Atlanta is lucky to have many options for the care of adolescents and children with eating disorders. Children’s Healthcare of Atlanta at Scottish Rite has a multidisciplinary team providing medical stabilization for the sickest eating disorder patients.
In 2013 staff at Children’s and local affiliated providers developed a clinical algorithm for the emergency room and for the inpatient providers to help in triaging patients who need to be admitted and helping to streamline care for these patients while managing their complications.
Dr. Laura Doerr, a pediatric hospitalist at Children’s, helped spearhead the development of the clinical pathway for this medical stabilization. The goal of a medical hospital admission for eating disorders is acute medical stabilization, nutritional restoration and to facilitate placement at an appropriate level of care for eating disorder treatment. Patients with weight suppression may also need weight restoration while avoiding refeeding syndrome.
Once medical stabilization has begun, these patients will need to continue care at a specialized eating disorder facility. The most comprehensive of these is Veritas Collaborative, which provides inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs for children, adolescents and adults. Dr Anna Tanner, Vice President of Child and Adolescent Medicine for Accanto Health (with brands the Emily Program and Veritas Collaborative), continues to work clinically as part of the medical team at Veritas Collaborative in Atlanta and with the doctors at Children’s to provide coordinated care.
Drs. Doerr and Tanner say much work still remains to be done, but that by learning more about how eating disorders present and what resources for treatment are available in our community, together we can decrease the morbidity and mortality of these illnesses.
Eating disorders are mental illnesses with significant medical complications. Morbidity and mortality are often related to the medical complications of the disorders. Additionally, we now know that eating disorders can affect persons of any age, gender, race, socioeconomic status and at any weight. And the prevalence of eating disorders has continued to increase. 1
Eating disorders are now seen in all racial and ethnic groups, with a mean age of onset of 12.5 years. Lesbian, gay and bisexual high school students have higher rates of unhealthy and disordered eating than their heterosexual peers. 2 Over 30 million people in the United States will struggle with an eating disorder at some point in their lifetime or about 9% of the population worldwide. And it’s the second leading cause of death among psychiatric illnesses (only preceded by opiate overdoses). One person dies roughly every hour from a complication of an eating disorder. About one-quarter of eating disorder patients will attempt to commit suicide. About 70% of patients with an eating disorder do not get treatment due to barriers in seeking care. 2 Only about 30% of eating disorder patients achieve remission and about 20% will remain chronically ill. 3
The etiology of eating disorders is thought to arise from a combination of genetic and environmental factors. Genetic research has identified regions of the genome that can be associated with Anorexia Nervosa. In Anorexia Nervosa specifically, having concurrent anxiety or depressive symptoms, a long duration of illness prior to hospitalization, low BMI and inadequate weight gain during hospitalization have been associated with poor outcomes in general.
Psychosocial stressors can be powerful as well. Patients will relate having been bullied or hearing someone such as a coach or a medical provider make a comment about their weight. This can cause patients to make dramatic diet changes which can lead to rapid weight loss, and this can put patients at higher risk of the complications of malnutrition.
It is thought that social media is a risk factor for disordered eating as patients seem more susceptible to media internalization and peer influences. One study published by Wilksch et al (2019) found that 75.4% of adolescent girls and 69.9% of boys have at least one social media account, and Instagram is the most common. Snapchat use was found to be associated with significantly higher rates of disordered eating in adolescent girls. All social media accounts were associated with higher rates of disordered eating in boys. Girls with Instagram and Facebook accounts had significantly higher levels of strict exercise and meal skipping. For boys, meal skipping was associated with any social media account. 5
Medical Complications
Eating disorders can affect every organ system, with potentially serious complications related to malnutrition, significant changes in weight or purging behavior. The psychological effects can be primary to the eating disorder, related to a comorbid condition such as depression, or be related to the effects of starvation.
Cognitive function studies have revealed that patients can develop deficits in executive functioning, such as global processing and cognition. The dermatological effects can include lanugo, angular cheilitis. There can be dental erosion and an increased risk of dental caries. And there are serious cardiac complications generally with restrictive eating disorders such as bradycardia, poor peripheral perfusion, and orthostasis.
Electrocardiographic abnormalities such as a prolonged QTc (> 440 milliseconds) has been found in about 10% of hospitalized patients, which can potentially precipitate a lethal arrhythmia. There is the potential for gastrointestinal complications such as superior mesenteric artery (SMA) syndrome, liver dysfunction, and Mallory- Weiss tears. There can be significant fluid and electrolyte abnormalities related to vomiting, dehydration, or laxative abuse.
Younger patients with restricting eating disorders are more at risk of other complications. There is potential for endocrine dysfunction, such as euthyroid sick syndrome, growth retardation, short stature, and pubertal delay. It is important to assess for bone mineral density in patients with amenorrhea and all male patients as this has the potential to irreversibly affect a patient’s skeletal health as an adult. These younger patients are more susceptible to the neurological consequences such as cerebral volume loss, which can have a permanent effect on brain development. 2
Eating Disorders and COVID
Since the start of the COVID-19 pandemic in 2020, there has been an increase in the number of eating disorder patients in crisis. It is thought that this is multifactorial. Adolescents were spending a lot more time evaluating themselves or seeing themselves online with virtual encounters. There were disruptions of their daily routines and less opportunities to engage in outdoor activities, which led to increases in concerns about weight and body image. It also seemed to affect eating patterns; without having clear routines, and structured mealtimes imposed by school or activities, there was an increase in eating disorder behaviors.
There was also less social support for patients during a stressful period of time. Social distancing has led to an increase in social media use, which has increased the risk for disordered eating. 4
There has been an increase in hospital admissions for medical stabilization during the pandemic overall by 48% compared to prior to the pandemic. It has impacted children’s and adult hospitals disproportionately, with an increase of 83% in pediatric admissions but only an increase of 16% in adult admissions. Patients are coming in with an increased severity of medical complications as well as an increase in comorbid symptoms such as depression, anxiety and suicidal thoughts. 6
Children’s Healthcare of Atlanta Scottish Rite Hospital averaged 16 eating disorder patient admissions a year between 2010-2012. That number increased yearly, and jumped during the pandemic. In 2021 there were 262 admissions. And there were more patients admitted to the Pediatric Intensive Care Unit (PICU). Prior to the pandemic 5.8% of patients were admitted to the PICU compared to 11.7% since the start of the pandemic. Since the pandemic started, hospitalists who previously had not seen large numbers of patients have been reaching out to Children’s and other large centers to try to find out how to manage their surge in patients.
This is affecting the outpatient sector as well. A recent study in JAMA (2022) by Hartman-Munick et al. saw a surge in outpatient volumes as well, with a nadir in 04/2020. After this month, there was a significant increase in the number of new eating disorder assessments seen in the outpatient clinics by about 8.1% per month. The demand for eating disorder treatment is outstretching the capacity to address it. There is a concern that it is going to create even greater strain on this system that is already struggling to meet the needs of this vulnerable population..7
Even eating disorder hotlines are overwhelmed. The National Eating Disorders Association helpline has had a 40 percent jump in overall call volume since March 2020.8
It is thought that COVID-19 unmasked a global eating disorder public health crisis. Dr. Debra Katzman, a Pediatrician at the University of Toronto said in the Journal of Adolescent Health, “those of us that treat eating disorders were woefully unprepared for the surge of patients.” She hopes that this will help eating disorders to be given the same priority as other “physical illnesses.”
The hope is that the increase in patients may highlight the critical need for more public health funding for eating disorder patients and the importance of restructuring our approach- focusing on prevention, early identification and continuity of care for those afflicted by it. As clinicians, it is important to share the lessons we have learned during the pandemic to help improve the quality of care for these patients.9
What Can You Do?
As medical providers, we’re in a unique position to recognize eating disorders early and intervene, ideally to help us to stop their progression. This is highlighting the need to schedule annual health supervision visits and preparticipation sports physicals as a chance to screen for underlying eating disorders. It’s important to screen for oligomenorrhea or amenorrhea which could be a clue to underlying energy deficiency and hormonal imbalance.
In history taking, screening for unhealthy and extreme weight-controlling measures before praising weight loss can help to avoid reinforcing these behaviors. Taking serial weight and height measurements to better assess a patients’ growth trajectory can be invaluable. If there is a big fluctuation in weight or rapid weight gain or loss this can be a red flag suggesting severe restriction of intake or binge eating. 2
In the emergency room, it is important to explore symptoms such as syncope, weakness, fatigue, bradycardia, hematemesis, and hypothermia as possible manifestations of severe malnutrition and purging. Laboratory testing is critical but can be normal in patients with eating disorders. It is important to remember that normal results may be present in patients with severe disease and these patients may still need hospitalization for medical stabilization.
Don’t wait. Early intervention is key!
Early intervention is critical because adolescents have greater success in recovering from eating disorders than adult patients, with recovery rates of about 70%. And early intervention is helpful in reducing one’s risk of mortality. Premature death is 4-5 times higher than the generally population in patients with Anorexia nervosa and 2-3 times higher in patients with Bulimia nervosa, with death typically occurring in adulthood. This helps to suggest why intervening early is so important. 2
If you are concerned that you or someone you care about has an eating disorder, what can you do?
- There are no simple solutions- seek professional help
- Access non-profits to learn more- NEDA and the Alliance are good places to start
- Know that there are local medical providers and eating disorders professionals who can evaluate and assess
- Adolescent Medicine Clinic | Children’s Healthcare of Atlanta (choa.org)
- Veritas Collaborative – Admissions 855-875-5812
References
- National Association of Anorexia Nervosa and Associated Disorders. (2022, December 12). General Eating Disorder Statistics. https://www.anad.org/
- Hornberger LL, Lane MA. AAP The Committee on Adolescence. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics 2021; 147 (1): e2020040279.
- Johansson T et al. Polygenic association with severity and long-term outcome in eating disorder cases. Translational Psychiatry 2022; 12:61.
- Rodgers RF et al. The Impact of the COVID-19 pandemic on eating disorder risk and symptoms. International Journal of Eating Disorders 2020; 53: 1166-1170.
- Wilksch SM, O’Shea A, Ho P, Byrne S, and Wade TD. The relationship between social media use and disordered eating in young adolescents. International Journal of Eating Disorders 2020; 53: 96-106.
- Devoe DJ et al. The impact of the COVID-19 pandemic on eating disorders: A systematic review. International Journal of Eating Disorders 2022; 1-21.
- Hartman-Munick et al. Association of the COVID-19 Pandemic with Adolescent and Young Adult Eating Disorder Care Volume. JAMA Pediatrics 2022; 176 (12): 1225-1232.
- Damour, L. (2021, April 28) Eating Disorders in Teens Have “Exploded” in the Pandemic: Here’s what parents need to know. The New York Times. Eating Disorders in Teens Have ‘Exploded’ in the Pandemic – The New York Times (nytimes.com)
- Katzman, DK. The COVID-19 Pandemic and Eating Disorders: A Wake Up Call for the Future of Eating Disorders Among Adolescents and Young Adults. Journal of Adolescent Health 2021; 69 (4) 535-537.
Dr. Laura Doerr
Dr. Doerr is an assistant professor of pediatrics at Emory University School of Medicine. She is board certified in general pediatrics as well as in pediatric hospitalist medicine. She is a pediatric hospitalist at Children’s Healthcare of Atlanta at Scottish Rite. She is also a member of the eating disorder team at Children’s and has helped to develop its clinical pathways related to the medical stabilization of eating disorder patients.
Dr. Anna B. Turner
Dr. Tanner is Vis President of Child and Adolescent Medicine for Accanto Health. She is a board-certified pediatrician who specializes in the care of complicated adolescent patients with eating disorders. Dr. Tanner completed medical school and residency at Vanderbilt University and is an adjunct assistant professor at Emory University School of Medicine and Morehouse School of Medicine. Dr. Tanner is a Fellow of the Society for Adolescent Health and Medicine (SAHM), a Certified Eating Disorder Specialist and a Certified Eating Disorders Supervisor.
