The youth peak in the acuity of eating disorders

To the Editor

Phillipou et al. (2020) have drawn attention to the life-threatening starvation effects of anorexia nervosa (AN) and distinguished these effects from the other concurrent and continuing psychopathology of the illness. They emphasise that refeeding is not a specific treatment for the full AN syndrome, but is essential for the medical management of starvation.

The starvation effects of eating disorders (EDs) are most evident in youth. As Figure 1 illustrates, Australian hospital admissions for EDs peak among girls and young women aged 15–24. Such inpatient admissions are usually reserved for the starvation effects of low body mass index (BMI) below the third age adapted percentile, dehydration, hypothermia, increased cardiovascular risk and metabolic imbalance associated with AN.

Figure 1.

Admissions for the treatment of eating disorders in Australia.

The youth peak in admissions occurs as young women are moving beyond the parental sphere of influence, while the peer group’s idealisation of thinness continues, and EDs become more entrenched (Treasure et al., 2020). After youth, there is increased physical maturity, safer weight maintenance despite continuing ED psychopathology and remission/recovery – all collectively contributing to diminishing admission rates. In addition, while many patients with severe and enduring AN experience starvation effects that warrant hospitalisation after the age of 25, they have increased autonomy and reduced contact with their family of origin, so consequently receive less encouragement to access inpatient treatment.

The median duration of illness for AN is approximately 10 years following mid-adolescent onset, with a third of patients having a persistent illness (Treasure et al., 2020). As psychosocial treatments for EDs have limited efficacy (Phillipou et al., 2020), specialist services need to be fully integrated across the duration of illness, in order to optimise patient outcomes. Service integration is achievable in primary care, but the transition from public sector paediatric to adult health services occurs during adolescence, potentially disrupting treatment and increasing morbidity and mortality (Allison et al., 2013). ‘Strictly enforced, this transition can cause delays in commencing or continuing treatment, disruptions to the therapeutic alliance, and even death’ among girls and young women with EDs (Treasure et al., 2020: 906).

Integrated speciality ED services can support adolescent patients entering adulthood and also provide continuity of care between inpatient admissions and outpatient care in youth. State/Territory governments have a vital role in developing joined-up ED services that cover patient care across the lifespan including the peak of acuity in youth with continuity towards midlife for severe and enduring EDs.