Screening and Monitoring for Eating Disorders in Youth Presenting for Obesity Treatment

Eating disorders (EDs) are serious brain-based disorders manifesting as maladaptive eating- and weight-related behaviors that are accompanied by distressing cognitions/attitudes and serious medical complications. These disorders may occur in individuals at any weight. The American Academy of Pediatrics (AAP) 2023 clinical practice guideline for managing pediatric obesity¹ highlights that EDs may present in youth seeking weight management. This publication raises awareness that pediatricians need increased knowledge on EDs in youth with elevated body mass index (BMI; kg/m²) to ensure safe, high-quality care. Specific areas of critical concern include inadequate familiarity with the prevalence and presentations of EDs in youth at higher weights, lack of a validated screening tool for EDs in children and adolescents, and knowledge gaps around medical risks of youth at higher weights who develop restrictive EDs. This perspectives piece aims to assist pediatricians who treat youth at higher weights in critically reviewing the 2023 AAP guidelines on obesity to improve ED detection and intervention.

EDs are common in youth. Over 20% meet criteria for an ED, with elevated BMI increasing the risk of bulimia nervosa (BN), anorexia nervosa (AN), atypical anorexia nervosa (AAN) and binge eating disorder (BED).² Elevated BMI is associated with body dissatisfaction, lower self-esteem, depression symptoms, and dieting,³ all of which prospectively increase the risk for ED development. While providers may screen youth with elevated BMI for binge eating and loss of control eating, they may incorrectly assume that behaviors such as restriction or purging are rare in this population. Providers must recognize that these youth may endorse other significant disordered behaviors beyond those associated with BED.

Before discussing weight loss with pediatric patients, providers should be aware that self-directed dieting may increase ED risk. Evidence suggests that some structured, family-based, weight management programs may improve symptoms of BN and BED;⁴ however, in some cases, an increased focus on food, eating, and weight may propagate or exacerbate latent ED symptoms.³ Until additional research can identify which youths with higher BMIs are most susceptible to ED development in the context of weight management, pediatricians must consider all patients with elevated BMI at risk and screen and monitor for ED concerns accordingly.

The lack of a well-validated ED screening tool targeting all youth, including those with elevated BMI, complicates the task of screening patients for EDs in the context of weight management. The 2021 AAP Clinical Report on Eating Disorders in Children and Adolescents⁵ highlights that pediatricians are in “a unique position to detect eating disorders early and interrupt their progression.” The AAP recommends that pediatric providers should monitor for concerns that may signal an ED including rapid weight fluctuations (gain or loss), pronounced deviation from historic growth trajectory, or pubertal delay.

For young patients, caregivers are an important source of collateral information. EDs are highly heritable, and family members should be asked directly about a family history of ED concerns. Caregivers are often the first to notice changes in eating habits, weight, or appearance concerns and may alert providers to prodromal symptoms that the child/adolescent may deny or minimize.⁵ Parent concerns should always be taken seriously and not dismissed without additional evaluation of the child/adolescent regardless of weight status. Concerning behaviors may include skipping meals, elimination of food categories, avoidance of family mealtime, bathroom use following meals, secretive eating, hidden food wrappers or missing food, and/or increasing exercise time or intensity.

Commonly used screening tools, such as the SCOFF questionnaire, lack adequate psychometric data in youth, and the United States Preventive Services Task Force (USPSTF) recently noted that there are insufficient data to recommend routine universal screening for EDs in primary care.⁶ However, the USPSTF did recommend that at-risk patients be screened (ie, targeted screening). Because elevated BMI is associated with increased ED risk, all youth with elevated BMI should undergo screening. Diagnostic tools have been studied for youth at higher weights; however, pediatricians need an easily implementable screening tool for widespread scale. Pediatricians and other researchers are currently collaborating to develop and test a potential pediatric specific screening tool that is inclusive of all ED behaviors, beneficial in youth at any weight, and can be applied in general pediatric practice.

Regardless of whether it is known if an ED is present, providers must avoid exacerbating prodromal, subclinical, or covert symptoms. Strategies for ED prevention and risk mitigation include reducing stigmatizing experiences in health care settings, monitoring for early signs and risk factors, and promoting protective factors.⁴ When ED concerns exist, pediatricians and families should consult with or obtain support from ED-informed providers. Providers struggling with referral options may benefit from a list of nonprofit ED resources (Figure 1) compiled by the AAP Eating Disorder Cross-Organizational Workgroup (EDWG) and featured in a recent free AAP webinar series for pediatricians on EDs (https://tinyurl.com/2rnd898n). In addition, when concerns for an EDs exist, pediatricians must closely monitor for medical complications as described in the AAP 2021 clinical report⁵ and briefly reviewed here.

EDs are associated with serious medical morbidities in youth and may require immediate medical stabilization at any presenting weight.⁵ However, pediatric providers may have less familiarity with AAN, thus young patients with a current or prior history of higher weight and significant restriction may face delays in diagnosis and treatment.⁴ Updated admission guidelines for medical instability are available from the Society for Adolescent Health and Medicine (SAHM)⁷ and should be applied to youth regardless of presenting weight or BMI in the context of weight loss and/or restrictive behaviors. Primary acute medical concerns include physiologic instability (bradycardia, hypotension, hypothermia, and orthostatic vital sign changes), dehydration, electrolyte disturbances, and abnormal electrocardiogram findings. Pediatricians must also remember that, beyond medical emergencies, youth with restrictive EDs are at risk for deleterious, irreversible impacts on growth and development.⁵ Total weight loss and rapidity of weight loss are established prognostic indicators of risk for acute medical instability in children and adolescents with restrictive EDs across the weight spectrum.⁷ Youth engaged in weight management who engage in extreme energy restriction or expenditure may exhibit rapid weight loss and may be at risk for the same medical complications as those with AN and AAN, which can include malnutrition and refeeding syndrome.⁷ 

Pediatricians play a critical role in the prevention and identification of EDs in youth, particularly those with elevated BMI and those for whom obesity treatment may be considered. Evidence-based recommendations for screening and monitoring youth at higher weights for EDs are summarized for providers (Figure 2). Although a patient-centered approach to care necessitates accounting for all presenting factors and patient goals, pediatricians may consider deferring weight management referrals in youth presenting with a suspected or emerging ED and/or strong genetic vulnerability. If weight management remains under consideration, pediatricians should acknowledge the potential risk of ED symptom emergence or exacerbation and consider focusing on sustainable lifestyle changes that support health rather than weight change with close and frequent monitoring for ED symptoms.

Additional research is needed to validate ED screening measures in youth of all sizes and to identify best practices to prospectively monitor physiologic stability, electrolytes, and growth and development in youth experiencing weight loss. Until additional research is available, co-management of patients alongside an ED specialist, or in close consultation with experts where specialty care is unavailable, is prudent.

AAN

atypical anorexia nervosa

AAP

American Academy of Pediatrics

AN

anorexia nervosa

BED

binge-eating disorder

BMI

body mass index

BN

bulimia nervosa

ED

eating disorder

EDWG

Eating Disorder Cross-Organizational Workgroup

SAHM

Society for Adolescent Health and Medicine

USPSTF

United States Preventive Services Task Force

We wish to thank the members of the AAP EDWG for the thoughtful collaboration and discussions that have led to education opportunities including the AAP webinar series and the development of potential tools for pediatricians. We particularly appreciate AAP staff members Ms Lindros and Torres. We also wish to thank the following workgroup members for their review and support of this manuscript: Drs Avila Edwards, Hampl, Peebles, Tanofsky-Kraff, Rome, Barlow, and Hassink. Additional thanks to Dr Tanofsky-Kraff for her work leading the development of a potential ED screening tool for children and adolescents that is body inclusive.