Eating disorders are common and dangerous conditions. They affect millions of Americans, across all racial and socioeconomic lines, occurring in both males and females. Eating disorders consistently challenge patients, families, and medical professionals.1 The management of eating disorders, whether treatment is in an inpatient or outpatient setting, requires a coordinated multidisciplinary team of individuals—ideally consisting of a physician (the patient’s primary care physician if he or she is comfortable in that role, a physician specializing in eating disorders, or a hospitalist physician), a registered dietician, a mental health provider, and a caregiver or parent.2 Although most patients with eating disorders are managed in an outpatient setting, this chapter provides a practical framework for the general pediatrics hospitalist to stabilize and initiate management of a patient hospitalized for an eating disorder.
Eating disorders pose a considerable public health concern and are associated with severe medical and psychiatric morbidity.3,4 Eating disorders are increasing in incidence and prevalence, and thus being diagnosed in adolescents with increasing frequency.5 Therefore it is of paramount importance that pediatricians and hospitalists are familiar with how to best detect and subsequently manage these disorders.1
The three major subgroups of eating disorders described in the literature are defined in the Diagnostic and Statistical Manual of Mental Disorders Fourth edition (DSM-IV) as anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS).5 These diagnostic categories and criteria have recently been updated in the DSM-5, as described later in this text.6 AN is estimated to affect 1% of adolescents and young adults, while BN has a higher prevalence of 3%.7 The majority of adolescents and adults presenting for eating disorder treatment are diagnosed with EDNOS,8 with an estimated prevalence between 0.8% and 14%.9 In addition, disordered eating behaviors are very common, with up to 25% of high school girls and 11% of boys reporting disordered eating severe enough to need evaluation, and 9% of high school girls and 4% of boys induce vomiting to control their weight.7
Females account for the majority of cases of AN and BN, but these disorders also occur in males. Males with eating disorders are increasing in prevalence, ranging from 10% to 25% of reported cases1 in recent reports. Eating disorders occur in all races and socioeconomic strata.10-12 Although the exact etiology of these disorders is unknown, they are thought to be multifactorial in origin, with strong evidence for neurobiological predispositions and gene–environment interactions.13,14
A patient presenting with weight loss, poor growth, pubertal cessation, restrictive attitudes about weight, unexplained vomiting, or abnormal eating behaviors should prompt a consideration of the diagnosis of eating disorder. AN usually presents with a refusal to maintain a minimally normal body weight. BN classically ...