QUESTIONS AND ANSWERS

Q. I have been hearing about “new eating disorders.” Can you explain? (J.B., Philadelphia)

A. After the COVID pandemic, we have seen an increase in the incidence of eating disorders, along with a generally lower age of onset. Two disorders are being discussed more commonly after the pandemic. A recent editorial by a group of Italian pediatricians and child neuropsychiatrists has specifically referred to two of these “new” disorders, atypical anorexia nervosa (AAN) and avoidant/restrictive food intake disorder, or ARFID (Nutrients. 2023. 15:1307). Both disorders are listed in the DSM-5 and typically affect children and young adolescents.

Both disorders involve prominent restrictive eating patterns, and both significantly impair physical health or psychosocial functioning among children and young adolescents, according to Dr. Alessia Salatto and colleagues in Naples, Italy.

While AAN and ARFID are important and common, neither is a “new” eating disorder. Those with ARFID often were not previously seen in the eating disorders setting, but rather more often in pediatric gastrointestinal or developmental settings. In that sense, ARFID might better be thought of as “new” in many eating disorders clinics. And, AAN has actually been known and studied for some time, but often is termed “subthreshold AN.” While technically true (because people with AAN “fall short of” full AN criteria), the subthreshold designation was problematic. Most importantly, it suggested that these cases were less severe, posed lower risk, and/or less need for treatment. None of this is true.

ARFID, predominantly found in children, involves low body weight and a state of malnutrition and dysfunction, and is considered a psychiatric disorder even though it is not associated with body shape. AAN has been newly included in the DSM; it is characterized by normal weight, which often leads to a delay in treatment. Helpful clues in the diagnosis of AAN include a history of previous obesity or overweight and results of assessing the patient’s body mass index.

The authors note that eating disorders may affect as many as 25% of children with normal psychophysical development and as many as 80% of those with developmental delays (Psychiatr Clin North Am. 2019. 42:57). This may appear as an inability to feed properly, resulting in problems gaining weight or in significant growth retardation. Young patients may refuse food, throw food away, or show a general lack of interest in food. According to the authors, individuals with AN and AAN share similar degrees of caloric restriction and malnutrition and have very similar symptoms.

Why is this important? Most nutritional disorders are transient, but in 3% to 10% of children they are linked to a risk of malnutrition. In addition to the problems of growth impairment, patients may have later problems traced back to pubertal retardation due to malnutrition. The rise in eating disorders, especially in more subtle forms, has also been seen in recurrence of diseases “of the past,” such as beriberi or scurvy, now uncommon and more difficult to recognize and treat, according to Dr. Salatto and colleagues. One of the main problems with diagnosing an eating disorder is an inadequate dietary history. Especially in the case of adolescents, considering the age of onset of eating disorders and performing more accurate interviews about eating can be crucial to identifying the risk of eating disorders.

The authors also provided a table of red flags for eating disorders among young patients.

Warning Signs for Future Eating Disorders

• A child only eats his favorite foods.
• Most of the calories consumed are from liquids.
• The child seems distracted while eating.
• The child eats food hidden in other foods or liquids.
• Meals last longer than 30 minutes.
• The young person has excessive concern about his or her body weight and shape.
• Certain foods are restricted, particularly fatty foods or those linked to concerns about gaining weight.
• The child or teen compulsively exercises and is increasingly anxious about established goals.
• The young person acts guilty or shows shame when eating with others.

In sum, these “new” eating disorders have been with us for a long time. They are being seen regularly and are an important part of eating disorders treatment.

—SC