Managing and treating eating disorders

At the 2024 NAPNAP conference, Kaitlin Borelli, CRNP, PMHS, MSN; Joanna Palac, MSN, CRNP-BC; and Lindsay Levitz, RD, LDN, CLC, from Children's Hospital of Philadelphia, delivered a session centered on managing eating disorders among youth in the outpatient setting. The session highlighted the importance of early identification, the role of primary care in managing these conditions, and the multidisciplinary approach needed to treat children and adolescents with eating disorders.

Borelli opened the discussion by stressing the significance of early detection in managing youth eating disorders, pointing out that delays in diagnosis can lead to more chronic and severe outcomes. "We really focused on early identification of these patients and screening for medical instability. We know that the longer a child is underweight or living in malnutrition, the more likely they are to develop chronicity of symptoms," Borelli explained. Early intervention not only helps address physical health concerns but can also improve the overall prognosis for these young patients. "With early identification and swift intervention of resources and treatment for these kids, we can actually help improve their outcomes."

Palac then discussed the practical side of the session, which aimed to equip primary care nurse practitioners with a simplified roadmap for identifying and managing eating disorders in their patients. "The aim of the presentation was to provide a less complicated roadmap for the primary care nurse practitioner, not only in identifying that their patient is potentially malnourished and later leading to an eating disorder diagnosis, but also, what does that follow up look like in the office?" She elaborated on the follow-up process, emphasizing the need for clear guidelines regarding how often patients should be seen and what specific labs should be monitored. "How often do we need to bring them back? What do we need to look at, what labs do we need to look at?"

Palac also acknowledged the challenges in addressing the behavioral health component of eating disorders and the difficulty many providers face in connecting families with appropriate community resources. "Recognizing that there is a behavioral health component, and that these resources in the community are often very challenging to connect a family with, whether this is a psychological component of having the family buy in to the diagnosis, but also, it could just be simply location and insurance barriers," she said. Palac emphasized that part of the primary care provider's role is to initiate conversations about what to expect after a diagnosis and to help families understand the levels of care that may be required. "So describing the different levels of care, and what that looks like for families and patients so that the primary care practitioner can get the ball rolling with the conversations and what to expect after the initial diagnosis."

Borelli further emphasized the crucial role that primary care providers play in the treatment of youth with eating disorders. "Primary care plays such a crucial role in these patients' trajectory through life," she stated. This role is even more critical in regions where access to specialized care is limited. Borelli highlighted the geographical disparities in healthcare resources, noting, "We’re very fortunate that we live in a very vast resource-dense area of the country, but we recognize that there are also very rural areas that don’t have the services that we have." She pointed out that in many cases, primary care providers may be the only consistent contact these patients have with the healthcare system. "In many cases, these primary care providers are the conversation and we just keep going with it."

She also drew attention to the mental health risks associated with eating disorders, particularly the higher rates of suicide among children and adolescents treated for malnutrition in inpatient settings. "We do know that children and adolescents who are treated for malnutrition, inpatient for eating disorders actually have higher suicide rates," Borelli said. To mitigate this risk, she advocated for swift intervention and treatment in primary care, when safe to do so, to prevent hospitalization and reduce suicide rates in this vulnerable population. "Swift intervention and treatment in primary care and keeping these kids out of the hospital, when safe to do so, actually will lower the rates of suicide in this population."

The discussion then turned to the signs that general practitioners should look for when screening for potential eating disorders. Palac explained that while no single risk factor necessarily indicates an eating disorder, there are certain key metrics that should raise a red flag. "There are a few aspects that we look at from a clinician perspective, when your patients coming into the office for whatever reason. It may be a well visit, it may be a sick complaint, and you'll start by looking at your objective data and usually it would be your weight metric that is first cueing the clinician that something is going on."

She noted that sudden changes in weight, bradycardia, and additional symptoms such as syncope or visual changes could indicate a deeper issue. "This could be your athlete that you note now has a significant bradycardia and additional symptoms of syncope or visual changes, headaches. So it's not specifically that there is any 1 risk factor, it's more so what to look out for," she said. Palac advised clinicians to broaden their differential diagnosis when these symptoms arise and to consider the possibility of a psychiatric component. "Specific key points or key metrics, that should be cueing the clinician to start thinking a little bit broader in their differential that this may be more of a psychiatric component."

Borelli then outlined the steps involved in treating eating disorders, underscoring the importance of a multidisciplinary approach. "So this is very much a multidisciplinary approach," she said. "In our resource-dense area, that includes a behavioral health clinician, your medical team, whether primary care or adolescent medicine, or a combination of both, and a dietitian." She stressed that it is essential for all team members to have experience in treating children and adolescents with malnutrition and eating disorders. "It's very important that all of these specialists and providers have experience treating kids and adolescents with malnutrition and eating disorders." Borelli also noted the invaluable role that social workers play in addressing insurance and logistical barriers to treatment. "Also, when available, a social worker is extremely helpful in figuring out insurance barriers and navigating other barriers to treatment in the home."

Palac added that the frequency of follow-up visits should be tailored to each patient’s medical stability. "First, we need to determine is my patient medically stable to continue in the outpatient setting? Once the answer is yes, then you need to determine what resources you have and how long it’s going to take to get that patient connected with this multidisciplinary team." Depending on the patient's needs, follow-ups may be required as frequently as every 48 hours or as infrequently as once a week. "You may have your patient coming back every 48 hours or every week."

Levitz, the team’s dietitian, explained her role in the treatment process, particularly in calculating the patient’s nutritional needs and goal weight. "So part of what the dietitian does is calculate goal calories using a resting energy expenditure and multiplying that by an activity factor, coming up with a calorie goal and also calculating goal weights based off of many different factors, including their historical growth curves, pubertal development, age, gender," she said. Levitz emphasized that primary care providers need to be educated on these calculations and how they relate to outpatient care. "It’s important to educate these primary care providers who are taking care of these kids outpatient."

The session concluded with a call to action for primary care providers to remain vigilant for signs of eating disorders and to initiate early intervention and multidisciplinary treatment to improve outcomes for affected children and adolescents.

Click here for more NAPNAP coverage.