(P24-010-25) Weight Loss in the Setting of Obsessive Compulsive Disorder (OCD), Severe Obesity and New Onset Atypical Anorexia Nervosa (AAN)

Objectives: Management of adolescent severe obesity is complex and includes treating cardiometabolic complications, preventing eating disorders, addressing rapid weight loss (RWL, >2lb/week), and respecting an adolescent’s emerging autonomy.

Methods: A 13-year-old male presented to the Emergency Department (ED) with 2 weeks of abdominal pain, tenesmus, diarrhea and constipation. His past medical history included Class III severe obesity, dyslipidemia, acanthosis nigricans, vitamin D insufficiency, obstructive sleep apnea, untreated OCD, anxiety, depression and suspicion of high functioning autism. He was followed for 18 months in a pediatric weight management clinic and had lost ~1.5 lb/week with lifestyle interventions. In the ED, he reported nausea and abdominal pain with ingestion, despite hunger, and his grandmother had noted increased weight loss. In the ED, he endorsed self-initiating a restrictive diet of  ~650 calories/day.

Exam findings included striae distensae to abdomen and extremities, no acanthosis nigricans, decreased extremity subcutaneous fat and muscle mass but normal strength bilaterally.  Labs revealed low bicarbonate, blood urea nitrogen, vitamin D and creatinine and normal phosphorus, magnesium and potassium.  Hemoglobin, hematocrit, and ferritin were normal. Urinalysis indicated ketonuria and high specific gravity.  EKG revealed sinus rhythm of 64 bpm. He was admitted and caloric intake gradually advanced to prevent risk for re-feeding syndrome.  Adolescent Medicine was consulted for Atypical Anorexia Nervosa (AAN) and Dietetics recommended a 2500 kcal/day diet and referral to the Eating Disorders Clinic.

Results: Very low calorie diets, RWL, and AAN can cause multi-system adverse effects.  RWL increases risk of weight regain and alters metabolism. For AAN, a goal caloric intake post weight loss that maintains BMI between the 5th through 84th%ile is reasonable (opposed to restoring prior obesity), as long as vital sign stability and healthy eating behaviors are achieved. Concurrent “habit reversal training” is also advised.

Conclusions: This case highlights the need to personalize treatment and monitoring to optimize mental health and cardiometabolic outcomes in a complicated adolescent patient with newly diagnosed AAN.

Funding Sources: Children's Hospital of Colorado
The University of Colorado Department of Pediatrics
NIDDK