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Disordered eating can be easily overlooked in this group.
“Some patients with [undiagnosed] restrictive eating disorders are hiding in plain sight,” write Ellen S. Rome, MD, MPH, and Radhika Rastogi (Cleveland Clinic Journal of Medicine. 202087:165). The authors stress that patients who are overweight or obese are just as likely to have a pattern of disordered eating as their normal-weight peers, but restrictive eating disorders tend to be overlooked in overweight or obese patients.
Adolescents who have been overweight are less likely to have had inpatient treatment, even if their symptoms are similar to those of teens with anorexia nervosa, for example. Moreover, the duration of illness before the adolescent seeks help may be significantly longer among patients with higher premorbid BMIs.
Malnutrition affects every system
The malnutrition that results from restrictive eating disorders affects every body system and can occur even if the patient is obese or overweight. An individual who uses restrictive eating can have cardiovascular, gastrointestinal, hematologic, musculoskeletal, hormonal, and menopausal, and for boys, testosterone-related disorders, as a result of restrictive eating.
Previously obese patients with restrictive eating have a different course of recovery of menses than their healthy-weight peers, according to the few studies that have examined restrictive eating among obese and overweight teens. As one study showed, amenorrheic patients with a history of obesity or overweight resumed menses at a higher weight but with similar amounts of absolute weight restoration as other patients. The likelihood of menses returning decreases with greater weight suppression and increases with greater weight gain in both groups. This suggests that weight goals associated with resumption of menses may need to be higher for patients with previously higher weights.
Some helpful steps to take
Despite the high risk among this population, only one study has compared outcomes between adolescents and young adults with eating disorders by premorbid weight status. Few studies have outlined the treatment goals and course of recovery for these patients, according to Drs. Rome and Rastogi. They suggest several steps to take for patients with restrictive eating who are overweight or obese.
- Encourage healthy forms of weight loss, but establish minimum requirements for protein, fat, carbohydrates, calcium and vitamin D. Obese or overweight patients who are embarking on a ketogenic diet or a “clean-eating diet” should consult both a primary care physician and a registered dietitian experienced in treating patients with eating disorders. This will help avoid electrolyte imbalances and medical complications [and potentially help avoid the development of disordered eating as another complication].
- Monitor for signs of caloric energy restriction. Some telltale signs include bradycardia, orthostatic hypotension, and amenorrhea.
- Watch for unhealthy weight loss strategies in overweight and underweight patients as well. According to the authors, it is just as important to watch for the patient whose weight changes from 220 to 180 lb. as the one whose weight changes from 120 to 80 lb.