A 12-year-old girl is brought to the office by her mother for an annual examination. The mother is concerned about her daughter's weight and restrictive diet, frustrated that "she won't eat certain things that I prepare for the rest of the family." The patient has not eaten red meat since age 11. Six months ago, she decided to stop eating chicken and fish after becoming involved with an animal rights group. The patient spends time researching vegetarian recipes to ensure she obtains all the nutrients she needs and prepares most of her own meals. She has fruit for breakfast and prepares her own lunch and dinner, typically eating foods such as beans, tofu, yogurt, and vegetables with rice or pasta. The mother adds that her daughter's room is "always a complete mess," and that her daughter can be moody and irritable at times, especially when they argue about her diet or the way she dresses. The patient maintains average grades, plays in the school band, and practices regularly with a dance team. She has no medical issues and takes a daily multivitamin. Menarche has not occurred. She weighs 55 kg (121.2 lb) and is 162.5 cm (5 ft 4 in) tall. Vital signs are normal. Examination shows a muscular build, Tanner stage 4 secondary sexual characteristics, and no abnormal findings. When seen without her mother, the patient says she is not concerned about her weight and feels good about her health. She is angry that her family is not more supportive of her beliefs and diet. Which of the following is the most appropriate next step?

Question

A 12-year-old girl is brought to the office by her mother for an annual examination.  The mother is concerned about her daughter's weight and restrictive diet, frustrated that "she won't eat certain things that I prepare for the rest of the family."  The patient has not eaten red meat since age 11.  Six months ago, she decided to stop eating chicken and fish after becoming involved with an animal rights group.  The patient spends time researching vegetarian recipes to ensure she obtains all the nutrients she needs and prepares most of her own meals.  She has fruit for breakfast and prepares her own lunch and dinner, typically eating foods such as beans, tofu, yogurt, and vegetables with rice or pasta.  The mother adds that her daughter's room is "always a complete mess," and that her daughter can be moody and irritable at times, especially when they argue about her diet or the way she dresses.  The patient maintains average grades, plays in the school band, and practices regularly with a dance team.  She has no medical issues and takes a daily multivitamin.  Menarche has not occurred.  She weighs 55 kg (121.2 lb) and is 162.5 cm (5 ft 4 in) tall.  Vital signs are normal.  Examination shows a muscular build, Tanner stage 4 secondary sexual characteristics, and no abnormal findings.  When seen without her mother, the patient says she is not concerned about her weight and feels good about her health.  She is angry that her family is not more supportive of her beliefs and diet.  Which of the following is the most appropriate next step?

Quizplus · Accepted Answer

Well-planned vegetarian diets can provide balanced nutrition. Although some adolescents may choose a vegetarian diet as a means of weight control and later develop inappropriate dietary restrictions and other disordered eating behaviors, there is no evidence that this is the case with this patient who has a positive body image and whose diet includes a broad range of foods. Her vegetarianism appears to be rooted in her concern for animals rather than a desire to be thin and lose weight. The patient's BMI (20.8 kg/m²) is within normal range and her vital signs, physical examination, and Tanner stage are normal. Amenorrhea would become a concern only if she did not menstruate by age 15. In addition, the patient has no behavioral symptoms that raise concern for psychiatric disorders. She functions well at school, is physically active, and participates in social activities. Her disorganized, messy room and irritability with her mother are characteristic of normal adolescent behavior. ² Therefore, reassuring the mother that the daughter is getting adequate nutrition and developing normally is appropriate. In contrast, an adolescent who has a significantly low weight for age and developmental stage along with a history of inappropriate dietary restriction, distorted body image, and/or physical findings suggestive of an eating disorder is a candidate for further evaluation. (Choice A) Asking the daughter to keep a food diary is not required since her weight is normal and she eats a range of nutritional foods. This intervention would likely result in unnecessary frustration for the patient and impair the physician-patient relationship. (Choices B and G) These interventions could be indicated if there is evidence raising concern for an eating disorder (eg, parotid hypertrophy, knuckle callouses). Dietary restriction and self-induced vomiting can cause electrolyte disturbances such as hypokalemia, hypochloremia, and hyperamylasemia. (Choice D) Disagreements between adolescents and their parents are common. Separating and developing one's own identity is typical of normal adolescent development, and this patient is functioning well socially and academically. If the mother's concerns and family tensions do not improve with the initial intervention of education and brief reassurance, then family therapy could be considered. (Choices E and F) Cognitive-behavioral therapy and nutritional counseling are first-line treatment for eating disorders, which are not demonstrated in this patient. Educational objective: Well-balanced vegetarian diets can meet the nutritional needs of adolescents. However, patients with low BMI, evidence of excessively restrictive diets, or distorted body image should be evaluated for eating disorders. References: Vegetarian diets in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/21532796)

A 12-Year-Old Girl Is Brought to the Office by Her