May was the month of teenage girls presenting with severe digestive problems, especially ‘food intolerances’, leading to avoidance of specific foods and at times significantly reduced food intake overall. As integrative health practitioners, validating and creating insight for clients on the nature and source of their food reactions is our bread and butter, right? Is it wheat? Dairy? Gluten? FODMAPs? Salicylates? Oxalates? We are not surprised by how many ‘sick’ patients we see in spite of a theoretically ‘healthy diet’ – healthy for others perhaps but not for the individual in front of you, right? But what if I told you that each of these teenage girls had a BMI < 18 kg/m2, does that change your opinion about your role? Would you assess, monitor and manage these teenage girls differently? You should.
Take the example of one of my clients: 14yo female with a BMI 16.3, who had her first confirmed food reaction under 2yo with failure to thrive, which was attributed by a paediatrician & dietitian at the time to severe salicylate sensitivity. She underwent jejunal biopsy at 3yo for suspected coeliac disease, due to ongoing concerns and a primary relative with CD but it was NAD. In the 11 years since, there have been a couple of other digestive diagnoses based on solid evidence, such as mainstream stool PCR testing. So surely, the fact that she is underweight & that she skips lunch at school due to digestive discomfort is proportionate and explained by her organic digestive issues. Or is it?
This question preoccupies me. Not only with this client but with other teens (and adults) who present similarly. Not simply because we could in fact be looking at a presentation of restrictive Anorexia nervosa on top of her confirmed digestive disorders – stemming from distorted body image and a desire for weight loss, which of course teenage girls are profoundly at risk of, but because it could be one of several other eating disorders, such as Avoidant/restrictive food intake disorder (ARFID), orthorexia, and the many other flavours of eating disorders that are much much harder to identify.
The often unanswerable questions of ‘which came first: the psychology or the pathology’ or ‘is there an unhealthy psychological component to this patient’s behaviour and beliefs’ can wrap your cortex in knots! And ultimately in most of these cases I recognise that I’m not the person who can make this call, because I don’t have enough training and specialist knowledge. These presentations necessitate a well-trained psychologist and good GP (to run patients through a medical checklist of red flags) working together to make the diagnosis. But what I have learned this year is a basic protocol to follow – thanks to one of my mentors Kate Worsfold, who is a psychologist with a special interest in the recognition and management of eating disorders. This protocol creates structure in a clinic situation that can be infinitely confusing and ensures my patients stay safe – so here it is:
- Map the height, weight and BMI of your client on the relevant paediatric growth charts
- Calculate your patient’s ‘% Expected Body Weight’ (%EBW)
- Calculate your patient’s BMI and just divide it by
- the 50th centile for BMI for you patient’s age (e.g. that would be 19.2 for a 14yo girl if you look at this growth chart) and then
- multiply this result by 100 to get your patient’s % EBW – so a 14yo girl with a BMI of 16.3 would have an %EBW of 84%
- If the %EBW is < 75% – regardless of the source of the anorexia this patient requires urgent referral to a doctor for review for potential hospitalisation & medical stabilisation
- If the %EBW is > 75% – review the case for other red flags
- In terms of risk of disordered eating – so consider using screening tools designed for this such as the EDEQ, skilled questioning around motivation around food avoidance BUT
- In terms of overt physical risk to the patient – key signs of malnutrition & starvation – so skipped menstrual cycles, neutropenia, low heart rate, orthostatic hypotension
- Above all keep the discussion with the patient and the patient’s parents (where applicable) focused on the safety of the patient and the need to exclude more concerning conditions – too often I think we don’t talk about this stuff with our clients for fear of ‘looking like a baddy’ or coming across as too ‘medicalised’. Nothing could be further from the truth. I encourage us all to not perpetuate the notion of ‘hospital’ as a threat or a punishment for underweight individuals – but instead the appropriate place to go for faster and more comprehensive assessment of an individual who is imminently under threat…whatever the underpinning diagnosis!
- And finally remember that you can have a patient with a very serious eating disorder who is not below EBW at all e.g. BN, BED, certain stages of AN
Personally, I find these clinical scenarios stressful – and this is an appropriate response. You see, this discomfort reminds me that these presentations are beyond the scope of any single practitioner and require a team approach, with specialist knowledge. As soon as I enact the protocol, get in contact with the patient’s doctor, share my concerns, include all evidence such as %EBW and any other red flags, sometimes suggest an initial appointment with a psychologist well versed in this area, all the while making it clear to the patient that we are just trying to get a better understanding of what is preventing them from being well (I, in particular, explain that a hx of legitimate digestive issues and food reactions can result in disordered eating through negative past experiences etc.) – my own discomfort settles.
Without a doubt – this is a grey area – and while we hate the idea of not validating people who have genuine health issues preventing them from eating well and freely, we run an enormous risk if we fail to recognise a potentially life-threatening situation (remember that AN has the highest mortality rate of all psychiatric disorders). And the reason for the high mortality rate and poor treatment response? Late identification and diagnosis and therefore delays in starting appropriate treatment. So let’s not be part of the problem but aim to be part of the solution.
Last year as part of our Access the Experts series, we recorded an interview with Kate Worsfold B.Psych (Hons1), M.Clin Psych (cand.) Post Grad & Adv Dip Nut Med, Adv Dip Nat, on this topic that I can not recommend highly enough. “Working on the edge – extremely healthy eating, orthorexia or another eating disorder? How to tell the difference and what to do from there”
In this interview you will learn:
- What resources we, as clinicians, need for better detection of eating disorders (Kate is the master of knowing the right scales and surveys to use!)
- What to do when you suspect an eating disorder is at play?
- How to help those whose pursuit of ‘healthy eating’ has in fact become their source of disease?