Our study aims to describe the clinical profile of adolescents admitted with anorexia nervosa in a tertiary care center in Southern India.

This was a hospital record review of adolescents hospitalized with anorexia nervosa and their follow up after atleast one year of discharge. We reviewed the data of adolescents (aged 10 to 18 years) who were admitted either in the adolescent medicine facility or the child and adolescent psychiatry unit between May, 2006, and December, 2019, and details of patients with a diagnosis of eating disorder or anorexia nervosa were extracted. Adolescents who fulfilled the DSM-V criteria for anorexia nervosa or other specified eating and feeding disorders (OSFED) were included in this study. Those with diagnoses of bulimia nervosa, psychogenic vomiting or unspecified feeding disorders were excluded.

Data regarding the clinical profile and hospitalization was collected from the hospital database. Follow up of these patients was done after atleast one year of hospital discharge following initial hospitalization, either by an outpatient visit or a telephonic interview. Information regarding clinical symptoms, weight gain, and school performance was collected.

Data entry and analysis was done using Epidata software.

Over the 13 year 8 month period, 43 adolescents of whom 12 (27.9%) were males, were studied. Anorexia nervosa restricting type was the diagnosis in 23 (53.4%) adolescents, and 9 (20.9%) had binge-purge type. Other specified feeding and eating disorders (OSFED) were diagnosed in 11 (25.5%).

Microcardia was present in 21 (48.8%) adolescents. The ECG changes seen in 6 (13.9%) adolescents included sinus bradycardia, QT prolongation and T wave changes. Echocardiography was done in five adolescents and was normal. Seven adolescents had MRI of the brain and abnormal findings were present in 5 (71.4%) of them. The abnormal findings included cerebral atrophy, white matter volume loss, periventricular hyperintensities and pituitary changes. Bone mineral density was done in 4 patients, 2 (50%) of whom had low mineral density.

Of the 43 adolescents, 33 (76.7%) were admitted for nutritional rehabilitation [mean (SD) stay, 13.7 (5.5) days]; the remaining 10 did not require hospitalization for medical treatment. Of the 33 admitted, 15 required initial feeding via nasogastric tube, while 1 patient required nasogastric feeds even at discharge. Hemodynamic instability was present in 12 (36.3%) of these patients, and refeeding syndrome was diagnosed in 10 (30.3%) of these patients. At discharge, the average daily calorie intake was 1935 calories and the average weekly weight gain was 1.1 kg.

Of the 43 patients, 10 (23.2%) were yet to complete a 1-year follow-up period, and 18 (41.8%) were lost to follow-up. One child died 18 months later with severe hemo-dynamic instability, and complications of electrolyte imbalance, coagulopathy and shock. Of the remaining 14 (32.5%) patients, 2 (14.2%) persisted to have symptoms, 1 (7.1%) patient had become overweight, and the remaining 11 (78.5%) had normal weight for age.

The proportion of males in the study was higher than that reported in other studies (9-15%) in adolescents [4,6]. Possible reasons include improved awareness and diagnoses, and the ease of families to attend an adolescent medicine clinic, thereby avoiding the stigma of referral to psychiatry. The age of presentation and onset was similar to data from Western studies [6,7], while the age of onset was lower than that reported in Asian studies [8,9]. The average BMI at presentation was similar to other studies [8,10]. Some adolescents who were overweight or obese prior to onset of symptoms, had a significant weight loss over a short period of time and their BMI at presentation was normal; the adolescents in this group were either the binge-purge type or the OSFED category.

Adolescents in the younger age group had a higher percentage of the binge-purge type of anorexia nervosa, while those in the older age group were of restrictive type. This finding is slightly different from previous studies, which show the younger age group to be more of the restrictive type [9]. The most common identified trigger factors were peer pressure and family influence, similar to data from other studies [9-11].

Mortality rates reported in adolescents [7,12,13] are lower compared to adults with anorexia [9,14,15]. Our small cohort size precludes comment on mortality, but further studies are required to better estimate mortality and outcome. The poor follow-up in our patients reflects the inability of the family to understand the severity of disease, stigma of a psychiatric illness and financial burden of treatment on the family.

Our data will assist pediatricians in identifying anorexia nervosa early, and lead to appropriate diagnosis and management to improve overall outcome.

Ethics clearance: Ethics Committee, Institutional Review Board, CMC, Vellore; No. 11511, dated September 3, 2018.

Contributors: MMB: concept and the study design was done; KEP, RJR, RYS, MMB: material preparation, data collection and analysis were performed; RJR, KEP: written first draft of the manuscript; MB, PM: revision of the manuscript; MB: final approval of the manuscript. All authors have read and approved the manuscript.

Funding: None; Competing interests: None stated.