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Editor's note: In this issue, the Adolescent Health Update newsletter features considerations for the pediatrician whose adolescent patient is a vegetarian. The following case vignette illustrates skills useful for the office encounter when the parents are concerned about their teen's nutritional well being. The editors asked one of the authors, Marcie Schneider, M.D., FAAP, an adolescent medicine specialist and director of Greenwich Adolescent Medicine Services at Greenwich Hospital, Greenwich, Conn., to adapt the original vignette for Consultant's Corner.
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The situation: Stephanie, your 15-year-old patient, recently announced to her family that she would no longer eat red meat, chicken or fish. After dissecting a frog in biology class, Stephanie had decided that eating things that were once alive was "gross." Her parents reported that Stephanie would join them for dinner, eating everything but the animal protein. She sometimes complained of nausea because there was meat on her plate and had left the table early on several occasions. Her mother made no changes to the family's menu but called for an appointment to discuss her concern about unhealthy eating behaviors.
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Office-based counseling: You meet first with Stephanie and her mom together, then with Stephanie alone. She tells you that she has been prone to nausea since the dissection; it had really bothered her and she had almost fainted.
Stephanie has done some reading about nutrition and is willing to eat eggs, milk and cheese because the animals aren't hurt in the process. A 24-hour dietary recall reveals that she has a varied diet with adequate protein coming from milk, eggs, cheese, beans and peanut butter. Stephanie denies any issue related to body image (although she "isn't thrilled with her thighs"), and has not been vomiting, bingeing, using diet pills, diuretics or laxatives, or over-exercising. Physical examination reveals that she is gaining weight as expected and is where she should be on the growth chart. Stephanie's vital signs are stable and the remainder of her examination is normal. Her menstrual periods are regular, and she has no symptoms or signs of malnutrition.
You call mom back in and reassure her that this seems to be a visceral response to the dissection. You can see that Stephanie is educating herself on vegetarianism and that her diet is nutritionally adequate. Mom asks a lot of questions about nutrition, and you offer the support of a nutritionist. Mom remains concerned about the family dinner; she asks Stephanie if there isn't some way they all can eat together without making her nauseated. Stephanie agrees that if her vegetarianism is accepted and the animal protein is not on her plate, she should be fine. You schedule a follow-up appointment to see Stephanie and her mom again in a few weeks. They both leave the office feeling better. A happy ending, but what about some of the other adolescents in your practice?
Eating disorder or vegetarian lifestyle
Becoming vegetarian may be seen as a socially acceptable way for an adolescent with an eating disorder to hide the true problem. One study of eating-disordered vegetarian patients found that most became vegetarian after they had developed their eating disorder.
An established vegetarian whose diet is more restrictive is less likely than a less restrictive vegetarian to have an actual eating disorder or to be involved with unhealthy weight behaviors. There also is some evidence that adolescent males who are vegetarian may be at high risk for behaviors associated with unhealthy weight.
Teens whose vegetarianism is part of their eating disorder may use vegetarianism as an excuse to avoid eating with nonvegetarians, saying that what is being served makes them uncomfortable. In reality, many eating-disordered teens refuse to eat with others in order to eat less, lose weight and avoid the comments that friends and family members make about their weight and eating.
Red flags: In looking at the dietary intake of teens whose vegetarianism is part of their eating disorder, a lack of fat is readily recognizable. It is likely that nuts, seeds, eggs with yolks, full or low fat cheese or yogurt are missing from the diet. For this reason, obtaining a detailed 24-hour dietary recall is essential. The dietary recall will reveal further clues. For example, eating-disordered teens are likely to be avoiding caloric drinks in addition to dietary fat. Instead, one may see excessive amounts of diet caffeinated drinks, which decrease the appetite and fill the stomach without calories, promoting weight loss.
If an eating disorder is suspected, ask about body image. What does the patient see as his/her ideal weight? How much and how often is he/she exercising? How frequently does he/she weigh herself? It is important to be as concrete and specific as possible. An anorexic patient who is exercising excessively, for example, may not share that up-front. The patient who is "stretching" every day and exercising every other day may be stretching with 200 abdominal crunches, 100 leg lifts and 50 push-ups. Her 45 minutes on the treadmill each day may exclude long warm-up and cool-down periods. Ask, "How many miles do you clock? At what speed? At what incline?"
Other questions to ask when an eating disorder is suspected relate to use of over-the-counter or herbal supplements, laxatives, diet pills and diuretics. Is the patient vomiting? Is there a menstrual history that reveals irregularity or amenorrhea? In the physical examination, look for signs of malnutrition, weight loss and lack of appropriate weight gain or growth.
If your examination of the patient in the vignette had revealed signs and symptoms of an eating disorder, you would have discussed your concerns with Stephanie, first alone and then with her parents. You would have asked her to start a detailed diet and exercise diary and to plan on seeing you regularly because you would need to monitor her weight and vital signs. Your conversation would include immediate referral to a nutritionist and eventually (after she has accepted the diagnosis) to a therapist. A psychiatrist for possible medications could be explored at a later date. (For information about medical management and supportive care of adolescents with eating disorders, refer to the February 2001 issues of Adolescent Health Update and Consultant's Corner.) If you felt uncomfortable about monitoring her progress, you would refer her to someone in the community who specializes in medical management of eating disorders, taking care to follow up and remain involved in her care.
A healthy ending
In the clinical vignette described above, the pediatrician was able to reassure the mother that Stephanie's dietary choices were not unreasonable or unhealthy. The patient had adopted a vegetarian diet in response to the dissection of an animal. She was eating everything but meat, and her diet included adequate protein, fat and carbohydrates. She revealed no symptoms of an eating disorder and indicated that menstrual function was normal. She was growing and gaining weight at appropriate rates. Most importantly, she and her mom were able to come to an understanding so that the family could be together at mealtime.
This column supplements the current issue of Adolescent Health Update and addresses topics relevant to the care of teens. Readers who want to share comments or questions on adolescent medicine topics in future issues should write to: Adolescent Health Update, American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007, or e-mail adolhealth@aap.org.
