As I have said many times in the past, complete weight restoration is the conditio sine qua non of childhood eating disorder treatment — if you do not get weight restoration, you will get nothing. While facilitating weight restoration, there are a number of biomarkers (in addition to weight gain) we monitor at Kartini Clinic to help ensure our patients’ adequate physical and hormonal restoration.
Pubertal Girls: Restoration of Menstruation
In a girl old enough to have periods or have had the initiation of menarche (average age in Caucasian females at about 12 and a half years of age, earlier in some ethnic groups), resumption of menstruation (ROM) is essential. Previous advice to “have patience” with a delay in ROM, believing that it “may take years” is probably misguided. The surge of luteinizing hormone (LH) which initiates ovulation and the ratio of LH to FSH (follicle stimulating hormone) greater than 1.0, are important values which can be easily followed longitudinally. ROM has been shown to be essential in cognitive recovery, to say nothing of bone growth.
In some females, there may be a delay in ROM despite apparent complete weight restoration, which we have found to be due to a suppression of leptin levels. Leptin has a permissive effect on LH. The most common causes, in our patients, of suppressed leptin levels would be:
- Guessing too low when establishing a weight goal
- Exercise, especially aerobic exercise, such as running, suppressing leptin
- Post-prandial hypoglycemia seen during recovery from starvation in some patients, which also suppresses leptin.
Pubertal Boys: Testosterone Tracking
In pubertal boys, it is possible to measure and track testosterone. Testosterone is critical to bone development, muscle strength and growth as well as to mood and energy levels. As boys have no “biological marker of normalcy”, such as menstruation, it is easy to set weight goals too low, especially in societies which value leanness. Height and weight should be tracked in boys of all ages and percentile changes should be interpreted by someone who understands childhood growth.
Pre-Pubertal Patients: Documented Growth Patterns
In pre-pubertal girls and in boys, the labs mentioned above will not prove useful, however. In the very young patient, there will be no substitute for measuring and charting changes in weight and height. Seeing a resumption of linear growth, and, in children old enough for this to occur, observing the eventual advancement of puberty, will assure us that our weight goals are adequate. This will mean that a provider trained in assessing stage of maturation (SMR or Tanner stages) will be an important member of a pediatric treatment team.
In children of all ages, improvement in socialization and sense of humor are also great signs of recovery, which one’s parents are in the best position to observe.
