Spot Eating Disorders via Child and Adolescent Growth Records

Eating disorder clinicians are noticing symptoms emerging at younger ages than before. While these illnesses can present at any time in life, early-onset eating disorders are concerning for several reasons. Childhood and adolescence are critical times for growth and development, and disruption of the nutrition required for the development of vital body structures can have lasting effects (Mumford, Kohn, Briody, et al. 2019). 

Eating disorders can significantly impact psychological and social development as well. It’s critical to detect these serious illnesses early to limit any of their lasting effects. 

Understanding How Eating Disorders Affect Growth Development

Eating disorder behavior is often present for a significant period before symptoms are noticed. In one study, researchers learned that 48% of participants showed disruption in growth an average of 9.7 months before parents reported eating disorder symptoms (Marion, Lacroix, Caquard, et al. 2020). 

Parents should of course keep an eye out for signs of an eating disorder in their children as best they can, but healthcare providers need to pay close attention as well. Pediatricians—as the provider who typically has the most face time with young patients—are in a unique position to spot growth abnormalities that may point to an eating disorder.

Many tools can be used to understand a child’s growth and development, including:

• CDC Growth Charts. Traditionally, pediatric providers have monitored growth and development using the CDC Growth Charts. Children typically grow at predictable rates, their growth and weight percentiles following a pattern. This pattern emerges over time as data points are added. 
• Family history. Information on parental and family growth patterns can provide a better understanding of a child’s individual potential. 
• Observing weight fluctuation. It is rare for a child’s growth to shift across two or more percentile lines after toddlerhood. The impact of eating disorder behavior on growth can be significant, often emerging as weight stagnation, weight loss, and slowed linear growth. Typically, weight stagnates or declines prior to growth slowing. 

If you notice deviations from your patient’s expected growth patterns, it is essential to understand why this shift may be occurring. An eating disorder evaluation can help. If an eating disorder is present, it is imperative to get your patient connected to the care they need as soon as possible 

The Importance of Early Eating Disorder Intervention

If pediatricians monitor typical growth patterns, detect eating disorder behaviors, and refer their patients to the proper care, then children and adolescents with these illnesses can receive specialty treatment sooner, leading to a more successful recovery. 

Veritas Collaborative’s partial hospitalization (PHP) and intensive outpatient programs (IOP) offer support to young patients who need greater structure and support than non-intensive outpatient treatment, but do not need medical stabilization or 24/7 monitoring. Prompt referral to PHP/IOP often leads to a quicker, longer-lasting recovery, while allowing patients to live in their everyday environments. 

Overcoming Barriers to Early Eating Disorder Detection

Pediatricians can make a positive impact on the lives of their patients by detecting an eating disorder early. However, it is essential to acknowledge the barriers:

• Current overall pediatric visits are down for both regular check ups and sick visits.
• Most insurers now cover well-child visits fully, but some costs must be shouldered for other care. Those who are not insured may not be able to see healthcare providers with any regularity.
• Families are more mobile and may not have a longstanding relationship with a single pediatric provider, leading to divided data across health records and electronic medical record systems (which may or may not be compatible). 
• Many families rely on urgent care centers for primary care, which means the visits are not designed to monitor a child’s growth over time. 

Whatever the reason may be, children going without continuous care from one provider can result in the lack of consistent growth monitoring. Their caregivers are then unable to provide growth charts for review when entering assessment for eating disorder care. 

If the growth charts are not available, pediatricians can support patients and their caregivers by piecing together data to create a representation of the patient’s development over time. Steps may include:

• Gathering any height and weight points the patient’s caregiver has access to from previous providers, as well as any information they have gathered themselves over the years
• Plotting data using the CDC growth charts
• Gathering developmental information from caregivers (i.e., learning whether the patient typically met developmental milestones and signs of puberty, or if they were earlier or later than their peers).
• Inquiring about the biological parent’s developmental information (if available), including:
  • Age of pubertal onset 
  • Both parental and familial developmental patterns (e.g., were they a typical, early, or later developer)
  • Adult height
• Calculating a Midparental Height for the patient using the biological parents’ heights. This will give a good indicator of the patient’s expected adult height.
• Plotting the Midparental Height on your patient’s growth chart at age 20, noting the percentile that aligns with the expected adult height.

How to Review Growth Data

Once you have obtained these charts or created them with the data points you have available, review them carefully, considering questions like:

• What has been the patient’s typical growth pattern? 
• Is the current Height for Age percentile similar to the Midparental Height percentile at age 20?
• Are there deviations in charts that may be related to eating disorder behavior use and onset?
• What familial patterns need to be considered?
• Has the patient’s growth been affected by their eating patterns and if growth has slowed, do they have the capacity to catch up? 

A growth and development paradigm supports early eating disorder detection and care. Analysis of growth charts within the context of other information provides an understanding of the patient’s eating disorder onset and the developmental impact of the illness. 

Together—with an understanding of a patient’s potential for growth—clinicians have an individualized foundation that can be used to conceptualize each case, establish patient specific treatment targets, and create pragmatic approaches to care that support healing, have better potential for patient and caregiver acceptance, and minimize the long-term consequences of an eating disorder. 

To learn more about adolescent growth and development as it relates to eating disorders, please join me Monday, February 27 for “Staying on Track: Evaluating Growth and Development in Adolescence. This Accanto Health Continuing Education event kicks off our five-day webinar series for Eating Disorders Awareness Week.

About the Author

Leah Graves, RDN, LDN, CEDRD-S, FAED, is the Vice President of Nutrition and Culinary Services of Accanto Health, the parent company of Veritas Collaborative and The Emily Program. Leah has been treating patients with eating disorders for over 30 years. Prior to joining Veritas, Leah was the Manager of Eating Disorders Nutrition Therapy for the Laureate Eating Disorders Program in Tulsa, OK. She graduated with the highest distinction from the University of Oklahoma Health Sciences Center in 1985 and then began her work with individuals with eating disorders.

Leah is a founding member of the Academy for Eating Disorders where she has served on the Academy’s Executive Team, Board of Directors and Chaired the North American Teaching Days for the International Conference on Eating Disorders in addition to serving the Academy on the Nominating, Fellowship Selection, and Membership Recruitment and Retention Committees. She has also been honored with the distinction of Fellow of the Academy for Eating Disorders.

Leah has been involved in eating disorders advocacy with the National Eating Disorders Association as a member of the Conference Planning Committee and with the Oklahoma Eating Disorders Association where she served as President and Governance Committee Chair. She currently serves on the Clinical Advisory Board for Rock Recovery.

Leah has been invited faculty at many eating disorders conferences including the International Conference on Eating Disorders, Hispano-Latin American Congress on Eating Disorders, International Association of Eating Disorders Professionals Symposium, Renfrew Foundation Conference, Multi-service Eating Disorders Association Conference, and the Academy of Nutrition and Dietetics Food and Nutrition Conference, as well as numerous regional and local conferences. Leah has written several publications pertaining to nutrition and eating disorders and is highly respected within the eating disorders field for her expertise in medical nutrition therapy, nutrition counseling, clinical supervision, and research.