Essential elements include being aware of commonly overlooked symptoms and weight stigma.
Having a chronic health condition, including physical and intellectual disabilities, can increase the risk of developing an eating disorder, particularly among young patients.
According to Dr. Maya Michelle Kumar, from the Division of Adolescent and Young Adult Medicine at the University of California, San Diego, adolescents with chronic health conditions are more likely than their peers to actively try to lose weight and to use unhealthy weight control behaviors (Nutrients. 2023. 15:3672). Some of these behaviors include fasting, self-induced vomiting, or the use of diet pills or laxatives (J Eat Disord. 2023. 1185; Curr Opin Psychiatry. 2022.35:362).
It’s normal for adolescents to be concerned about their weight and shape, but individuals with chronic health conditions have poorer body image and increased body dissatisfaction than their healthy peers. Their chronic health conditions and/or needed treatments may lead to shorter stature, delayed puberty, altered body composition, and a need for assistive devices, all of which alter their physical appearance. And, some may need medications that cause them to gain weight, including steroids, antipsychotics, or medications that lower glucose levels.
One group at particularly high risk includes patients who need dietary treatment. Their increased attention to labels, food ingredients, and eating and exercise patterns and having one’s weight monitored more closely than their peers may all contribute to disordered eating. Those at even higher risk include youth with type 1 diabetes, celiac disease, cystic fibrosis, inflammatory bowel disease, food allergies, or inborn metabolic errors.
Finally, this group has a higher risk for anxiety and depression, which can increase or maintain eating disorder symptoms. Dietary restriction, purging, and binge eating are often used to cope with stress and negative emotions such as sadness, anger, and fear.
In one study, more than 50% of youth with avoidant restrictive food intake disorder, or ARFID, had a comorbid medical condition (J Adolesc Health Off. Publ Soc Adolesc Med. 2014.55:49). Youth with ARFID may fear reactions from eating, including choking and vomiting, and thus may limit their food intake or show little interest in food. These so-called “picky eaters” may be unable to feel comfortable eating in social situations or outside their home due to fear of embarrassment.
Although there are no studies that have specially linked binge eating disorder (BED) to chronic health conditions, BED is strongly associated with gastrointestinal disorders, asthma, menstrual dysfunction, and polycystic ovary syndrome.
Identifying eating disorders in patients with chronic disorders
The author outlines a number of ways healthcare professionals can detect eating disorders among patients with chronic illnesses. One early clue is weight loss, and the author suggests that all factors that can contribute to malnutrition must be identified and treated. One helpful step is to ask young patients (without caregivers being present) if they are concerned about their weight, shape or appearance. It is also helpful to look for dietary restriction, skipping meals, over-exercising to lose weight, or even more dangerous weight-control methods, such as aggressive dietary restriction, self-induced vomiting, diet pill use, or abuse of laxatives.
Dr. Kumar adds that body image concerns should be followed up, and suggests that special screening questionnaires are widely available for this. Some screening questionnaires include the Diabetes Eating Problem Survey-Revised (DEPS-R), a 16-item questionnaire validated in youth with type 1 diabetes. It includes questions related to insulin manipulation and intentional use of hyperglycemia and ketosis in order to lose weight (Diabetes Care. 2010. 33:495). Also, many young patients with chronic health problems are not aware that their risky behaviors are exacerbated by their chronic health problems, and thus educating them about the risk is important.
Dr. Kumar also suggests steps that will help clinicians, parents, and other adults intervene to halt progression of disordered eating or eating disorders among chronically ill youth. These include partnering with adults other than parents, frequent screening, and working to encourage a healthy relationship with food from earliest childhood on.
Partnering with other adults
Partnering with as many adults as possible in the young person’s life will go far to help detect poor body image and disordered eating behaviors, according to the author. In fact, physicians may be the last to realize that a young person is struggling with an eating disorder or poor body image Young patients may be extremely uncomfortable discussing disordered eating behavior or distress about body image while in a medical office. However, other adults, who may be closer to the young patient and who may play important roles in the youth’s life, may suspect a developing eating disorder and can quickly ask for help. Coaches and directors of community groups can be extremely helpful in earlier intervention.
It is critical to screen young patients with chronic diseases for depression, anxiety, poor self-esteem, and poor coping methods. Some screening suggestions include The Patient Health Questionnaire 9 (PHQ-9), a depression screen, the Generalized Anxiety Disorder 7 (GAD-7), or the Screen for Child Anxiety-Related Emotion Disorders(SCARED) (J Gen Intern Med. 2001. 16:606; Arc Intern Med. 2006.166:1092; Depress Anxiety. 2000.12:85).
Help encourage a healthy relationship with food
With the help of clinicians, parents and caregivers can create a culture of healthy and happy eating in their homes. For example, they can introduce the Total Diet Approach (J Acad Nutr Diet. 2013.113:307), which is recommended to prevent overweight, underweight, and disordered eating behaviors ( https://teammates.atriumhealth.org/livewell/-/media/livewell/documents/total_diet_approach_to_healthy_eating.pdf. ).
For those with chronic medical conditions (even if some foods need to be avoided or eliminated), nutrients from major food groups (for example, calcium-rich foods) are still needed. Nutrients from all food groups should be included—no foods are good or bad, and adopting a neutral stance toward all medically safe foods is recommended. Variety in the overall pattern of eating is more important than the individual foods consumed, says the author.
For youth with chronic conditions associated with or worsened by obesity, one key is working to minimize weight stigma, keeping the focus on health rather than weight, and avoiding prescribing weight loss or setting weight targets. Also, all should be conscious of language used when discussing weight: for example, avoid terms such as “heavy,” “chubby,” or “fat.”
As recent studies have shown, bias against higher-weight individuals is prevalent even among individual care providers and in health care settings (Nat Med. 2020. 26:485). Weight stigma can worsen other physical conditions, including elevated blood pressure, increased anxiety, cortisol levels, c-reactive protein and other markers. Those who experience weight bias also have higher rates of psychological complications, including depression, anxiety, and suicidality.