Look beyond stereotypes to spot patients with eating disorders
■ A national statistical analysis indicates that rates for these illnesses are on the rise among younger patients and other unexpected demographics.
By Victoria Stagg Elliott — Posted April 20, 2009
David S. Rosen, MD, MPH, an adolescent medicine specialist in Ann Arbor, Mich., treats hundreds of patients who have anorexia or bulimia nervosa. What has become clear to him is that many don't fit the traditional image medical school taught him to look for -- that of an upper-class, perfection-obsessed teen girl. And, more and more, the patients he sees are presenting with severe symptoms at younger ages.
"Eating disorders are ... increasing. Many people in my field are seeing younger and younger people appearing more severely ill, and we're all seeing more atypical patients," said Dr. Rosen, professor of pediatrics, internal medicine and psychiatry at the University of Michigan.
These observations are starting to be borne out in government statistics. For instance, the Agency for Healthcare Research and Quality on April 1 issued an analysis from the Nationwide Inpatient Sample. An estimated 23,807 people were hospitalized for eating disorders each year in 1999 and 2000. This amount jumped 18% to 28,155 both in 2005 and in 2006.
Women age 19 to 30 still make up the largest group hospitalized for eating disorders, but researchers found such statistics grew markedly among demographics not usually considered at high risk. Hospitalizations of boys and girls younger than 12 grew 119% from the 1999-2000 period to 2005-06, while admissions among men of any age jumped 37%. Hospitalizations of patients age 45 to 65 increased by 48%.
"The age distribution is much more extended than what we anticipated," said William Encinosa, PhD, the paper's lead author and one of the quality research agency's senior economists. "This is moving out to younger kids and also to older men and women."
Patients also were admitted with more serious diagnoses. The number of patients discharged with a cardiac dysrhythmia as a secondary diagnosis went up 125% from 650 to 1,462. Acute renal or liver failure increased 118% from 99 to 216. Agency officials and eating disorder experts are particularly concerned about these numbers because the death rate for those hospitalized is approximately six per 1,000. This number did not change significantly from 1999 to 2006, but it is considered high because the affected population is so young.
"This is a group for whom we have not had as effective treatments as we would like. Many of them have multiple relapses. It's an expensive, difficult, long-term disorder to treat," said Walter Kaye, MD, professor of psychiatry and director of the eating disorders program at the University of California, San Diego.
Behind the numbers
It's unclear what is driving these trends, although some hope awareness is leading to earlier diagnosis and improvements in management.
"Generally, for eating disorders in adolescents, it is being recognized more than it used to be," said David W. Kaplan, MD, MPH, head of adolescent medicine at the University of Colorado Denver School of Medicine. "It's being better diagnosed. That's probably one factor." Dr. Kaplan chaired the American Academy of Pediatrics' Committee on Adolescence when it issued its January 2003 policy statement on identifying and treating eating disorders. This statement is being updated.
But concern also surrounds the idea that efforts to reverse the obesity epidemic, particularly in children, may initiate eating disorders in people who are genetically predisposed.
"BMI testing or weighing of kids may wind up triggering something even worse," said Edward Tyson, MD, medical director of the Cedar Springs Eating Disorder Treatment Center in Austin, Texas. "I have a lot of patients who start out wanting to get healthy, but they don't keep things in balance with exercise and food. Eating disorders are all about being out of balance."
The impact of eating disorders is even more widespread than the analysis suggests, because only a small portion of people who develop eating disorders needs to be hospitalized. To reduce the risk of these illnesses progressing to such a crisis point, eating disorder experts are calling for physicians to be alert to the early signs. For instance, patients at risk should be weighed while wearing medical gowns, because they sometimes use heavy clothes or other strategies to avoid detection.
"The best thing to do is be very vigilant of their weight and not just be lulled if they tell you that everything is fine, because it might not be," Dr. Kaplan said. "If you think things are not going well, you need to refer to a center that has significant experience with these kids."
While awareness of the scope of eating disorders is growing, work also is under way to recognize eating disorders as serious mental illnesses. Concerns stem from reports of patients having difficulty getting coverage from public and private insurers, which interferes with access to care. The Academy for Eating Disorders published a statement in the International Journal of Eating Disorders urging that anorexia nervosa, bulimia and other disordered eating be considered serious mental illnesses.
"There's a misperception that eating disorders are less serious and are associated with fewer psychiatric and medical consequences than other mental illnesses," said Kelly Klump, PhD, lead author and the organization's immediate past president. "Actually, data really suggest that's not the case. And eating disorders are biologically based, just like any other form of mental illness."
The American Medical Association's Council on Science and Public Health issued a June 2007 report on eating disorders and a healthy body image to assist physicians with early recognition and treatment. The AMA also supports increased funding for research on the epidemiology, etiology, diagnosis, prevention and treatment of eating disorders.