Nutrition III - NCC Pediatrics Residency at Walter Reed

NCC Pediatrics Continuity Clinic Curriculum:Nutrition III: School-Age & AdolescentFaculty GuideGoal:To understand the nutrition recommendations and key issues for school-age children andadolescents, and to be able to translate them into practical, anticipatory guidance for parents.* Note: Obesity will be covered separately in the Nutrition IV Module.Pre-Meeting Preparation:• “School-Age & Adolescent Nutrition” (Excerpts from HealthyChildren.org)• “Vegetarian Diets in Children and Adolescents” (PIR, 2009)• “Diagnosis of Eating Disorders in Primary Care” (AAFP, 2003)• “Feeding & Eating Disorders” (DSM-V Update, 2013)• Be prepared to provide a case-example or FAQ related to School-Age & AdolescentNutrition from your clinic experience. Discuss how you approached the case/ question.Conference Agenda:• Review Nutrition III Quiz• Complete Nutrition III Cases• Round table discussion of resident School-Age & Adolescent casesPost-Conference: Board Review Q&AExtra Credit:Please review the following enclosures, related to the practical guidelines, above:• AAP Clinical Report on Eating Disorders (Pediatrics, 2010)• Eating Disorders (PIR, 2011)• Vegetarian Eating for Children and Adolescents (JPEDHC, 2006)• Vitamin Deficiency & Overdose Chart (helpful for Board Review questions)

• Sugar: Many children consume sugar in great quantities, usually at the expense of healthier foods(e.g. sodas and juice, instead of milk or water). Keep consumption at moderate levels.• Salt: The habit of using extra salt is acquired. Thus, as much as possible, serve your child foodlow in salt, to decrease the risk of high blood pressure. Use herbs, spices, or lemon juice to flavorfoods and avoid processed foods such as cheese, instant puddings, canned vegetables and soups,hot dogs, salad dressing, pickles, and potato chips.VitaminsSupplements are rarely needed in middle childhood, since a balanced diet contains sufficient quantitiesfor the essential vitamins and minerals. However, children with poor appetite, erratic eating habits, orhighly selective diets (e.g. vegetarian or vegan) may need vitamin supplements.Over-the-counter supplements (e.g. Flintstones chewables or gummies) are generally safe; however, iftaken in excessive amounts or combined, some—particularly fat-soluble vitamins (ADEK)—can be toxic.Of note, “mega-vitamin therapy” or “orthomolecular medicine”— in which vitamins are given inextremely large doses for conditions ranging from the common cold to hyperactivity— has no provenscientific validity and may pose risks.Following are some of the vitamins and minerals necessary for normally growing children, and some ofthe foods that contain them. (Review this “Vitamin Deficiency & Overdose Chart” chart for a morecomplete list of vitamins and the conditions associated with deficiency or excessive intake).• Vitamin A promotes normal growth, healthy skin, and tissue repair, and aids in night and colorvision. Rich sources include yellow vegetables, dairy products, and liver.• B vitamins promote red blood cell formation and assist in a variety of metabolic activities. Foundin meat, poultry, fish, soybeans, milk, eggs, whole grains, and enriched breads and cereals.• Vitamin C hastens the healing of wounds and increases resistance to infection. Found in citrusfruits, strawberries, tomatoes, potatoes, Brussels sprouts, spinach, and broccoli.• Vitamin D promotes tooth and bone formation and regulates calcium absorption. Sources includefortified dairy products, fish oils, fortified margarine, and egg yolks. Sunlight also contributes todietary sources of vitamin D, stimulating the conversion in the skin.Adolescent NutritionMaterial adapted from: http://www.healthychildren.org/English/ages-stages/Calories & ServingsThe body demands more calories during early adolescence than at any other time of life. On average,boys require about 2800 calories per day; and girls, 2200 calories per day. Typically, the ravenoushunger of adolescence starts to wane once a child has stopped growing, though not always. Kids whoparticipate in physical activity will still need increased amounts of energy into late adolescence.Serving sizes for teenagers should still be about the same as they are for adults. Please review thechart on the following page to see the number of servings and sizes recommended for the average teen.The USDA “Food Plate” can still be used as a visual guide.

Food GroupNumber of Servings Per DayFemalesCalories Aged 11-24Total Calories: 2,200MalesAged 11-14Total Calories: 2,500Aged 15-18Total Calories: 3,000Aged 19-24Total Calories: 2,900Bread, Cereal, Rice and Pasta Group6-11 servingsMilk, Yogurt and Cheese Group4-5 servingsVegetable Group3-5 servingsFruit Group2-4 servingsMeat, Poultry, Fish, Dry Beans, Eggs and Nuts2-3 servings9 servings 11servings4 or 5 servings Aged 11-18: 4 or 5 servingsAged 19-24: 2-3 servings4 servings 5 servings3 servings 4 servings6 ounces total 7 ounces totalTotal Fat 73 grams Aged 11-14: 83 gramsAged 15-18: 1,000 gramsTotal Added Sugar 12 teaspoons 18 teaspoonsVariety & NutrientsThere are a number of obstacles to balanced adolescent nutrition:• Skipping meals: According to a recent poll, about ½ boys and girls aged 9-15 years said thatthey didn’t eat breakfast on school mornings. Breakfast-to-go options include a bagel andpeanut-butter, a hard-boiled egg, nuts & raisins, a yogurt, or an apple.• Snacking: 1/3 of the caloric intake of adolescents comes from snacks—particularly unhealthyones. It’s therefore important to keep the refrigerator and pantry stocked with healthy optionslike low-fat cheeses, applesauce, air-popped popcorn, and baked potato chips.• Eating away from home: At school, adolescents will often settle for a stop at the vendingmachine for lunch. After school, they may decide that fitting in with their peers at a fast-foodrestaurant or pizza shop is more important than making healthy food selections. Brainstormhealthy alternatives and/or other activities to do with their peers.• The lure of fad diets: As teenage girls “hopscotch” from one fad diet to another, good nutritionmay fall by the wayside. Reinforce that these diets are too restrictive and unhealthy and bad forweight-loss in the long-run.The guidance in the above section for “Foods to Reduce” still applies to adolescents. Also remember,each gram of protein and carbohydrates supplies 4 calories, whereas fat contributes 9 calories/gram.VitaminsAdolescents—particularly girls, who eat roughly 25% fewer calories per day than boys— tend to fallshort of their daily quotas of vitamins and minerals. Calcium, iron and zinc are most vulnerable.

Calcium:Adolescence provides a window of opportunity for avoiding osteoporosis later in life. During the teenageyears, the growing bones absorb more calcium from the blood than at any other time of life. By earlyadulthood, our bones stop accepting deposits, and not long after, the gradual loss of calcium begins.In a clinical study sponsored by the National Institute of Child Health and Human Development, onegroup of teenage girls received daily supplements containing an extra 500 mg calcium; the other group’scalcium came strictly from food. The girls who were given supplements saw their bone density improveby 14%. Each 5% increase in bone mass reduces the risk of suffering a bone fracture by 40%.The American Academy of Pediatrics recommends the following daily intake of calcium:Age Calcium Need (mg per day) Servings of Milk to Meet Need4–8 years 800 3 servings9–18 years 1,300 4 servings19–50 years 1,000 3–4 servingsMilk and milk products provide ¾ of the calcium in the American diet. Other foods contain calcium, likebroccoli and collard greens. However, these vegetables also contain substances that impair the body’sability to absorb calcium, so that a teen would need to eat approximately 9 cups of broccoli a day to meetthe recommended intake. Also consider calcium-fortified juice (no more than 8-12 oz/day!) and cereals.Unfortunately, 2/3 of adolescent girls in the US fail to meet the daily requirement for calcium. The NIHsupports the use of supplements for young people who don’t get sufficient calcium through their diet. Foroptimal absorption, no more than 500mg should be taken at one time.Also remember that other factors can decrease calcium and impair bone health: excessive soda intake;vegan diets; caffeine, alcohol, and tobacco; certain medications (e.g. diuretics) and GI diseases (e.g. IBD).Iron:According to a national survey conducted by the USDA, three in four teenage girls’ diets are deficient inthis essential mineral, as compared to just one in five of their male counterparts. Adolescent girls are alsoprone to iron-deficiency due to menstrual losses.Foods rich in iron include meats (beef, pork, lamb, liver); poultry (especially dark meat); fish; dark-greenleafy vegetables (kale, collards, broccoli); legumes (lima beans, peas, dry beans); dried fruit (prunes,apricots, raisins); potatoes with skin; seeds (sunflower, pumpkin, squash); and whole-wheat breads.Other points to keep in mind are, as follows: (1) the iron in meat, poultry, and fish is more readilyabsorbed than the iron in vegetables, beans, and grains; (2) vitamin C & citric acid in fruits promotesabsorption of iron; (3) the tannins in tea can interfere with metabolism of non-heme (i.e. non-meat) iron.Please review “Screening for Iron Deficiency” (see Health Maintenance II) for more information aboutthe pathophysiology, evaluation, and treatment of iron-deficiency anemia.

Article nutritionVegetarian Diets in Childrenand AdolescentsMeredith Renda, MD,*Philip Fischer, MD*Author DisclosureDrs Renda and Fischerhave disclosed nofinancial relationshipsrelevant to thisarticle. Thiscommentary does notcontain a discussionof an unapproved/investigative use of acommercial product/device.IntroductionVegetarianism is becoming more common among adults, with 1 in 40 adults currentlychoosing a vegetarian diet. Consequently, more children are raised as vegetarians. Vegetarianismis adopted for various reasons, including moral, religious, and health. Numerousstudies have shown significant health benefits for individuals following this type of diet.Pediatricians should be well informed about vegetarianism and its role in our pediatricpopulation.Case 1A first-time mother and her 2-month-old boy present to the clinic for a health supervision visit.The mother is breastfeeding, and her baby is growing appropriately. At the end of the visit, themother mentions that she is a vegetarian and that she would like to raise her son in the sameway. She would like to know what she should be doing as a breastfeeding mother and how she canmake sure that her son has the appropriate nutrition in the future.The physician should begin by taking a dietary history from the mother to determinewhat type of vegetarianism she practices. He or she should explain to the mother that herinfant’s nutrition is based on her own dietary intake for as long as she continues tobreastfeed. The pediatrician should counsel the mother on the importance of diet variety.If the mother is vegan, the pediatrician must take time to ensure that she is getting enoughvitamin B 12 and calcium in her diet. When she is ready to wean her infant, she shouldcontinue to focus on dietary variety. The mother should be cautioned that adult vegetariandiets that are high in bulk and low in calories are not always appropriate for the growingand developing child. Finally, the pediatrician should ensure that the mother has theappropriate resources to guide her in finding the best foods for her child’s nutritionalneeds.Initiating a DialogueWhen confronted with this scenario, it is most important to take a dietary history.Although this mother defines herself as a vegetarian, she did not specify what type ofvegetarianism she practices (Table 1). In the simplest sense, a vegetarian eliminatesanimal-flesh foods and products from the diet (including fish). However, the definition canbe delineated further. A lacto-ovovegetarian consumes milk and egg products. A lactovegetarianconsumes milk in addition to plant products. A vegan eliminates all animal and fishproducts. Recommendations for this mother depend on what form of vegetarianism shefollows.Comparing Human Milk CompositionFor the first 6 to 12 months after birth, most babies are lactovegetarians. Their primarysource of nutrition is milk, either from human milk or formula. Studies have shown that forthe first 6 months, the human milk of a lacto-ovovegetarian does not differ significantlyfrom that of an omnivore. (1) Specifically, the composition of human milk betweenlacto-ovovegetarians and omnivores is similar in minerals, trace elements, lactose, and totalfat. Another study revealed that human milk from vegetarians has fewer environmental andindirect additives than that of nonvegetarians. (2)* Department of Pediatrics, Mayo Clinic, Rochester, Minn.Pediatrics in Review Vol.30 No.1 January 2009 e1Downloaded from http://pedsinreview.aappublications.org/ at National Naval Medical Center (NNMC) on August 12, 2011

nutritionvegetarian dietsTable 1. Types of VegetarianismSemivegetarianIncludes poultry and fishLacto-ovovegetarianIncludes milk and egg productsLactovegetarianIncludes milk productsVeganEliminates all animal and fish productsImportant Nutritional ConsiderationsLacto-ovovegetarians and lactovegetarians (who consumemilk or eggs or both in their diet) tend to be lessdeficient in certain elements than vegans, who eliminateall fish and animal products. Surprisingly, the humanmilk of poorly nourished women often has relativelyadequate volume and composition. One hypothesis isthat human milk composition is maintained to the detrimentof the mother’s overall nutritional status. Regardlessof the volume and composition, human milk ofpoorly nourished women may have fewer calories, watersolublevitamins, calcium, and protein. (3) All vegetariansshould pay special attention to the amount of vitaminB 12 , folate, and omega-3 fatty acids that they consume.Vitamin B 12 and folate are important factors in proteinand DNA synthesis as well as in growth and developmentof the brain and nervous system. Omega-3 fatty acidsplay a significant role in brain and retinal development.During times of growth and reproduction, requirementsfor these elements increase.Vitamin B 12Reliable sources for vitamin B 12 for the vegetarian includecereal, nondairy beverages, meat analogs, and supplements.It is important to read the labels to ascertainthat the item has been fortified with vitamin B 12 .Ifavegan mother does not consume enough B 12 -fortifiedfoods or supplements, her infant receives 0.4 mcg/day ofvitamin B 12 during the first 6 postnatal months and0.5 mcg/day after 6 months of age. (4) Another reasonthat a breastfed infant might need to receive supplementationwith vitamin B 12 is if the mother had an ilealresection. Removing this section of the bowel preventsthe body from absorbing vitamin B 12 .FolateFolate is found in enriched breads, pastas, cereals, greenleafy vegetables, and orange juice. Interestingly, mostvegetarians consume more than the recommendedamount of folate. Although the addition of folate tofortified foods has helped to reduce the risk of neuraltube defects in infants, folate can mask some of thehematologic changes that signal a vitamin B 12 deficiency.A vitamin B 12 deficiency that has been masked by folatemay not be apparent until deleterious neurologic consequencesalready have occurred. (5)Omega-3 Fatty AcidsOmega-3 fatty acids are important in all lactating womenbecause they assist in brain and retinal development ofnursing infants. However, they also serve a special rolefor vegetarians because they act as building blocks for thelonger chain fatty acids docosahexaenoic (DHA) andeicosapentaenoic acid (EPA), which are found in fish.DHA and EPA are critical for brain and organ developmentin the fetus and newborn. A daily intake of 3 to 5 gof omega-3 fatty acids is adequate, based on a 2,000-kcal/day diet. However, lactating women (especiallyvegetarians) should consider supplementation with reliablesources of fatty acids. Omega-3 fatty acids can befound in walnuts, flax seed, hemp, dark greens, and tofu.Quality fish oil supplements and DHA-rich eggs also areavailable for consumption. (6)Weaning Future VegetariansWhen weaning infants from human milk, it is importantto ensure that they receive adequate nutrition. Dietaryproblems that stem from certain inadequacies are seenmore often in children than in adults. Children havegreater energy requirements relative to their bodyweight, and they are not always in control of what theyeat. Many of the significant deficiencies seen in childrenoccur because of inappropriate understanding and dietarychoices by adults.Vegetarian diets that are appropriate for adults are notalways right for children. Adults tend to want to consumefoods that are lower in caloric and fat content, yet high inbulk. The bulk ensures that the stomach feels full despitethe adult consuming a lesser amount of calories and fat.A child who is 1 to 3 years of age has a stomach capacityof only 200 to 300 mL at each meal. Thus, problemsensue when high-bulk foods are eaten by children. Childrenmay feel satiated quickly, even though they have noteaten an adequate amount of their nutritional requirements.(7)When well-informed parents raise vegetarian children,e2 Pediatrics in Review Vol.30 No.1 January 2009Downloaded from http://pedsinreview.aappublications.org/ at National Naval Medical Center (NNMC) on August 12, 2011

nutritionvegetarian dietsstudies show that the children’s means for height for age,weight for age, and weight for height are close to the50th percentile of the National Center for Health Statisticsreference values. (8) Another study of vegetarianBritish children, ages 1 to 18 years, found heights,weights, and head and chest circumferences to be withinnormal range compared with those of nonvegetarianBritish children. (9)Dietary Variety is the Secret to SuccessWhen a vegetarian follows a well-rounded diet, thehealth benefits are numerous. In an analysis of five prospectivestudies examining mortality in vegetarians andnonvegetarians, vegetarians had a 24% decrease in ischemicheart disease. (10) Vegetarian children tend to beleaner and have lower relative body weights and skinfoldthicknesses while retaining normal growth and maturation.(11) As food sources become increasingly fortified,it is easier and more convenient to provide vegetarianchildren with appropriate food elements. Parents shouldensure that their children are receiving adequateamounts of vitamin B 12 , folate, iron, and zinc (Table 2).Food also should be high in energy density withoutsignificant bulk.Table 2. Nutrients and FoodSourcesProteinTofu, tempeh, legumes, grains, eggs, dairyOmega-3 Fatty AcidsFlax seed, dark greens, tofu, fish oil, nutsIronLegumes, nuts, dried fruit, spinach, fortified grainsCalciumKale, broccoli, fortified orange juice, fortified soy, figs,dairyZincWhole grains, legumes, nuts, wheat germ, whole grainpastaFolateLegumes, dark green leafy vegetables, fortified cereals/breadsVitamin B 12Fortified eggs, fortified dairy, cereals, breads, somefortified soyToddlers and preschool-age children tend to developstrong eating preferences, and it may be difficult topresent a variety of foods to them each day. Patience,along with repeated exposure to unfamiliar foods, mayhelp. When opting for prepackaged foods made with tofuor tempeh (fermented soy), it is important to read thenutritional information. Many of these processed foodstend to be high in fat, sodium, and calories, similar tononvegetarian packaged foods.Parents should make “whole plant food” the primarystaple in their child’s diet. This element includes wholegrain breads, pastas, cereals, tofu, soy, legumes, vegetables,and fruits. Legumes are a class of vegetables thatincludes a variety of beans, peas, and lentils. Nutrients invegetables are preserved best when they are cooked withthe least amount of heat, water, and time. Therefore,ideal cooking includes steaming vegetables in a smallamount of water, stir-frying, and boiling in a bag. Asmentioned, vitamin B 12 and folate are found in a varietyof fortified cereals and breads. Iron can be found in driedfruits, legumes, nuts, and fortified foods. Zinc also isfound in legumes, nuts, and whole grains.Although protein can be a concern, plant foods providemore than 10% of their calories in the form ofprotein. Plant foods combined with meat substitutessuch as soy and tempeh tend to provide adequate proteinfor the vegetarian child. The protein intake of veganchildren has been shown to be similar to that of nonvegetarianchildren, and the intake also is higher than therecommended standard. (12)Case 2A new patient and his parents present to the clinic for ahealth supervision visit. The boy is 7 years old and has hadappropriate growth and development. The parents arelacto-ovovegetarians, and they have raised their son in thesame way. As their son becomes older and more independent,they have concerns about his eating patterns andnutrition. They want to ensure that he makes appropriatefood choices at school and at friends’ houses. They ask you foradvice in ensuring that he continues to have appropriatenutrition now and in the future.It is important to identify the parents’ reasons forbeing vegetarian as well as their reasons for raising theirson as a vegetarian. It also is essential that the physicianask both the parents and child how each feels about beingvegetarian. Although the boy is only 7 years old, he mostlikely is exposed to many different types of food while atschool and friends’ homes. How have these experiencesinfluenced his feelings about his daily diet? The physicianshould follow this discussion with a dietary history. IfPediatrics in Review Vol.30 No.1 January 2009 e3Downloaded from http://pedsinreview.aappublications.org/ at National Naval Medical Center (NNMC) on August 12, 2011

Planning AheadBecause of the many motivations and rationales forchoosing vegetarianism, parents’ discussions will differamong their children. Regardless of the differences, parentscan be more prepared to work through specificissues if they have some universal tools at their disposal.Following a vegetarian diet can be challenging to eventhe most experienced vegetarian. Despite advancingpublic awareness, vegetarian options are not always available;planning ahead is often necessary. This proves to beof greater consequence when a child is involved. Thevegetarian school-age child always should leave thehouse with an appropriate meal or at least with a snackthat he or she can eat if there are no vegetarian options. Ifpeer inclusion is an issue, parents should think aboutpacking vegetarian foods that mimic popular meat products(ie, veggie burger, soy nuggets). Children feel moreincluded in peer groups if their meal appears similar.Packing food for other situations may be more complex.If a vegetarian child is asked to dinner at a friend’shouse, the child and his parents may seem impolite if thechild brings his or her own food. In this case, communicationis the key. Once nonvegetarian parents understandthe situation, they may be very accommodating interms of offering food that is appropriate for the vegetarianchild. On the other hand, some parents may welcomehelp from a vegetarian parent in terms of suggesting orpacking appropriate foods. Parents of nonvegetarianchildren may be very agreeable to preparing foods fortheir vegetarian guest, but they may not know what tocook. Vegetarian parents can offer some basic educationif they think other parents would be open to suggestions.Although planning ahead can address many scenarios,parents and children should role-play to practice scriptsthat deal with unexpected situations. Role-playing isparticularly useful because it may help parents understandwhat type of circumstance causes their children themost worry or apprehension. Acting out a few scenarioscan do wonders in terms of quelling a school-age vegetarian’sconcerns regarding diet.Finally, it is important for parents to discuss vegetarianismand nonvegetarianism in a way that does not placeundue positive or negative values on either group.A common defense mechanism for parents of a vegetarnutritionvegetarian dietsadditional education is needed to teach the family aboutappropriate nutrition, more time should be arranged todelve into this issue. The physician should ensure thatthis family has the appropriate resources available tothem. Finally, the physician needs to begin to touch onthe topics of independence and autonomy. Dependingon how this boy feels about being a vegetarian, thephysician may want to counsel the parents on ways thatthey can be accepting of their son regardless of whetherhe chooses to be vegetarian in the future.Raising a School-age VegetarianFrom a nutritional standpoint, raising a school-age vegetarianis not very different from raising a younger vegetarian.These children require the same nutritional considerationsas their younger counterparts, with particularattention paid to elements such as vitamin B 12 , folate,omega-3 fatty acids, and protein. Dietary variety is thebest way to ensure normal growth and development forvegetarian children.Aside from the nutritional issues, however, manyother aspects of vegetarianism during elementary schoolages should be considered. Whereas the toddler orpreschool-age child is still eating most of his or her mealsat home, the school-age child often eats a large portion ofhis or her daily diet away from the home (school, extracurricularactivities, friends’ homes). Not only is it moredifficult for parents to be in control of what their childrenare eating, but it also may be difficult for the child tomake appropriate choices based on the foods that areavailable.The school-age child places a great deal of interest andimportance on fitting in among his or her social group.Acceptance in one’s social group often depends on theability to relate to other children and share in commonexperiences. If a vegetarian child is unable to share incommon experiences, such as meals, this state may bedistressing for the child and peers alike.Finally, school-age children are just beginning to realizethat children and families are not all similar to theirown. Depending on school and social experiences, somevegetarian children may be exposed to many differentfoods that they have never encountered. Curiosity maycause vegetarian children to desire new foods, includingmeat products. If vegetarian children feel that they areunjustly restricted, or if the restriction causes them distress,they may begin to resent their vegetarian diets.To identify and resolve issues related to school-agevegetarians, parents should determine how strongly theyfeel about reinforcing a vegetarian diet inside and outsideof the home. As children enter school and become moreindependent, some parents allow their children the freedomof dietary experimentation. Others may feel that avegetarian diet takes precedence, regardless of the circumstances.Once a viewpoint has been determined,parents should include their children in a discussion thattackles the issues pertinent to school-age vegetarians.e4 Pediatrics in Review Vol.30 No.1 January 2009Downloaded from http://pedsinreview.aappublications.org/ at National Naval Medical Center (NNMC) on August 12, 2011

nutritionvegetarian dietsian child who is questioning his or her diet may be tospeak of nonvegetarians negatively. This type of copingskill is detrimental because it accentuates the differencesthat already are of concern to the vegetarian child. It alsomay have a paradoxic effect in that the vegetarian childmay have heightened negative feelings about his or herdiet if the child feels that his or her parents have spokennegatively about a cherished friend or peer. Parentsshould attempt to discuss issues of diet with objectivity.In doing so, they will make their argument more effectivelywithout alienating others.Case 3A 16-year-old girl returns to the pediatric clinic for her firsthealth supervision visit in 5 years. When questions ariseconcerning her diet, she appears very defensive. She statesthat she became a vegetarian on February 16, approximately2 months ago. She reluctantly shares that her dietconsists largely of pasta, bagels, and “side dishes” from thefamily meal. She cites “animal cruelty” as her motivationto become a vegetarian.The physician should begin by taking a dietary historyas well as attempting to determine what prompted thisteen to change her diet, remembering that adolescence isa unique period of development that may have played arole in this teen’s motivations. To provide the mostcomprehensive education regarding vegetarianism, theteen’s family should be included in the discussion wheneverpossible. The physician should ensure that the teenand her family have access to accurate resources that canprovide them with important information. Finally, thephysician should take the time to ensure that this teen’sdecision to be vegetarian was not based on an underlyingemotional problem, including an eating disorder.Adolescent Vegetarians: A Unique ChallengeDuring adolescence, youth assert their independence,develop their self-identity, and build relationships withboth sexes. Adolescent vegetarians should not bethought of as younger versions of adult vegetarians. Thecommon adult explanations for a vegetarian diet includehealth, religious, familial, and cultural reasons. However,these motives do not always influence adolescents in thesame way. Often, the decisions that adolescents make arerelated directly to their developmental needs and developmentalstage. (13)The most challenging of adolescent vegetarians is onewho has been raised as an omnivore and who decides tochange dietary habits independent of his or her family’seating style. Of a sample adolescent population in Minnesotaof just fewer than 20,000 individuals, 0.6% ofadolescents identified themselves as vegetarians. (14)The starting point for an appropriate dialogue with ateenage patient is similar to that of a breastfeeding mother:taking a dietary history. It is most important toascertain what it means to this young woman to be avegetarian. Similarly, how does she define and apply thisform of diet in her own life?The Typical Adolescent VegetarianMost adolescent vegetarians tend to be female. In onestudy that investigated adolescent vegetarians in Minnesota,81% of self-identified vegetarians were female, andonly 19% were male. (14) Most often, adolescent vegetariansshare negative feelings toward eating meat, feelstrongly about animal cruelty, and place more importanceon their appearance and environment. (13) Anothercommon characteristic of adolescent vegetarians isthat they engage in many positive behaviors. Adolescentvegetarians tend to consume more fruits and vegetableswhile consuming fewer sweet and salty snack foods.These youth also tend to weigh less than their nonvegetarianpeers.An important aspect of adolescence is that many decisionsare made impulsively and without much considerationfor the future. Consequently, positive aspects ofvegetarianism also can lend themselves to negative orharmful behaviors. All vegetarians are at risk for nutritionalinadequacies if they do not consume appropriateamounts of foods rich in protein, iron, calcium, and zinc.Adolescents are at even greater risk if their decisions tobecome vegetarian were sudden and without properattention to necessary details and information.The adolescent patient in this case revealed a distinctdate in history when she changed her eating habits. Hersudden dietary changes, as well as her current foodchoices, imply that her decision was not well researched.If she were to continue to eat the foods that she describes(pastas, bagels, and “side dishes”), she would be at riskfor specific nutritional deficiencies. However, adolescentsfrequently have difficulty imagining the future, andit can be challenging to impress on them future consequences.Regardless, efforts should be made to preparethem for the future because adolescents will be in chargeof all their dietary choices once they leave the home forcollege or employment.The Vegetarian Food Guide Pyramid, a NewModelTo capitalize on positive benefits and minimize negativeconsequences, it is important that adolescent vegetariansreceive appropriate counseling and guidance regardingPediatrics in Review Vol.30 No.1 January 2009 e5Downloaded from http://pedsinreview.aappublications.org/ at National Naval Medical Center (NNMC) on August 12, 2011

nutritionvegetarian dietsFigure 1. The Food Guide Pyramid.their dietary choices. One of the challenges in providingappropriate information is the limited number of easilyaccessible models that demonstrate what foods are importantand how they should be applied to the diet. Mostadolescents are familiar with the Food Guide Pyramid, amodel that shows how nutritional guidelines and requirementsfit into one’s daily food choices (Fig. 1). Thedifficulty in using the Food Pyramid as a guide whentalking to vegetarian adolescents is that it targets a populationof omnivores. Thus, the nutritional standards arebased on a nonvegetarian diet. (15)There are adaptations of the food guide to account forvegetarianism. One example is the United States Departmentof Agriculture’s Food Guide Pyramid. In thisguide, flesh foods are eliminated from the protein foodgroup. Unfortunately, this guide does not take intoaccount that some vegetarians exclude all animal and fishproducts. Therefore, dairy products and eggs also shouldbe eliminated. Additionally, the proportions of the pyramidno longer are appropriate because certain staplefoods have been removed without accounting for relativeproportions or nutrient composition.When presented with accurate information, vegetarianscan fulfill all of their nutritional requirements in allstages of life. Many individuals would like to becomevegetarians because they are aware of the health benefits.However, these individuals are at a loss as to how to makethe transition when there are no appropriate and easilyaccessible guides.Recently, a Vegetarian Food Guide Pyramid was introducedto the United States Congress by organizers ofthe Third International Congress on Vegetarian Nutrition(Fig. 2). (15) The bottom tiers of the pyramidconsist of the five major plant-based food groups: wholegrains, legumes, vegetables, fruits, nuts, and seeds. At thetop of the pyramid are the foods that may or may not beincluded in a vegetarian diet: vegetable oil, dairy, eggs,and sweets. The hope is that this provisional guide willmotivate additional research and development of futureguides. (15)Involving the FamilyAnother opportunity to counsel adolescent vegetarianscomes about because of an adolescent’s impulsivity. Suddenchanges in diet for newly converted adolescent vegetariansoften are not accompanied by a change in theirfamilies’ eating habits. Many families tend to be acceptingof their child’s new eating habits, but provisions arenot always made to help the child receive the nutritionthat he or she needs. The new vegetarian adolescentdescribed in the case reports eating “side dishes” at thefamily meal. The most common reason for eating onlye6 Pediatrics in Review Vol.30 No.1 January 2009Downloaded from http://pedsinreview.aappublications.org/ at National Naval Medical Center (NNMC) on August 12, 2011

nutritionvegetarian dietsFigure 2. Vegetarian Food Guide Pyramid, depicting the specific food groups that may be included in a vegetarian diet along withthe appropriate food proportions for each food group. The Dairy, Eggs, and Sweets categories are optional. Modified from Haddadet al. (15)“side dishes” is that the main dish usually is an animal orfish product. Many families assume that their vegetarianchild is going through a phase and soon will return to ameat-based diet.Although most adolescents no longer depend solelyon their families for food, it still is important to educateTable 3. Available ResourcesUnited States Department of AgricultureMyPyramid.govLocal Farmers’ Marketshttp://www.ams.usda.gov/farmersmarkets/Vegetarian Resource Groupwww.vrg.orgVegetarian Children and AdolescentsVegetarianteen.comVegetarian Restaurants Around the WorldVegdining.comparents and siblings about vegetarianism and availableresources (Table 3). Families should not be expected tochange their eating habits, but it is important that appropriatefoods be available for the vegetarian child. Wellinformedparents can guide vegetarian adolescents whoare having difficulty adapting to their new dietary restrictions.Vegetarian adolescents commonly eat foods out ofconvenience, such as pasta and bagels. It is important tostress that these foods may be meatless, but they do notprovide adequate nutrition. It also is important to stressthat adolescent vegetarians need to be aware of nutritionalinformation for preprepared vegetarian meals.Vegetarians often have the misconception that certainfoods must be healthy because they contain productssuch as tofu or tempeh. As with any food, assessingnutritional information concerning fat, sodium, calories,and sugar is important.Potential Disorders in the AdolescentVegetarianAn important point that often can be the most difficult toelicit is whether an adolescent’s choice to be a vegetarianis a form of restriction. Is it possible that vegetarianismPediatrics in Review Vol.30 No.1 January 2009 e7Downloaded from http://pedsinreview.aappublications.org/ at National Naval Medical Center (NNMC) on August 12, 2011

COVER ARTICLEPROBLEM-ORIENTED DIAGNOSISDiagnosis of Eating Disordersin Primary CareSARAH D. PRITTS, M.D., and JEFFREY SUSMAN, M.D.University of Cincinnati College of Medicine, Cincinnati, OhioEating disorders, particularly anorexia nervosa and bulimia nervosa, are significantcauses of morbidity and mortality among adolescent females and young women. Eatingdisorders are associated with devastating medical and psychologic consequences,including death, osteoporosis, growth delay, and developmental delay. Prompt diagnosisis linked to better outcomes. A good medical history is the most powerful tool.Simple screening questions, such as “Do you think you should be dieting?” can be integratedinto routine visits. Physical findings such as low body mass index, amenorrhea,bradycardia, gastrointestinal disturbances, skin changes, and changes in dentition canhelp detect eating disorders. Laboratory studies can help diagnose these conditionsand exclude underlying medical conditions. The family physician can play an importantrole in diagnosing these illnesses and can coordinate the multidisciplinary team of psychiatrists,nutritionists, and other professionals to successfully treat patients with eatingdisorders. (Am Fam Physician 2003;67:297-304,311-2. Copyright© 2003 AmericanAcademy of Family Physicians.)O A patient informationhandout abouteating disorders, writtenby the authors ofthis article, is providedon page 311.Members of variousfamily practice departmentsdevelop articlesfor “Problem-OrientedDiagnosis.” This is onein a series from theDepartment of FamilyMedicine at the Universityof Cincinnati Collegeof Medicine.Guest coordinator ofthe series is SusanMontauk, M.D.See page 237 for definitionsof strength-ofevidencelevels.Eating disorders are amongthe most common psychiatricproblems that affectyoung women, 1 and theseconditions impose a highburden of morbidity and mortality.Unfortunately, the diagnosis of eatingdisorders can be elusive, and more thanone half of all cases go undetected. 2 Thefamily physician’s office is an ideal settingto identify eating disorders and initiatetreatment in a timely fashion. This reviewfocuses on recognition and diagnosis ofeating disorders in primary care. A comprehensivereview of treatment and otheraspects of these conditions is available inthe American Psychiatric Association’spractice guideline on the treatment ofeating disorders. 3EpidemiologyEating disorders occur most commonlyin adolescents and young adults and are10 times more common in females thanin males. They occur in all ethnic groupsbut are most common among whites inindustrialized nations. The principal eatingdisorders are anorexia nervosa,bulimia nervosa, and nonspecified eatingdisorder. Anorexia has two subtypes—restricting type and binge-eating/purgingtype. Bulimia also has two subtypes—purging and nonpurging.In young women, the risk of developinganorexia is 0.5 to 1 percent, andmortality is estimated at 4 to 10 percent.4,5 In the same population, the riskof developing bulimia is 2 to 5 percent, 1,6and the incidence of disordered eatingthat does not meet strict criteria for eatingdisorders may be twice that of theabove conditions. 2 Frequent dieting anddesire for weight loss occur much morecommonly than overt eating disorders.In 1999, the Youth Risk Behavior SurveillanceSurvey 7 reported that 58 percentof students in the United States hadexercised to lose weight, and 40 percentof students had restricted caloric intakein an attempt to lose weight. Many adolescentsand young adults who do notmeet the strict diagnostic criteria foreating disorders have disordered eatingpatterns, which can have a significantadverse impact on health. The distinctionbetween normal dieting and disor-JANUARY 15, 2003 / VOLUME 67, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 297

It is important to aggressively treat patients who have traitsof eating disorders but who do not meet the full criteriafor anorexia or bulimia.TABLE 1Diagnostic Criteria for Anorexia Nervosadered eating is based on whether the patienthas a distorted body image.EtiologyRisk factors for developing an eating disorderinclude participation in activities that promotethinness, such as ballet dancing, modeling,and athletics, 4 and certain personalitytraits, such as low self-esteem, difficultyexpressing negative emotions, difficultyresolving conflict, and being a perfectionist. 1Eating disorders are particularly common inA. Refusal to maintain body weight at or above a minimally normal weightfor age and height (e.g., weight loss leading to body weight less than85 percent of that expected; or failure to make expected weight gainduring period of growth, leading to body weight less than 85 percent ofthat expected)B. Intense fear of gaining weight or becoming overweight, even though patientis underweightC. Disturbance in the way in which one’s body weight or shape is experienced,undue influence of body weight or shape on self-evaluation, or denial of theseriousness of the current low body weightD. Amenorrhea in postmenarchal females (i.e., the absence of at least threeconsecutive menstrual cycles. A woman is considered to have amenorrheaif her periods occur only following hormone administration.)Specify type:Restricting type: during the current episode, the patient has not regularlyengaged in binge eating or purging (i.e., self-induced vomiting or the misuseof laxatives, diuretics, or enemas)Binge-eating/purging type: during the current episode, the patient hasregularly engaged in binge eating or purgingReprinted with permission from Diagnostic and Statistical Manual of Mental Disorders.4th ed, text revision. Washington, D.C.: American Psychiatric Association,2000:589.young women with type 1 diabetes mellitus.Up to one third of women with type 1 diabetesmay have eating disorders, and thesewomen are at especially high risk of microvascularand metabolic complications. 8The role of family history in the developmentof eating disorders is not clear. Somestudies 9 of twins demonstrate a strong link,and others demonstrate no correlation. Afamily history of mood disorders in a firstdegreerelative also might be a risk factor. 5DiagnosisEarly diagnosis with intervention and earlierage at diagnosis are correlated withimproved outcomes in patients who have eatingdisorders. 5 Because family physicians serveas primary care providers for a large percentageof adolescents, they have an importantrole in diagnosing these disorders.The hallmark of anorexia is a refusal tomaintain body weight at or above 85 percentof expected weight, as defined by age-appropriatebody mass index charts. Patients withanorexia use caloric restriction or excessiveexercise to control emotional need or pain,and they are terrified of becoming overweight.Patients with nonpurging-type bulimia alsomight severely restrict calories or exerciseexcessively to lose weight but do not meet theweight criteria for diagnosis of anorexia.Bulimia is characterized by uncontrollablebinge-eating episodes, often followed by purgingbehaviors such as vomiting or the use oflaxatives. Patients with binge-eating/purgingtypeanorexia also might binge and purge.Patients who have bulimia may be of normalweight, or they may be under- or overweight,whereas patients with binge-eating/purgingtypeanorexia are underweight.Both of the major eating disorders are characterizedby a disturbance in the perception ofbody shape, which is closely tied to self-image.Summaries of diagnostic criteria for anorexiaand bulimia are provided in Tables 1 and 2. 10It is also important to aggressively treatpatients who have traits of eating disorders298 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 2 / JANUARY 15, 2003

Eating Disordersbut who do not meet the full criteria foranorexia or bulimia. 11Differential DiagnosisA wide variety of medical problems canmasquerade as eating disorders. Hyperthyroidism,malignancy, inflammatory bowel disease,immunodeficiency, malabsorption,chronic infections, Addison’s disease, and diabetesshould be considered before making adiagnosis of an eating disorder. Most patientswith a medical condition that leads to eatingproblems express concern over their weightloss. However, patients with an eating disorderhave a distorted body image and express adesire to be underweight. 10Psychiatric comorbidity is extremely common;illnesses such as affective disorders, obsessive-compulsivedisorder, somatization disorder,and substance abuse must be consideredwhen patients present with such symptoms. 12Major depression is the most commoncomorbid condition among patients withanorexia, with a lifetime risk as high as 80 percent.5 Anxiety disorders, especially social phobia,also are common. 5 Obsessive-compulsivedisorder has a prevalence of 30 percent amongpatients with eating disorders. 13 Substanceabuse prevalence is estimated at 12 to 18 percentin patients with anorexia and 30 to 70 percentin patients with bulimia. 14Personality disorders (Axis II diagnoses)also are common, with comorbidity ratesreported at 21 to 97 percent. 15 The wide rangeis related to the complexity of evaluating thesediagnoses. Patients with bulimia are morelikely to have a cluster B diagnosis (dramatic/erratic), whereas patients with anorexia aremore likely to have a cluster C diagnosis(avoidant/anxious). 15Screening ToolsAll patients in high-risk categories for eatingdisorders should be screened during routineoffice visits. 16 The medical history is themost powerful tool for diagnosing eating disorders.Physical examination and laboratoryPatients with eating disorders have very high rates of comorbidpsychiatric conditions.findings might be normal, especially early inthe course of eating disorders.A number of comprehensive psychiatricinterviews can be used to diagnose eating disorders,17,18 but these are impractical in the primarycare setting. One promising screeningtool is the SCOFF questionnaire (Table 3). 19Because of its 12.5 percent false-positive rate,this test is not sufficiently accurate for diagnosingeating disorders, but it is an appropriatescreening tool.TABLE 2Diagnostic Criteria for Bulimia NervosaA. Recurrent episodes of binge eating. An episode of binge eating ischaracterized by both of the following:(1) In a discrete period of time (e.g., within any two-hour period), eating anamount of food that is larger than what most people would eat during asimilar period of time and under similar circumstances(2) A sense of lack of control over eating during the episodeB. Recurrent inappropriate compensatory behavior in order to prevent weightgain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas,or other medications; fasting; or exercising excessivelyC. The binge eating and inappropriate compensatory behaviors both occur, onaverage, at least twice a week for three monthsD. Self-evaluation is unduly influenced by body shape and weightE. The disturbance does not occur exclusively during episodes of anorexianervosaSpecify type:Purging type: during the current episode, the patient has regularly engaged inself-induced vomiting or the misuse of laxatives, diuretics, or enemasNonpurging type: during the current episode, the patient has used inappropriatecompensatory behaviors, such as fasting or exercising excessively, buthas not regularly engaged in self-induced vomiting or the use of laxatives,diuretics, or enemasReprinted with permission from Diagnostic and Statistical Manual of Mental Disorders.4th ed, text revision. Washington, D.C.: American Psychiatric Association,2000:594.JANUARY 15, 2003 / VOLUME 67, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 299

TABLE 3SCOFF QuestionsDo you make yourself Sick (induce vomiting)because you feel uncomfortably full?Do you worry that you have lost Control over howmuch you eat?Have you recently lost more than One stone(14 lb [6.4 kg]) in a three-month period?Do you think you are too Fat, even though otherssay you are too thin?Would you say that Food dominates your life?One point for every yes answer; a score ≥ 2 indicatesa likely case of anorexia nervosa or bulimia nervosa(sensitivity: 100 percent; specificity: 87.5 percent).Reprinted with permission from Morgan JF, Reid F,Lacey JH. The SCOFF questionnaire: assessment of anew screening tool for eating disorders. BMJ 1999;319:1467.Other screening questions that might behelpful are listed in Table 4. 18,20 Positiveresponses to any of these questions shouldprompt further investigation with a morecomprehensive questionnaire. When screeningpatients, it is important to take their developmentalstage into account; some questionsmight be inappropriate for younger patients.History and Presenting SymptomsPatients with eating disorders can have awide range of symptoms. Those with milderillness might have nonspecific complaints,such as fatigue, dizziness, or lack of energy. 4Patients might deny that they have symptoms,but their family members mightexpress concern. Patients who have anorexiatypically will be unconcerned about significantweight loss. Other symptoms that mightbe reported or elicited include amenorrhea,sore throat, gastroesophageal reflux disease,abdominal pain, cold intolerance, constipation,polyuria, polydipsia, and palpitations.When taking a medical history, it is alsoimportant to take a dietary history to askabout the use of laxatives or diuretics. Table 5compares important clinical features ofanorexia and bulimia.When obtaining a history, it is important toestablish trust and rapport with the patient,especially when the patient does not perceive aproblem. Talking to the family and patienttogether, as well as talking to the patient individually,is appropriate. If the patient is anadolescent, questions must be asked in adevelopmentally appropriate, precise, nonjudgmentalway. 21Physical ExaminationComplications of anorexia and bulimia canaffect nearly every organ system. However,many patients might have a completely normalphysical examination, especially early inthe disorder. It is important to explain topatients and their families that a normal physicalexamination does not rule out an eatingdisorder.Accurate weight measurements are importantin diagnosing an eating disorder. Abnormalgrowth curves, especially in children andadolescents, can be revealing. A patient whoTABLE 4Suggested Screening Questions forAnorexia Nervosa and Bulimia NervosaHow many diets have you been on in the past year?Do you think you should be dieting?Are you dissatisfied with your body size?Does your weight affect the way you think aboutyourself?A positive response to any of these questions warrantsfurther evaluation.Information from Anstine D, Grinenko D. Rapidscreening for disordered eating in college-agedfemales in the primary care setting. J Adolesc Health2000;26:338-42.300 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 2 / JANUARY 15, 2003

Eating DisordersTo avoid revealing their true weight, some patients witheating disorders might drink extra fluids, put weights intheir pockets, or wear layers of heavy clothing beforebeing weighed.initially had normal growth parameters mightstop gaining weight or might lose weight whileheight increases. Eventually, height will beaffected, and growth will diminish.To obtain accurate weight measurements,office staff must be trained to use standardizedprotocols to record consistent, reliable measurements.Scales should be located in a privatearea, and comments about weight shouldbe minimized and made discreetly. Staffshould be aware that some patients with eatingdisorders, to avoid revealing their trueweight, might drink extra fluids, put weightsin their pockets, or wear layers of heavy clothingbefore being weighed. 1Vital signs might be abnormal, such asbradycardia, orthostatic hypotension, andhypothermia. Abnormal skin findingsinclude dry skin, loss of subcutaneous fat,lanugo (fine body hair), and hypercarotenemia(an orange hue caused by increasedingestion of carrots). Patients who inducevomiting might have calluses on the dorsumof the dominant hand, as well as loss of dentalenamel. Salivary gland enlargement isanother sign of purging behavior.Pulmonary complications of eating disordersare rare, but vomiting can cause a pneumomediastinum.Pulmonary edema mayoccur in patients who undergo refeeding. Inaddition to bradycardia, cardiac findings mayinclude acrocyanosis and decrease in overallheart size and stroke volume. Cardiomegalycan indicate ipecac use. Electrocardiogramfindings may include bradycardia, prolongedQT interval, and nonspecific ST-T changes.The gastrointestinal system also can beadversely affected. There can be decreasedbowel motility, leading to abdominal distension.Gastroesophageal reflux and pancreatitisTABLE 5A Comparison of Features of Anorexia Nervosa and Bulimia NervosaFeatures Anorexia nervosa Bulimia nervosaHistory and Amenorrhea, constipation, headaches, Bloating, fullness, lethargy, GERD,symptoms fainting, dizziness, fatigue, cold abdominal pain, sore throatintolerance(from vomiting)Physical findings Cachexia, acrocyanosis, dry skin, hair loss, Knuckle calluses, dental enamelbradycardia, orthostatic hypotension, erosion, salivary gland enlargement,hypothermia, loss of muscle mass and cardiomegaly (ipecac toxicity)subcutaneous fat, lanugoLaboratory Hypoglycemia, leukopenia, elevated Hypochloremic, hypokalemic, or metabolicabnormalities liver enzymes, euthyroid sick syndrome alkalosis (from vomiting), hypokalemia(low TSH level, normal T 3 , T 4 levels) (from laxatives or diuretics), elevatedsalivary amylase (might also be presentin binging/purging subtype of anorexia)ECG findings Low voltage; prolonged QT interval, Low voltage; prolonged QT interval,bradycardiabradycardiaGERD = gastroesophageal reflux disease; TSH = thyroid-stimulating hormone; T 3 = triiodothyronine; T 4 = thyroxine;ECG = electrocardiogram.JANUARY 15, 2003 / VOLUME 67, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 301

The Authorscan cause epigastric pain. If the patient is constipated,stool might be palpable in the leftlower quadrant.Laboratory EvaluationLaboratory findings might be completelynormal, but targeted laboratory testing can behelpful to rule out medical illness. In patientswho have eating disorders, the completeblood cell count might be normal, butleukopenia is not uncommon, probablybecause of increased margination of neutrophils.Immune function does not appearto be impaired. In severe cases, pancytopeniamight be present. 12 Blood glucose levelsmight be low. 2 Hypochloremic, hypokalemic,or metabolic alkalosis might be present inpatients who purge. Hypokalemia also mightresult from diuretic and laxative use. Severehypokalemia might lead to cardiac arrhythmias,muscle weakness, or confusion. Hyponatremiamight occur with excessive waterintake. Thyroid-function test findings mightbe consistent with the euthyroid sick syndrome,with low triiodothyronine and thyroxinelevels and a normal thyroid-stimulatinghormone level.Osteopenia in eating disorders can resultfrom several factors. Decreased estrogen levelsand inadequate micronutrients, especiallyduring adolescence when bone strength istypically increasing, can lead to clinically significantosteopenia after as few as six monthsSARAH D. PRITTS, M.D., is assistant professor of clinical family medicine and a memberof the predoctoral faculty at the University of Cincinnati College of Medicine. Shereceived her medical degree from Northwestern University Feinberg School of Medicine,Chicago, and completed a residency in family medicine at the University ofCincinnati/Mercy-Franciscan Mt. Airy Hospitals.JEFFREY SUSMAN, M.D., is professor of family medicine and director of the Departmentof Family Medicine at the University of Cincinnati College of Medicine. Hereceived his medical degree from Dartmouth Medical School, Hanover, N.H., and completedhis residency at Lancaster General Hospital, Lancaster, Pa.Address correspondence to Sarah D. Pritts, M.D., University of Cincinnati Medical Center,Department of Family Medicine, P.O. Box 670582, Cincinnati, OH 45267-0582(e-mail: prittssd@fammed.uc.edu). Reprints are not available from the authors.of illness. 2 It is worthwhile to obtain dualenergyx-ray absorptiometry scans after sixmonths of amenorrhea in patients withanorexia and in patients with bulimia whohave a history of anorexia. 12TreatmentTreatment intensity and setting depend onthe severity of the illness. Patients with mild illnesscan be managed on an outpatient basis.Patients who are medically or psychiatricallyunstable require inpatient treatment (Table 6). 3[Evidence level C, expert opinion] Treatmentgoals include attainment and maintenance ofa healthy weight, management of physicalcomplications, management of comorbidpsychiatric illness, and prevention of relapse.Eliciting cooperation from the patient, helpingto change maladaptive thoughts, and educatingthe patient about proper health andnutrition also are important. 3Adequate treatment of eating disordersrequires a multidisciplinary team approach.The family physician can and should be anintegral member of that team. Early in the illness,frequent visits to the primary care physician’soffice are helpful for surveillance ofmedical conditions, as well as for nutritionalre-education. The family physician also will beindispensable in the role of coordinating theentire team of professionals involved in thepatient’s care.PrognosisThe prognosis of patients who have eatingdisorders is variable. The general consensus isthat 50 percent of patients with anorexia havegood outcomes, 30 percent have intermediateoutcomes, and 20 percent have poor outcomes.The percentages are similar in bulimicpatients, with 45 percent having good outcomes,18 percent having intermediate outcomes,and 21 percent having poor outcomes.Patients with anorexia have a mortality ratesix times that of peers without anorexia. 5Factors that predict improved outcomes foreating disorders include early age at diagnosis,302 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 2 / JANUARY 15, 2003

Eating DisordersTABLE 6Level-of-Care Criteria for Patients with Eating DisordersLevel 2:Level 1: Intensive Level 3: Level 4: Level 5:Characteristic Outpatient outpatient Full-day outpatient Residential treatment center Inpatient hospitalizationMedical complications Medically stable to the extent that more extensive monitoring, Medically stable (not Adults: HR < 40 beats peras defined in Levels 4 and 5, is not required requiring NG feeds, minute; BP < 90/60 mm Hg;IV fluids, or multiple glucose < 60 mg per dLdaily laboratories)(3.3 mmol per L); K + 85 percent > 80 percent > 70 percent < 85 percent Adults: < 75 percentof healthy body weightChildren and adolescents:acute weight decline withfood refusalMotivation to recover Good to fair Fair Partial; preoccupied Fair to poor; preoccupied Poor to very poor; preoccupied(cooperativeness, insight, with ego-syntonic with ego-syntonic with ego-syntonic thoughts;ability to control thoughts more thoughts 4 to 6 hours per uncooperative with treatmentobsessive thoughts) than 3 hours per day; cooperative with or cooperative only withday; cooperative highly structured treatment highly structured environmentComorbid disorders Presence of comorbid condition may influence choice of level of care Any existing psychiatric disorder(substance abuse,that would requiredepression, anxiety)hospitalizationStructure needed for Self-sufficient Needs some structure Needs supervision at all Needs supervision during andeating/gaining weight to gain weight meals or will restrict after all meals, or NG/specialeatingfeedingImpairment and ability Able to exercise for fitness; able to Structure required Complete role impairment, cannot eat and gain weight byto care for self; ability control obsessive exercise to prevent self; structure required to prevent patient from compulsiveto control exercise excessive exercise exercisingPurging behavior Can greatly reduce purging in nonstructured settings; no Can ask for and use support Needs supervision during and(laxatives and diuretics) significant medical complications, such as ECG abnormalities or skills if desires to purge after all meals and inor others suggesting the need for hospitalizationbathroomsEnvironmental stress Others able to provide adequate Others able to Severe family conflict, problems, or absence so as unable toemotional and practical support provide at least provide structured treatment in home, or lives aloneand structure limited support without adequate support systemand structureTreatment availability/ Lives near treatment setting Too distant to live at homeliving situationNG = nasogastric; IV = intravenous; HR = heart rate; BP = blood pressure; K + = potassium level; ECG = electrocardiogram.Adapted with permission from Practice guideline for the treatment of patients with eating disorders (revision). American Psychiatric Association Work Groupon Eating Disorders. Am J Psychiatry 2000;157(suppl 1):20.brief interval before initiation of treatment,good parent-child relationships, and havingother healthy relationships with friends ortherapists. 5Because of the severity of these illnesses andthe improvement in outcomes when diagnosisoccurs earlier, the family physician can play acrucial role in helping patients recover fromeating disorders by detecting them at an earlystage.JANUARY 15, 2003 / VOLUME 67, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 303

Feeding and Eating DisordersThe chapter on Feeding and Eating Disorders in the fifth edition of the Diagnostic and Statistical Manualof Mental Disorders (DSM-5) includes several changes to better represent the symptoms and behaviorsof patients dealing with these conditions across the lifespan. Among the most substantial changesare recognition of binge eating disorder, revisions to the diagnostic criteria for anorexia nervosa andbulimia nervosa, and inclusion of pica, rumination and avoidant/restrictive food intake disorder. DSM-IVlisted the latter three among Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence, achapter that will not exist in DSM-5.In recent years, clinicians and researchers have realized that a significant number of individuals witheating disorders did not fit into the DSM-IV categories of anorexia nervosa and bulimia nervosa. Bydefault, many received a diagnosis of “eating disorder not otherwise specified.” Studies have suggestedthat a significant portion of individuals in that “not otherwise specified” category may actually havebinge eating disorder.Binge Eating DisorderBinge eating disorder was approved for inclusion in DSM-5 as its own category of eating disorder. InDSM-IV, binge-eating disorder was not recognized as a disorder but rather described in Appendix B:Criteria Sets and Axes Provided for Further Study and was diagnosable using only the catch-all categoryof “eating disorder not otherwise specified.”Binge eating disorder is defined as recurring episodes of eating significantly more food in a short periodof time than most people would eat under similar circumstances, with episodes marked by feelings oflack of control. Someone with binge eating disorder may eat too quickly, even when he or she is nothungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat aloneto hide the behavior. This disorder is associated with marked distress and occurs, on average, at leastonce a week over three months.This change is intended to increase awareness of the substantial differences between binge eatingdisorder and the common phenomenon of overeating. While overeating is a challenge for many Americans,recurrent binge eating is much less common, far more severe, and is associated with significantphysical and psychological problems.Anorexia NervosaAnorexia nervosa, which primarily affects adolescent girls and young women, is characterized by distortedbody image and excessive dieting that leads to severe weight loss with a pathological fear ofbecoming fat. The criteria have several minor but important changes:• Criterion A focuses on behaviors, like restricting calorie intake, and no longer includes the word“refusal” in terms of weight maintenance since that implies intention on the part of the patient andcan be difficult to assess. The DSM-IV Criterion D requiring amenorrhea, or the absence of at leastthree menstrual cycles, will be deleted. This criterion cannot be applied to males, pre-menarchalfemales, females taking oral contraceptives and post-menopausal females. In some cases, individualsexhibit all other symptoms and signs of anorexia nervosa but still report some menstrual activity.

Bulimia NervosaBulimia nervosa is characterized by frequent episodes of binge eating followed by inappropriate behaviorssuch as self-induced vomiting to avoid weight gain. DSM-5 criteria reduce the frequency of bingeeating and compensatory behaviors that people with bulimia nervosa must exhibit, to once a weekfrom twice weekly as specified in DSM-IV.Overall ChangesThe Eating Disorders Work Group intended for DSM-5 changes to minimize use of the catch-all diagnosesof Other Specified Feeding and Eating Disorder and Unspecified Feeding and Eating Disorder.A primary goal is for more people experiencing eating disorders to have a diagnosis that accuratelydescribes their symptoms and behaviors. Determining an accurate diagnosis is a first step for cliniciansand patients in defining a treatment plan.DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American PsychiatricAssociation (APA) will publish DSM-5 in 2013, culminating a 14-year revision process. For more information, go to www.DSM5.org.APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment,prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.organd www.healthyminds.org. For more information, please contact Eve Herold at 703-907-8640 or press@psych.org.© 2013 American Psychiatric Association2 • Feeding and Eating Disorders

Nutrition III Quiz1. Please fill-in the serving ranges for the “Food Plate” of an early-to-middle adolescent:Calories/day(school-age):Calories/day(adolescent):2. What are the most common nutritional deficiencies in adolescent females, and how mightthey present?3. What are the most common nutritional deficiencies in vegetarians and how do they present?4. Please match the following diagnostic features with the appropriate eating disorder:A. Amenorrhea___________________________B. Prolonged QT interval___________________________C. hypoCl, hypoK metabolic alkalosis___________________________D. GERD___________________________E. Hair loss___________________________F. Hypoglycemia___________________________G. Salivary gland enlargement___________________________5. Among young women, the risk of developing anorexia is _______. Among anorexics,approximately ______ do well over time, ______ continue to have symptoms, and ______ dopoorly. The mortality rate is ________, which is _____times that of peers without anorexia.

Nutrition III CasesCase 1: Eating DisordersAbby, a 16-year old previously healthy female, presents for a school physical. You glance at thefollowing growth charts, imported by your corpsman, as she enters your room.Weight vs. AgeHeight vs. AgeBMI vs. Age

Based on the growth chart, what is your biggest concern? What else is in your differential?What history do you want to obtain to clarify your diagnosis?Abby tells you that, although her body weight today in clinic is

Case 2: Vegan/Vegetarian EatingHM3 Smith presents with his pregnant wife and son, age 4, and daughter, age 13, for their schoolphysicals. In taking a dietary history, you learn that the 13 year-old has decided to become“vegan”, after watching a rerun of “The Vegan Challenge” episode on Oprah. She also DVR’dthe episode for her mother and convinced her to start cooking vegan for the entire family. Mrs.Smith proudly reports that, for the last year, the entire family has been eating vegan, and she hasnoticed that she and her children have been healthier and more energetic. HM3 Smith, who hasbeen missing his steak dinners, asks you to explain to his wife and strong-willed 13-year-old whya vegan diet is unhealthy.What is eliminated in a vegan diet versus a vegetarian diet?Can you make an argument to support Mrs. Smith? What are the benefits of a vegan orvegetarian diet?HM3 Smith seems even more distressed by this explanation. To diffuse the situation, you askthe others to step out the room, so that you can do your HEADSS exam for the 13-year-old.Regarding her choice to become vegan, what sorts of questions and counseling do you wantto address to this adolescent?The 13-year-old reassures you that her reasons for becoming vegan were due to Oprah—and notan underlying eating disorder. You complete the remainder of her HEADSS and physical exam,and you nervously invite the rest of the family back into the room. After examining the 4-yearold,HM3 Smith asks you to provide his wife with guidance for the younger children, “since sheinsists on this vegan nonsense”.What guidance would you give for the toddler Smith? What guidance would you give forMrs. Smith, as she anticipates the arrival of Baby #3?

Nutrition III Board Review1. You are evaluating a 2-year-old daughter of strict vegan parents. Her birthweight at term was 3.5 kg. Sinceweaning at 12 months of age, the child’s diet has included a homemade, macrobiotic-based formula. In your officetoday, the girl’s weight is 11.2 kg.Of the following, the child’s diet MOST likely is deficient inA. essential amino acidsB. linoleic acidC. vitamin AD. vitamin B12E. vitamin C2. A 7-month-old child presents for a follow-up office visit after undergoing a Kasai procedure for biliary atresia at6 weeks of age. The mother states that the boy is irritable when his right arm is moved. On physical examination, theinfant is jaundiced. You detect tenderness in the anterior radial head. Radiography of the affected regiondemonstrates metaphyseal fraying and a fracture.Of the following, the MOST appropriate laboratory studies to obtain next areA. calcium and phosphorus measurement and bone densitometry (DEXA scan)B. calcium and phosphorus measurement and urinary calcium-to-creatinine ratioC. calcium, phosphorus, and 25-hydroxyvitamin D measurementD. calcium, phosphorus, and magnesium measurementE. magnesium, phosphorus, and parathyroid hormone measurement3. A 12-year-old boy has had cholestasis since infancy from Alagille syndrome. He has been lost to medical followupfor the last several years. He now presents to your office with pain in his right upper thigh after a fall. His thigh isintensely tender, and ultrasonography demonstrates a large hematoma in his quadriceps. The parents state that he hastended to bruise easily in the past few months.Of the following, the condition MOST likely to account for this patient’s symptoms isA. factor VIII deficiencyB. idiopathic thrombocytopenic purpuraC. vitamin C deficiencyD. vitamin K deficiencyE. von Willebrand disease4. A 16-year-old boy in your practice has cystic fibrosis. As a complication of his illness, he has developed cirrhosisand cholestasis. He now complains of shaky hands. Neurologic examination demonstrates hyporeflexia and tremorwith hands outstretched.Of the following, the patient’s symptoms are MOST consistent with deficiency ofA. vitamin AB. vitamin B1 (thiamine)C. vitamin CD. vitamin DE. vitamin E5. A medical student rotating in your clinic tells you about a 5-month-old infant he has evaluated. He reports thatthe infant is fed goat milk exclusively and asks you if this is adequate nutrition at this age.Of the following, the MOST likely deficiency in this infant is ofA. folateB. ironC. niacinD. vitamin AE. vitamin D