders. In: Making weight: men’s conflicts with food, weight, shape and appearance. Carlsbad, Calif: Gürze, 2000:32-7
- Sokol MS. Infection-triggered anorexia nervosa. Eating Disord Rev 2001;12(5):1-3
- Sokol MS. Infection-triggered anorexia nervosa in children: clinical description of four cases. J Child Adolesc Psychopharmacol 2000;10(2):133-45
- Reas DL, Williamson DA, Martin CK, et al. Duration of illness predicts outcome for bulimia nervosa: a long-term follow-up study. Int J Eat Disord 2000;27(4):428-34
- Lewinsohn PM, Striegel-Moore RH, Seeley JR. Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 2000;39(10):1284-92
Resources on eating disorders for physicians and patients
Books and periodicals
Bruch H. The golden cage: the enigma of anorexia nervosa. Cambridge, Mass: Harvard University Press, 1978; ISBN: 0674356500
Gabbard GO. Substance-related disorders and eating disorders. In: Gabbard GO. Psychodynamic psychiatry in clinical practice. 3rd ed. Arlington, Va: American Psychiatric Press, 2000:329-62; ISBN: 1585620025
Keys A, Brozek J, Henschel A, et al. The biology of human starvation. Minneapolis: University of Minnesota Press, 1950 (out of print)
Kreipe RE, Golden NH, Katzman DK, et al. Society for Adolescent Medicine position paper: eating disorders in adolescents. J Adolescent Health 1995;16(6):476-9
Lask B, Bryant-Waugh R, eds. Anorexia nervosa and related eating disorders in childhood and adolescence. 2nd ed. New York: Psychology Press, 2000; ISBN: 0863778046
Lemberg R, Cohn L. Eating disorders: a reference sourcebook. Rev. Westport, Conn: Oryx Press, 1998; ISBN: 1573561568
Treasure J. Anorexia nervosa: a survival guide for families, friends and sufferers. New York: Psychology Press, 1997; ISBN: 0863777600
American Anorexia/Bulimia Association
American Psychiatric Association
Eating Disorder Referral and Information Center
Gürze Books Eating Disorders Resources
Harvard Eating Disorders Center
National Eating Disorders Association
National Women’s Health Information Center
Public Broadcasting System
The authors thank Andrea Burgett for her assistance.
Dr Kondo is a fellow in child and adolescent psychiatry, department of psychiatry, Duke University Medical Center, Durham, North Carolina. Dr Sokol is associate professor of psychiatry and pediatrics, Creighton University School of Medicine, and director, Eating Disorders Program, Children’s Hospital, Omaha, Nebraska. Correspondence: Mae S. Sokol, MD, Eating Disorders Program, Children’s Hospital, 8200 Dodge St, Omaha, NE 68114. E-mail: email@example.com.