BELLEVUE, WASH. – There’s no evidence that asking about an eating disorder will cause one, so busy clinicians should ask a few key questions to zero in quickly on adolescents who may have an eating disorder, one expert said.
General questions start with asking the teen what his or her maximum and minimum weights have been, and what their desired weight is, Dr. Cora C. Breuner said at the conference, which was sponsored by the North Pacific Pediatric Society.
Dr. Cora C. Breuner
Ask adolescents if they eat with their families (not counting eating fast food in a car). A family that doesn’t eat together at least three to five times per week is a red flag, said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.
Ask teenagers if there are any foods that they or their families consider "off limits," and whether any friends or family members have abnormal eating behaviors. Does the teen think he or she should be dieting?
Some useful questions come in pairs, Dr. Breuner said. Follow "How much do you exercise?" with "How do you feel if you can’t exercise?" If "Do you ever eat more than feels comfortable to you?" elicits a positive response, be sure to ask, "What do you do if you do that?"
Ask the adolescent to describe a typical day’s eating routine, and whether "energy drinks" are part of that. "Sadly, many don’t eat breakfast," she said.
To quickly identify physical symptoms of anorexia, ask the adolescent about amenorrhea, cold hands or feet, headaches, fainting or dizziness, and dry skin. Also query they about hair loss when brushing hair, or finding hair on the pillow in the morning.
Ask also about constipation. "Many kids don’t know what this means," Dr. Breuner said. Inquire if they have lost appetite and don’t get enough to eat.
To hone in on mental symptoms of eating disorders, ask about difficulty making decisions and about poor concentration – does it take longer to finish a test than it used to? A big symptom with teenagers is irritability: "Are you snapping at your friends?" Dr. Breuner suggests asking.
Inquire about depression and social withdrawal, which can be symptoms of eating disorders, as well as obsessiveness about food, guilt, or anxiety.
Some 50%-75% of adolescents with eating disorders have comorbid depression. With anorexia, more than 60% have comorbid anxiety, and more than 40% have comorbid obsessive-compulsive disorder (OCD).
"I think eating-disordered kids are anxious first, then find they’re less anxious if they don’t eat. We need to give them something else for the anxiety" or for the OCD, to replace the harmful don’t-eat strategy, she said.
Substance abuse also can be a red flag. Among patients with bulimia, 30%-37% also have substance abuse, studies suggest. Among the approximately half of patients with anorexia who will develop bulimia, 40% develop substance abuse, she said.
If the answers to these questions raise suspicion of an eating disorder, refer the patient for evaluation or look for clinical signs of eating disorders in your physical exam.
Physical signs of anorexia include hypothermia, acrocyanosis, resting bradycardia, hypotension, orthostatic blood pressure and pulse, and loss of muscle mass.
"A lot of times what I bill for is what I find on the physical exam" because coding the bill for an eating disorder slots the case into mental-health categories with lower reimbursements, Dr. Breuner said. "This is a medical problem, not just a mental problem."
Physical signs of binge eating include weight gain, bloating, fullness, lethargy, and salivary gland enlargement. Mental signs include guilt, depression, and anxiety.
Physical signs of vomiting or laxative abuse include weight loss, electrolyte disturbance, hypokalemia, hypochloremic metabolic alkalosis, dental enamel erosion, hypovolemia, or knuckle calluses. Mental signs include guilt, depression, anxiety, or confusion.
Dr. Breuner reported having no relevant financial disclosures.