A study of eating disorders in children and adolescents from a tertiary care centre in India

Abstract

Background: Eating Disorders (ED) were largely thought of as a western phenomenon; however studies have shown that these disorders exist in India. The exact incidence & prevalence of ED is not known in India. We present data from a 10 year retrospective chart review from a tertiary care child and adolescent psychiatry centre in India.
Methodology: A 10 year (March 2002-March 2012) retrospective chart review of children and adolescents (up to 16 years) who had attended the child and adolescent psychiatry outpatient services at our centre and diagnosed to have Eating Disorders according to ICD-10 were included in the study.
Results: The 10 year prevalence rate of eating disorders was 0.063%. Eating disorders was more common in females (83.3 %)( n=10) in this sample. The female to male ratio was 5:1. The mean age at presentation was 14.42 years (SD 1.08). 83.3% had a co-morbid psychiatric disorder with obsessive-compulsive disorder and depression being the most common.
Conclusion: The prevalence of eating disorders was low, however further epidemiological studies are required to ascertain community prevalence of eating disorders. The rates of psychiatric comorbidity including suicidality are high. Therefore, both eating disorders and comorbid psychiatric disorders require a thorough evaluation and holistic management.

Full text

AP J Psychological Medicine Vol. 17 (1) January-June 2016
ORIGINAL ARTICLE
A study of eating disorders in children and adolescents from a tertiary care centre in India
Preeti Jacob1, Suneetha K Sadananda2, John VK Sagar3, Shoba Srinath4, Shekhar P Seshadri5
1Assistant professor of Psychiatry, 3Additional professor of Psychiatry, 4Senior professor of Psychiatry, 5Professor and Head
of the department, Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurological
Sciences, Bangalore, Karnataka, India, 2Consultant Psychiatrist, Mani superspeciality hospital and research institute, Hassan,
Karnataka, India.
ABSTRAC T
Background: Eating Disorders (ED) were largely thought of as a western phenomenon; however studies have shown
that these disorders exist in India. The exact incidence & prevalence of ED is not known in India. We present data from
a 10 year retrospective chart review from a tertiary care child and adolescent psychiatry centre in India.
Methodology: A 10 year (March 2002-March 2012) retrospective chart review of children and adolescents (up to 16
years) who had attended the child and adolescent psychiatry outpatient services at our centre and diagnosed to have
Eating Disorders according to ICD-10 were included in the study.
Results: The 10 year prevalence rate of eating disorders was 0.063%. Eating disorders was more common in females
(83.3 %)( n=10) in this sample. The female to male ratio was 5:1. The mean age at presentation was 14.42 years (SD
1.08). 83.3% had a co-morbid psychiatric disorder with obsessive-compulsive disorder and depression being the most
common.
Conclusion: The prevalence of eating disorders was low, however further epidemiological studies are required to ascertain
community prevalence of eating disorders. The rates of psychiatric comorbidity including suicidality are high. Therefore,
both eating disorders and comorbid psychiatric disorders require a thorough evaluation and holistic management.
Key message: Even though the prevalence of eating disorders was low in our study, a significant proportion had psychiatric
comorbidity which must be thoroughly evaluated and treated.
Keywords: eating disorders, child, adolescent, India
Date of first submission: 13/4/16 Date of initial decision: 1/5/16 Date of acceptance: 16/5/16
Address for correspondence: Dr John Vijay Sagar Kommu,
Additional professor of Psychiatry, Department of child and
adolescent psychiatry, NIMHANS, Bangalore, India.
Phone number: +91- 80-26995348
Email: sagarjohn@gmail.com
How to cite this article: Preeti J, Suneetha KS, John VSK,
Shoba S, Shekhar PS. A study of eating disorders in
children and adolescents from a tertiary care centre in India.
AP J Psychol Med 2016; 17(1): 1-5.
INTRODUCTION:
Eating disorders were largely considered as culture bound
syndromes present in western societies. [1, 2] However, eating
disorders have been reported from non-western developing
countries as well. [3-5] Globalisation, adoption of western
attitudes and beliefs and exposure to western media are some
of the factors which have been implicated in eating disorders.[6-
8] A survey among psychiatrists in Bangalore revealed that
two-thirds of them reported seeing at least one case of eating
disorder indicating that eating disorders are not uncommon
in urban India.[7] Several case reports of eating disorders from
India exist.[9,10] A study examining eating disorders in children
and adolescents presenting to a general hospital in south India
has also been don e. [ 11] However, n o systematic
epidemiological studies have been conducted to ascertain the
incidence and prevalence of eating disorders in India.[12] This
study was conducted to assess the period prevalence of eating
disorders among children and adolescents presenting to a
tertiary care child and adolescent psychiatry centre. We were
also interested in the socio-demographic and clinical profile
of children and adolescents diagnosed to have eating disorders
from our centre.
METHODOLOGY:
A 10 year (March 2002-March 2012) retrospective chart
review of children and adolescents (up to 16 years) who had
attended the Child and Adolescent Psychiatry (CAP)
outpatient services at our centre and diagnosed to have Eating
Disorders according to ICD-10 (F50-50.9) were identified
by the Hospital Medical Records Department and included
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AP J Psychological Medicine Vol. 17 (1) January-June 2016
in the study. All cases were diagnosed by a consultant child
and adolescent psychiatrist and a detailed management plan
was made. The 1st and 2nd authors (PJ & SKS) reviewed the
case files for demographic and illness related variables that
were recorded previously of the children and adolescents
diagnosed to have an eating disorder as per ICD-10.
Reversible anonymization, limited access and disclosure of
the data were done to ensure that confidentiality was
maintained. Appropriate statistical analysis was applied using
SPSS (Version 21).
RESULTS:
Totally 19,151 patients attended the out-patient services
during this 10 year period. We identified 12 patients with a
diagnosis of Eating Disorder according to the ICD-10 codes
(F50-50.9) in the records. Based on the above data the 10
year period prevalence of eating disorders in the child and
adolescent psychiatry out patient population at a tertiary care
centre was 0.063 per cent.
All the patients studied belonged to the upper or middle socio-
economic strata. 41.7% (5) belonged to Karnataka state while
the remaining patients were from other parts of the country.
83.3% (n=10) of the sample was female. The female: male
ratio was 5:1. The mean age of the sample was 14.42 (SD
1.08) years with the youngest patient being 13 years.
The symptoms and signs and psychological variables recorded
from files at the time of detailed evaluation are shown in
Table 1.
The average duration of illness recorded was 318 days (SD
111.72) with a minimum of 123 days duration and a maximum
of 537 days. Among the psychological and psychosocial
variables perfectionistic traits were recorded in 6 subjects as
were a small social circle of friends in 6 subjects. Eight
children were teased by family members or friends for being
“plump” prior to the onset of these symptoms and their initial
weight loss was even appreciated and 10 subjects reported
being compared to siblings and friends felt bad about the same.
Table 1. Common symptoms/signs and psychological variables
Symptoms and signs pertaining to Eating disorders (N=12) Number (n) Percentage (%)
Avoids high calorie food 12 100
Body image distortion/ dread of fatness 11 91.7
Weight loss 10 83.3
Fear of loss of control over food 9 75
Significant anxiety and distress over food and meal times 11 91.7
Amenorrhoea 8 66.7
Excessive exercise 8 66.7
Self-induced vomiting 5 41.7
Bingeing 2 16.7
Purging 2 16.7
Use of medications to lose weight 1 8.3
Other symptoms
Irritability 12 100
Mood swings 11 91.7
Aggression towards others 5 41.7
Suicidal ideation 7 58.3
Suicidal attempts 4 33.3
*WHO BMI-for-age (5-19 years)
Severe thinness (< 3SD) 6 50
Thinness (<2 SD) 3 25
Normal 3 25
Psychological and psychosocial variables
Teased by family and friends for being fat/plump 8 66.7
Low self esteem 11 91.7
Comparison with peers 10 83.3
High parental expectations 7 58.3
Not going to school 5 41.7
2Preeti J, et al: Eating disorders in children and adolescents

AP J Psychological Medicine Vol. 17 (1) January-June 2016
Preeti J, et al: Eating disorders in children and adolescents
Table 2 shows the diagnoses made and the medical and
psychiatric comorbidity seen in the sample. Nine adolescents
received a diagnosis of Anorexia nervosa. One adolescent
received a diagnosis of Atypical Anorexia nervosa as she did
not have amenorrhoea. She however had the other classical
symptoms of anorexia nervosa. The patient diagnosed to have
“other eating disorder” had psychogenic loss of appetite but
none of the features of anorexia nervosa with no organic
etiology that could be identified for the loss of appetite.
“Eating disorder unspecified” was diagnosed in the one of
the patients as she had severe depression with psychotic
symptoms as well as body image distortion, avoidance of high
calorie food and amenorrhoea and these symptoms were not
part of her psychotic symptomatology. No patients in this
sample received a diagnosis of bulimia nervosa (F 50.2, F
50 . 3 ) or overeating associated with psychological
disturbances (F 50.4) or vomiting associated with other
psychological disturbances (F50.5). .
Medical comorbidity was seen in 66.7% (8) of the sample
studied. Anaemia was the most common medical comorbidity
seen. One patient developed hypotension, bradycardia and
hypothermia after admission to the child psychiatry centre
(in-patient services) and was referred immediately to a general
hospital for further management. One of the patients
historically reported one episode of hypotension prior to
adm i ssion. Another patient h ad two episodes of
hypoglycaemia and tetany prior to admission .
Psychiatric comorbidity was seen in 83.3% (10) of the sample.
This includes patients with sub-syndromal disorders. As
described in the table above, 4 subjects had moderate to severe
depressive episodes at the time of presentation. 4 subjects
had sub-syndromal depressive symptoms at the time of
presentation. Similarly 4 subjects had obsessive-compulsive
disorder, while 2 subjects had sub-syndromal obsessive
compulsive symptoms as recorded in their case files. The main
obsessive compulsive symptoms seen were contamination
related obsessions and washing compulsions (4 subjects),
magical thinking (2 subjects), mental compulsions (2
subjects), sexual obsessions (1 subject). Patients had more
than one/multiple obsessions and compulsions at the time of
presentation. 2 patients had obsessive-compulsive disorder
with moderate depression.
Management included detailed evaluation (both medical and
psychiatric), in-patient or out-patient care depending on the
nature and severity of symptoms and the willingness of the
patient and family for in-patient care. Multi-disciplinary
inputs were given from the child psychiatry team consisting
of consultants and residents from all three disciplines namely
psychiatry, psychology and psychiatry social work and
referrals to other professionals including Nutrition ,
Paediatrics , Endocrinology and consultation liaison with these
professionals. 75% (9) received in-patient care for varying
durations ranging from 2 days to 50 days. 5 children who
received in-patient care got discharged within 8 days of
admission for a number of reasons. The most common reason
was that the child or family was unwilling for in-patient care.
2 of these patients were from other states and had not come
prepared for admission. One patient had to be referred to a
gen eral hospital as sh e developed com plication s
(hypothermia, bradycardia and hypotension). The other two
patients were from Bangalore and agreed to regular out-patient
care rather than in-patient care.
Ten out of the 12 patients were referred to our centre for
further management by psychiatrists from other parts of the
country. The remaining two patients were brought by their
families. Pharmacotherapy and psychotherapy were the main
modalities of treatment. 58.3% (7) were alr ead y on
psychotropic medication at presentation. 2 patients did not
receive any medication at during their treatment at our centre
one of whom was referred within two days of admission due
to a medical complication and the other patient was treated
with only psychotherapy. Selective Serotonin Reuptake
Table 2. Diagnosis and comorbidity (medical and psychiatric) seen in the sample
Diagnosis as per ICD-10 recorded in the file (N=12) Number (n) Percentage (%)
Anorexia nervosa 9 75
Atypical anorexia nervosa 1 8.3
Other eating disorders 1 8.3
Eating disorder unspecified 1 8.3
Medical Comorbidity 8 66.7
Anaemia 4 33.3
Reflux esophagitis 1 8.3
None 4 33.3
Psychiatric comorbidity 10 83.3
Depressive episode (current) 4 33.3
Obsessive-compulsive disorder 4 33.3
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AP J Psychological Medicine Vol. 17 (1) January-June 2016
Preeti J, et al: Eating disorders in children and adolescents
Inhibitors were the most common medication used (75%).
Among the Selective Serotonin Reuptake Inhibitors (SSRI)
the prescriptions were as follows Sertraline (4 subjects),
Escitalopram (2 subjects), Fluoxetine (1subject), Citalopram
(1subjects), Fluvoxamine (1 subject). 3 adolescents were on
Risperidone and 3 others were on Olanzapine. One adolescent
was on Lithium along with an antidepressant for Recurrent
Depressive Disorder.
Out of them 83.3% (10 subjects) received psychotherapy
either at the out-patient or in -patient ser vices. The
psychotherapy sessions received ranged from a minimum of
3 sessions to a maximum of 50 sessions. The main themes
discussed in psychotherapy were psychoeducation about
anorexia nervosa, nutritional counselling, understanding body
image distortions, correction of cognitive distortions and
dysfunctional beliefs using cognitive behavioural therapy
methods, weight restoration and insight facilitation. Among
the two patients who did not receive psychotherapeutic inputs,
one got discharged against medical advice a day after
admission and the other patient was referred to a general
hospital due to medical complications.
Outcome is not known in 66.7% (8 subjects) of the sample.
Among the 4 subjects who came back continue to be on follow
up, all are maintaining weight and BMI and no longer fulfill
criteria for anorexia nervosa. However, the 4 subjects continue
to avoid high calorie food.
DISCUSSION:
As expected our study showed a much lower prevalence of
eating disorders as compared to western literature. [13-15 ]
However, the prevalence of eating disorders in this study
seems lower than other published data from India and Asia
as well. [12,16,17] The low prevalence rate could be explained
due to a selection bias as the data has been gathered from an
exclusive tertiary care child and adolescent psychiatry centre.
Those children and adolescents with sub threshold symptoms
may be seen in primary care settings by paediatricians, or in
general hospitals. Severe cases of eating disorders especially
complications arising from anorexia nervosa are managed in
a general hospital setting with a consultation liaison team
rather than purely by a mental health team. [11,12,16,17] A study
from a south Indian general hospital reported that the 6 year
period prevalence of eating disorders in children and
adolescents was 1.25% when psychogenic vomiting was
included. This sample had 6 adolescents with anorexia
nervosa. [11] If we look at the rates of anorexia nervosa alone,
the rates in the present study and the general hospital sample
are almost comparable.
The mean age of presentation was seen in adolescence which
concurs with world literature on eating disorders. [18-20] A large
proportion of subjects in this study were diagnosed with
anorexia nervosa and there were no cases of bulimia nervosa
(Table 2). This con cur s with findings from oth er
epidemiological studies which have shown that anorexia
nervosa has a younger age of onset and bulimia nervosa was
seen from mid to late adolescence and early adulthood. In a
general hospital based study done in India, the most common
diagnosis in pre-pubertal children was psychogenic vomiting
and anorexia nervosa was the next most common diagnosis.
Females represented the majority of the sample (83.3%) as
seen in other studies. [11,14,18]
The rates of psychiatric comorbidity seen in this study were
high (83.3%) which concurred with the rates seen in other
studies as well. [21-23] The main psychiatric comorbidities seen
in this study was depression and obsessive compulsive
disorders, similar to other studies. [11,16,22] This is an important
finding as internalising disorders are often seen with eating
disorders and may worsen the eating disorders if not
appropriately treated. Suicidal ideation was seen in 58.3%
and suicidal attempts were present historically in 33.3% of
the sample (Table 1) which was seen in other studies in eating
disorders as well. [24, 25] Since suicide is the major cause of
death in anorexia nervosa it requires the treating psychiatrist
to be ever vigilant. Suicidal ideation and suicidal attempts
also increases with additional psychiatric comorbidity
especially mood disorders. Both psychiatric comorbidity and
suicidality are serious problems and require a comprehensive
psychiatric evaluation and holistic management. [24,25]
The strengths of the study are a large clinical sample was
taken from an exclusive tertiary care child and adolescent
psychiatry centre where the diagnosis was made by trained
psychiatrists. The limitations are that it was a retrospective
study and therefore depends on previous documentation.
Another limitation is that no specific instrument was used to
evaluate the severity of eating disorder, or psychiatric
comorbidity including suicidality. Since the study was based
on a niche population attending a tertiary care child and
adolescent psych iatr ic centre the findings cannot be
generalised. Large scale epidemiological studies are required
to ascertain the exact prevalence of eating disorders in India.
CONCLUSIONS:
The prevalence of eating disorders seen was low. Eating
Disorders were more common in females. The most common
diagnosis seen was Anorexia Nervosa. The rates of psychiatric
comorbidity were high and this is an important finding with
significant clinical import. Further epidemiological studies
are needed to determine the prevalence of eating disorders
and to understand cross cultural differences in the prevalence
and presentation of eating disorders in India.
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Preeti J, et al: Eating disorders in children and adolescents
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ACKNOWLEDGEMENTS: Nil
Conflict of interest: None declared
Source(s) of support: Nil
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