Management of eating disorders in children and adolescents in Hong Kong
Eating disorders (EDs) are serious psychiatric illnesses with high rates of morbidity and mortality.1 In recent years, a higher prevalence of EDs has been observed among children and adolescents. Traditionally, behaviorally focused therapies are considered as effective treatments. And promising results from these treatments, including additional support from family-based approaches for children and adolescents suffering from EDs, have been observed. In a recent interview with Omnihealth Practice, Dr. Chan, Kwok-Ling Phyllis, Chief of Service, Consultant in Child and Adolescent Psychiatry, Department of Psychiatry, Queen Mary Hospital, shared her insights on the management of children and adolescents with EDs in Hong Kong.
The burden of EDs
EDs can be divided into five categories: anorexia nervosa, bulimia nervosa, binge-eating disorder, other specified feeding or EDs, and unspecified feeding or EDs. All of these disorders are thought to exist within a broader spectrum, and patients frequently move between them.2 The prevalence of early-onset EDs has increased in the past several decades, with more girls affected than boys, and observed even in children as young as 10-11 years.3 However, a recent study conducted in the United States found that the prevalence of EDs among young children was similar between girls and boys, indicating a trend towards incidence of EDs among males.4 Whereas, ED is more common in girls than boys in Hong Kong.
In adolescence and early adulthood, EDs have one of the highest disability adjusted life years (DALYs) among all mental disorders. In the Global Burden of Disease Study 2013, anorexia nervosa and bulimia nervosa combined were the 12th leading cause of DALYs in 15-19-year-old girls in high-income countries, accounting for 2.2% of all DALYs.5,6 However, it is important to note that these figures are often underestimated as they cannot reflect the overall economic and emotional burden of EDs to the society and sufferers’ families.5
Common behaviors observed in EDs
In Hong Kong, it was previously unusual to encounter children with EDs, but this has been changed in recent years. Initial presentation of EDs usually occurs after menarche, and it is commonly observed among 14-15-year-olds children in Hong Kong now. The most common symptom noticed by the parents or caregivers is significant weight loss. The child either starts eating less than usual, stating that they are “dieting”, or they will completely avoid specific food items, such as fried foods. At severe stages, they may avoid eating completely, claiming they are feeling full or have already eaten. Other secretive behaviors may also emerge, such as increasing the types and duration of exercises, consuming medications like laxatives and inducing vomiting.
Causes and risk factors for EDs
The etiology of EDs is multifactorial in terms of the biological, psychological or social nature. Biological factors are mostly hereditary, which contribute to 50%-80% of the development of the disease. Environmental factors play a lesser part compared to the genetics. A family history of EDs has a strong correlation with the disease occurring during adolescence. Most girls who are affected share similar traits, such as perfectionism and high demands for themselves. Furthermore, they are reported to be goal-driven, strict, afraid of taking risks and having low self-esteem. Most individuals with EDs also perform well academically, showing competitiveness at school and determination to achieve high goals. The perfect body image advertised by social media may also contribute in creating a distorted and idealized conceptualization of body shapes.
In individuals who are prone to EDs, any life-event introducing changes to their diet can lead to the establishment of the disease. For example, adolescents might undergo changes in fat distribution and body weight of up to 50% during puberty. In these situations, normal individuals may adopt a diet plan for weight loss and stop after reaching a certain target. However, individuals susceptible to EDs tend to continue dieting even after achieving their weight loss goal. This is commonly demonstrated among children of upper middle class in developed countries. Subsequently, these eating disorder individuals (EDIs) can become controlled by the disease itself. They execute unrealistic dietary plans for weight loss due to distorted body image resulting in very low body mass index (BMI). Long-term low BMI levels disrupt body functions and trigger life threatening conditions. If the affected girls are prior menarche, hormonal imbalances can delay puberty.
Management of the EDs
A patient with an anorexic mind is difficult to engage in a rational conversation and remains hyperactive despite low BMI. In addition to causing the highest mortality compared to any other psychological disease, EDs are also associated with several comorbidities. Therefore, a thorough risk assessment is needed before embarking on treatment. The care pathway is first decided by whether they are inpatient or outpatient bound. The inpatient treatment depends on a number of factors including BMI, cardiovascular risk, metabolic risk, dehydration, hypothermia and failure in outpatient management (Table 1).7
If inpatient treatment is necessary, most clinical guidelines recommend a child and adolescent psychiatric or a pediatric unit with “developmentally aware and sensitive staff” experienced in the treatment of EDs.7 A multimodal approach is usually adopted, involving an interdisciplinary team working closely together. Depending on the healthcare system, the core professionals of the multidisciplinary team are child and adolescent psychiatrists and/or pediatricians, dieticians, physiotherapists and experienced nurses.
In Hong Kong, there is a specific clinic allocated for EDs at the Child and Adolescent Psychiatric Service, Department of Psychiatry in Queen Mary Hospital. This clinic particularly focuses on managing children and adolescents, who are suffering from EDs, in three aspects:
- Restoring body weight
In the treatment of adolescent EDs, restoration of a healthy body weight for age-appropriate growth and resumption of menstruation in girls are the major goals. Most importantly, achieving a normal BMI of 19/20 is considered a targeted consensus for the ED individuals. Recent studies on adolescent’s anorexia nervosa have indicated an age-adapted BMI percentile of 25 as a necessary condition for the resumption of menstruation.8 There is ongoing discussion about how to proceed in re-feeding severely malnourished patients. According to a systematic review with children and adolescents, the initially prescribed energy intake varies largely according to individual needs, which will be increased gradually based on the latest calorie intake.9
Therefore, a discussion with the dietician and patient on required BMI is mandated. After a suitable diet plan has been devised, the calorie intake should then be increased gradually to 2,000-2,200kcal per day. On the other hand, due to the higher mortality associated with re-feeding syndrome, patients should be carefully monitored with regular blood tests in order to assess their tolerance level and adjust the amount of food intake incrementally. Additionally, it is important for ED patients to be on complete bed rest during re-feeding, and it is expected that the body weight should increase by 0.5kg to 1kg weekly. A longer period of time is usually required to achieve normal BMI, after which the social cognitive skills of the brain begin to function, resulting in a lower relapse rate. Young people with EDs are also at risk of growth impairment and pubertal delay. These effects are potentially reversible; health care providers should encourage weight restoration to avoid adverse effects and allow opportunity for catch-up.
- Normalizing eating habits
In order to re-establish normal eating behaviors, an individualized meal plan consisting of three main meals and three snacks is recommended. Due to delayed gastric emptying, patients take longer time to experience hunger. Hence, even after a small meal, a feeling of fullness is always present in EDIs. Caregivers or families should understand the patients’ related discomfort and make them comfortable during meals. ED patients need to be supported emotionally, especially when they argue about consuming larger quantities of food. Moreover, continuous monitoring during food intake is essential to avoid problematic behaviors, such as hiding food, vomiting, cutting food into small pieces to show a larger amount or arranging food differently on the plate. As eating could be normalized when supported early, a nurse should prepare to sit with the patients and support them emotionally during mealtimes in an inpatient setting. In outpatient settings, support from mothers, school or caregivers during food intake is necessary, and those knowledge of support for EDIs during mealtime can be gained through the group psychoeducation or personal coaching from the therapist.
Psychotherapy is an essential part of ED treatment that is delivered on an individual basis or family-oriented approach and includes regular sessions for the caregivers to help managing the underlying etiological factors of individuals with ED. During psychotherapy, a number of stress coping mechanisms are introduced to prevent stress-induced alterations in eating patterns. The success of psychological therapy depends on the continuous support from the family as well as school. The basis and extent of psychotherapy are normally assessed during the inpatient stage according to the treatment outcome and the patient status. It consists of family therapy, cognitive behavioral therapy, MANTRA (Maudsley Model) for anorexia nervosa treatment for adults, acceptance and commitment therapy, etc. If a normal BMI can be achieved, there is a possibility of favorable prognosis, leading to a reduced duration of psychotherapy.
Message to physicians
A prevalence study on EDs has not been conducted in Hong Kong. Therefore, the lack of this knowledge hampers adequate prevention and effective management of the disease. Since more young people, particularly boys, are presenting with EDs, it is mandatory to advocate healthy eating habits in Hong Kong. Healthcare providers should be cautious about families with high risk of EDs and individuals who exhibit high-risk ED behaviors.
Recent studies indicated a significant increase in the prevalence of EDs among children and adolescents. Family oriented therapies play a major role in managing these young children with EDs. In Hong Kong, these therapies are provided at the ED clinic in Queen Mary Hospital and is a good model to manage ED patients in a multidimensional approach, resulting in optimal treatment outcomes.