Eating disorders represent serious psychiatric conditions, encompassing anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorders, and avoidant restrictive food intake disorder. The aetiology of these disorders is multifaceted, with a complex interplay of genetic and environmental factors likely influencing disease progression. Risk factors may be biological, environmental, or psychological in nature. 

Biological risk factors include genetic susceptibility, which is especially seen in anorexia nervosa, family history of an eating disorder or mental health disorder, higher parental or childhood body weight or a diagnosis of type 1 diabetes. 

Environmental influences include cultural or societal norms around thinness and dieting, weight stigma, family history of dieting, and employment in professions with a strong focus on appearance. 

Psychological factors include having traits consistent with a perfectionist attitude, neurodiversity, history of trauma or abuse, low self-esteem and poor body image.

Eating disorders in Ireland

The HSE launched the National Clinical Programme for Eating Disorders in Ireland in 2018. It is estimated that 188,895 people in this country will experience an eating disorder at some point in their lives. Furthermore, Ireland has seen an increase in treatment referrals for eating disorders in recent years. Due to the increased prevalence, eating disorders are commonly encountered by dietitians in community and acute health care settings.

Restrictive eating disorders

Eating disorders may be restrictive or non-restrictive in nature. Restrictive eating disorders include anorexia nervosa and avoidant restrictive food intake disorder. Restriction may also be a feature of other eating disorders, such as bulimia nervosa. 

As a result of the extensive calorie restriction experienced in these disorders, the person’s nutritional status is markedly affected to a much greater degree than in non-restrictive eating disorders. At present, anorexia nervosa holds the highest mortality rate of all psychiatric disorders. Severe caloric restriction results in a high risk of malnutrition in those affected, which is a known contributor to psychological eating disorder symptoms. The average age of onset of anorexia nervosa is 14-18 years of age, meaning adolescents are faced with a significant risk of poor intake and its associated effects. 

Malnutrition can have many negative effects on both the physical and psychological health of individuals of any age, however malnutrition during adolescence carries additional risks due to the important physical and psychological development that occurs in adolescence, which may be stunted. 

Intervention

Early assessment and treatment of eating disorders improves the likelihood of recovery. With regards to malnutrition, timely dietetic intervention plays a crucial role in ensuring adolescents can meet their energy and protein requirements, as well as realising their psychological, physical, and developmental potential. Screening and diagnosing malnutrition play a vital role in effectively managing this serious condition and its associated effects. 

The aim of our analysis was to assess the risk, prevalence, and degree of malnutrition within restrictive eating disorders in an adolescent population attending an adolescent day programme in the National Eating Disorder Recovery Centre (NEDRC). The NEDRC’s adolescent programme is a 12-week multidisciplinary programme that offers support to young people and their families in managing their eating disorder.

Research design

The study group included adolescents aged 13-18 attending the day programme over a six-month period with a diagnosis of a restrictive eating disorder. Anthropometric measurements, including weight, height and BMI, were recorded at initial dietetic assessment by a dietitian and weekly thereafter. 

Malnutrition risk was evaluated using the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP), which assesses nutritional risk by focusing on three main components: clinical diagnosis, estimated nutritional intake, and weight and height percentiles. Each component carries a score of 1-3 and the total score reflects the risk of undernutrition. Malnutrition risk was classified as low (0-1), medium (2-3), or high (4-9). 

Percentage median BMI (%mBMI) was used to assess the presence and classify the degree of malnutrition. A %mBMI of <90% identified the presence of malnutrition. The degree of malnutrition was classified as mild (80-90%), moderate (70-79%), or severe (<70%).

Study findings

A total of ten adolescents were included in our study, and all were female. Anorexia nervosa and avoidant restrictive food intake disorder accounted for 90% (n=9) and 10% (n=1) of cases, respectively. The mean age was 15.5 years (14-18 years), and mean BMI was 17.8kg/m2 (15.2-20.9kg/m2). All of the participants were deemed at high risk of malnutrition. Mean %mBMI was 86.9% (76-100%). Some 70% (n=7) were diagnosed with malnutrition, while 40% (n=4) and 30% (n=3) were classified as mildly and moderately malnourished, respectively. Three participants (30%) did not meet the diagnostic criteria for malnutrition. 

Conclusion

Our analysis confirms that there is a high prevalence of mild to moderate malnutrition within this population, which may not be represented when looking solely at BMI categories. Diagnosing malnutrition plays a crucial role in guiding dietetic interventions as it enables the achievement of weight restoration while effectively managing potential risks of refeeding syndrome.