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In the past, parents may have tried to coax their picky eaters to dinner with misguided reminders of starving children—or perhaps letting them imitate farm animals. But, the parents of today now have a scarier prompt.
A British teenager has permanent vision loss, hearing loss, and weak bones after years of eating only select types of junk food. The teen’s doctors eventually diagnosed him with a relatively newly defined eating disorder called avoidant-restrictive food in-take disorder (ARFID). They report the teen’s case this week in the Annals of Internal Medicine.
The case is a rare one in developed countries, which have a ready supply of nutritious foods. The teen’s doctors in Bristol were initially stumped by his progressive symptoms. But they caution other physicians in their case report that such damage from poor nutrition is potentially reversible—if it’s caught early—and even people with normal weights may be struggling with eating disorders.
The first clue of the teen’s troubles came when the boy was 14 years old. He showed up to his family doctor complaining of tiredness. Other than being described as a “fussy eater,” the teen was healthy and not taking any medications. Tests indicated that he had a type of anemia that makes red blood cells unusually large, as well as low levels of vitamin B12. His doctor treated him with vitamin B12 injections and dietary advice.
But the teen’s condition worsened. Just a year later, he returned to doctors with unexplained hearing loss. Shortly after, he developed problems with his vision. Over the next two years, his vision continued to deteriorate. By age 17, his visual acuity was 20/200 in both eyes, meaning he would need to be 20 feet away to see something a person with normal vision would see sharply from 200 feet away.
Scans found no lesions on his optic nerves and genetic tests were negative for hereditary explanations for blindness. His blood tests were mostly normal except that his blood cells were still enlarged and he had elevated levels of homocysteine and methylmalonic acid, which are all indicators of vitamin B12 deficiency.
This pointed doctors toward a nutritional problem. But the teen had a body mass index in the normal range, with average height and weight. He told doctors he didn’t drink alcohol, take drugs, or use tobacco products.
The crack in the case came when he finally confessed that he had only eaten foods with certain textures since elementary school. His diet consisted of a daily order of fries from a local fish and chip shop, Pringles chips, white bread, processed ham slices, and sausages. The vitamin B12 shots he was prescribed at 14 had lapsed.
Metabolic testing showed he had low copper and selenium levels, a high zinc level, remarkably low vitamin D level, and low bone mineral density, the doctors reported.
His doctors finally diagnosed him with nutritional optic neuropathy, which is dysfunction of the optic nerve when nutrients essential for nerve fiber function are in short supply. It is an uncommon condition, particularly in developed countries, but sometimes found in people with alcohol dependence. The doctors also diagnosed the teen with ARFID.
Though many kids could be described as fussy eaters, the problem rises to the level of an eating disorder when eating “is restricted to junk foods and causes multiple nutritional deficiencies,” the doctors explain.
They treated the teen with nutritional supplements and referred him to mental health services to address his ARFID. In their report, the doctors caution physicians to keep an eye out for ARFID, which unlike other eating disorders like anorexia, isn’t driven by body weight or shape. “As in this patient, BMI is often normal,” they write.
Though the teen’s vision stabilized, it didn’t improve. His vision loss is permanent. The doctors hope their report will help others identify ARFID and nutritional optic neuropathy early, before it has a chance to cause permanent damage again.
For parents of fussy eaters who don’t have an eating disorder, the American Academy of Pediatrics offers handy tips for addressing eating issues early on. (Spoiler: guilting and scaring your child into eating are not recommended methods.) If you are concerned that your child has an eating disorder, talk with your doctor. Cognitive-behavioral therapy is a commonly used method to help patients with ARFID establish a healthier diet.
Annals of Internal Medicine, 2019. DOI: 10.7326/L19-0361 (About DOIs).