Bright Futures in Practice: Physical Activity

EATING DISORDERS

Medical History and Physical Assessment

If the child or adolescent is at high risk for an eating disorder (based on the warning signs listed in Tables 19 and 20), a number of assessments should be performed in addition to the initial screening. These assessments are best done by an interdisciplinary team of health professionals working together to evaluate the child or adolescent at high risk:

Rule out organic illness as an explanation for weight loss or menstrual abnormalities.
Ask about history of binge eating and/or compensatory behaviors (e.g., self-induced vomiting; laxative, diuretic, or diet pill use; excessive physical activity). If the child or adolescent has diabetes mellitus with elevated H_bA_1c levels, evaluate the possibility of insulin withholding as a means of weight control.
Assess for orthostatic changes in pulse and blood pressure.
Keep in mind that results of laboratory tests are not definitive markers for diagnosing the presence of eating disorders. Children and adolescents with eating disorders often have results within the normal range when assessed with the following tests:
- Amylase. Serum amylase is elevated in some children and adolescents who vomit regularly.
- Calcium and magnesium. Hypocalcemia (decreased calcium in the blood) and hypomagnesemia (decreased magnesium in the blood) may be observed with laxative abuse, malnutrition, and inadequate dietary intake.
- Potassium. Hypokalemia (decreased potassium in the blood) may be observed with prolonged malnutrition or purging.
- Urine ketones. These compounds may be elevated because of chronic fasting or inadequate food intake.
- Urine-specific gravity. This measurement may be elevated (suggesting dehydration) or may be low because of excessive fluid intake.
Assess the need for hospitalization.11 (See the Referral and Treatment section.)

Nutrition Assessment

Take the child's or adolescent's health and weight history, including history of binge eating or purging (e.g., self-induced vomiting; laxative or diuretic use). Some children and adolescents do not want to talk about their eating and physical activity behaviors and are more likely to answer health-focused questions phrased in a supportive, nonblaming way. (For example, "To make sure your body is getting everything it needs, I'm going to ask you a couple of questions about what you are eating and drinking. Can you tell me everything you had to eat and drink yesterday?")
Request a 3- or 5-day food/physical activity record that provides information on the types and quantities of food consumed, as well as the places and times food was eaten, the number of other people present, and the types of physical activities performed during the time period.
Assess triceps skinfold and arm-muscle circumference to estimate body fat stores and muscle mass depletion.
Rule out clinical nutritional deficiencies as causes of symptoms such as hair loss or dry skin.

Psychosocial Assessment

Interview the child or adolescent and parents about circumstances surrounding the onset of changes in eating behaviors or weight.12
Assess for depression, and rule out other psychiatric disorders (e.g., anxiety disorder, obsessive-compulsive disorder, bipolar disorder) as primary or comorbid conditions that might explain changes in eating behaviors and preoccupation with body weight and shape and size.12
Assess risk of suicide.12

Counseling

In addition to providing health professionals with an opportunity to screen and assess children and adolescents for eating disorders, health supervision visits and sports preparticipation physical examinations provide an opportunity to promote healthy eating and physical activity behaviors and a positive body image.

Nutrition

Emphasize the importance of adequate energy (calories) and protein in the diet.
Reinforce the importance of consuming a variety of foods to provide adequate nutrition.
Encourage adequate calcium intake for maintaining good bone health.
Discourage meal skipping and other restrictive eating.
Keep in mind that a discussion of pubertal changes may be a "safe" place to talk about body image with adolescents.
- Females. Emphasize the fact that fat deposition (especially in the hips and thighs) is normal.
- Males. Discuss the wide variability in the timing of normal growth and maturation and muscle development.
Use BMI charts to discuss the wide range of body shapes and sizes within a range of healthy body weights.
For overweight children and adolescents, carefully phrase recommendations for weight maintenance or loss, and help them identify behaviors they can improve.

Physical Activity

Encourage regular physical activity with emphasis on activities the child or adolescent enjoys.

Encourage parents to assess any physical activity program the child or adolescent is involved in to make sure it provides a healthy and safe environment. (See Tool D: Characteristics of Excellent Physical Activity Programs for Children and Adolescents.)

Provide guidance on developmentally appropriate physical activities.

Provide guidance on what is considered excessive physical activity and when parents should be concerned.

Discuss the roles of calcium and physical activity in developing and maintaining healthy bones.
Discuss physical symptoms that may be associated with excessive physical activity (e.g., dizziness, lightheadedness, amenorrhea, low heart rate, cold intolerance, stress fractures).

For Physical Education Teachers and Coaches

Health professionals may interact with a child's or adolescent's physical education teacher or coach. Many children as young as 4 or 5 years of age start taking direction from teachers and coaches, who can have a major influence on them.

Health professionals can encourage teachers and coaches to take the following positive actions:

Encourage the child or adolescent to participate in developmentally appropriate physical activities.
Provide feedback about the child's or adolescent's performance, emphasizing strength and mental focus and deemphasizing body fat and weight.
Do not make negative comments about the child's or adolescent's physical appearance, weight, or eating behaviors. If a teacher or coach is concerned about a child's or adolescent's weight, the child or adolescent should be referred to a health professional.
Discourage comparisons between children and adolescents and their performance and body size or

weight.
Learn the warning signs of eating disorders, and refer children and adolescents at risk to a health professional.
Provide water, and encourage children and adolescents to drink sufficient fluids before, during, and after physical activity. If weight loss is a concern, weigh children and adolescents before and after practice and make sure that they drink enough water to regain their lost weight before the next practice.

Referral and Treatment

Comprehensive screening, assessment, and treatment of eating disorders in children and adolescents require an interdisciplinary team of health professionals who can provide nutrition counseling, medical care and monitoring, psychiatric evaluation, and individual and/or family therapy.

Hospitalization may be needed if the child or adolescent is severely malnourished, shows metabolic disturbances, or is at risk for suicide.13 If the child or adolescent has anorexia nervosa, it is essential to ensure a gradual and carefully planned return to healthy eating behaviors to prevent the "refeeding syndrome" associated with hypophosphatemia. Close monitoring of food intake and output, hydration status, physical activity, and weight is necessary for adjusting the dietary recommendations for steady weight gain.

Children and adolescents with eating disorders need long-term treatment and follow-up by a physician, mental health professional (including at least one evaluation by a psychiatrist), and dietitian. Because of the complexity of these disorders and the need to set clear, consistent behavioral limits, teamwork is essential.

References

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American Medical Association, Department of Adolescent Health. 1995. Guidelines for Adolescent Preventive Services (GAPS): Recommendations Monograph (2nd ed.). Chicago, IL: American Medical Association, Department of Adolescent Health.
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Kriepe RE, Higgins LA. 1996. Anorexia nervosa. In Rickert VI, ed., Adolescent Nutrition: Assessment and Management (pp. 159–180). New York, NY: Chapman and Hall (Aspen Publishers).