Recently, an adolescent patient visited the medical clinic to discuss a possible eating disorder. The patient discussed feeling overweight because her cousin and sister had called her fat, even though this patient was within normal weight for her height with a normal body mass index (BMI). She began to spiral out of control with a restrictive pattern of eating and excessive exercising to lose weight, which led to significant mental health concerns and an eating disorder. During my consultation with the patient, she indicated that her pediatrician at a well visit told her not to gain any more weight because her BMI was exactly where it needed to be, and that any weight gain would put her in the overweight category. Unfortunately, this is not an uncommon story heard in my adolescent medicine clinic.
Prevalence of Eating Disorders
Eating disorders are underdiagnosed and we are now seeing higher rates in younger children, boys, and minority groups.1 They are increasingly recognized in patients with previous histories of obesity, and these patients are at risk for delayed diagnoses and complications. Medical complications of eating disorders are common and affect every organ system; therefore, early intervention can affect prognosis.1
The average American woman is 5′4” tall and weighs 140 pounds.2 However, the average American model is 5′11” tall and weighs 117 pounds.2 Most fashion models are thinner than 98% of American women. Therefore, there is an obvious difference between reality and what is portrayed on media outlets. We also know that on average, 25% of American men and 45% of American women are on a diet on any given day.3 Also, 49% of teenagers worldwide have access to the Internet4 and there are websites that promote eating disorders as a lifestyle choice and not as a disease. These websites include pro-anorexia (“pro-ana”) and pro-bulimia (“pro-mia”) information committed to maintaining, promoting, and supporting eating disorders by teaching young people the best way to starve themselves, purge, and how to avoid detection by those around them.5
The prevalence of anorexia nervosa (AN) is 0.9% in women and 0.3% in men.6 Bulimia nervosa (BN) has a prevalence of 1.5% in women and 0.5% in men.6 Typically, the onset of AN is approximately mid-adolescence and for BN is late adolescence. However, as noted in the Youth Risk Behavior Surveillance Report, many patients report body image concerns and disordered eating in the preteen years.7 There are 42% of first through third graders who want to be thinner, and 81% of 10-year-old girls who are afraid of becoming fat.7
Unfortunately, eating disorders have the highest mortality rate of any mental illness.8 Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.9
The Youth Risk Behavior Surveillance Report showed that, regarding methods of weight loss, 5% of those who answered the survey indicated that they took diet pills without a doctor's advice in the past 30 days, 4.4% vomited or took laxatives to lose weight or keep from gaining weight, and 13% did not eat for 24 or more hours in the past 30 days to lose weight or keep from gaining weight.7
This survey also reported on obesity and level of activity, and it indicated that 13.7% of those who responded were obese and 16.6% were overweight. Fifteen percent reported that they did not participate in 60 minutes of physical activity in the past week, 41.3% stated they played video games or were on their computer ≥3 hours/day, and 32.5% watched television ≥3 hours/day.
The following signs may help identify a child with an eating disorder: food rituals, refusal to eat foods they once enjoyed, avoiding meals with family and friends, over-exercising in a rigid manner, eating in secret, preoccupation with food, calorie counting, fear of becoming fat, binge eating, purging, and food phobias or avoidance.1 If a child or adolescent is demonstrating eating behaviors of concern such as anxiety around food and eating, depression, irritability, and sudden mood changes, he or she should be evaluated. Other behaviors to be concerned about include obsessing about calories, cutting out whole groups of food, rapidly dropping weight, or failing to meet weight-gain requirements for a particular developmental stage.
Eating Disorder Types and Diagnostic Criteria
Common eating disorders include AN, BN, binge-eating disorder, body dysmorphic disorder, and avoidant restrictive food intake disorder. They each have unique characteristics that both parents and health care providers should be knowledgeable about to know whether children and adolescents are displaying any symptoms.
AN is characterized by restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sexual development, and physical health. It involves intense fear of gaining weight or becoming overweight even though the person is underweight. There is a mental disturbance in the way in which one's body weight or shape is experienced. There is also undue influence of body shape and weight on self-evaluation or denial of the seriousness of current body weight. Secondary amenorrhea, or lack of a menstrual cycle in girls who have already started a period, can be a sign of anorexia; however, this is no longer a part of the diagnostic criteria for AN.10 There are two types of anorexia: (1) the restricting type, which means that during the current episode of anorexia the person has not engaged in binge eating or purging behavior and (2): the binge eating/purging type, which means that during the current episode of anorexia, the person has regularly engaged in binge eating or purging behavior.
BN is characterized by recurrent episodes of binge eating. The person eats, within a discrete time, an amount of food that is larger than what most people would eat during a similar period of time under similar circumstances. There is a sense of lack of control regarding eating during the episode. Recurrent inappropriate compensatory behavior to prevent weight gain is present. These symptoms occur on average at least 2 times a week for 3 months.10 Self-evaluation is influenced by body shape and weight. Purging means that the person regularly engages in self-induced vomiting or use of laxatives or diuretics in an attempt to get rid of the food they have just eaten. Nonpurging means that the person uses other inappropriate compensatory behaviors such as fasting or excessive exercising without regular use of vomiting or medications to purge.
Binge-eating disorder involves recurring episodes of consuming significantly more food in a short period than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with binge-eating disorder may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior.10 This disorder is associated with marked distress and occurs, on average, at least 1 time a week over 3 months. Although overeating is a challenge for many Americans, recurrent binge eating is much less common, much more severe, and is associated with significant physical and psychological problems.
Body Dysmorphic Disorder
Body dysmorphic disorder is an intensive obsession over appearance and body image, often for several hours a day. The perceived flaw causes significant distress, and affects one's ability to function in daily life. People who have body dysmorphic disorder may seek out numerous cosmetic procedures or excessively exercise in an attempt to “fix” the perceived flaw, but are never satisfied. This is also known as dysmorphobia, which is the fear of having a deformity.
Avoidant Restrictive Food Intake Disorder
Avoidant restrictive food intake disorder is where the consumption of certain foods is limited based on the food's appearance, smell, taste, texture, or a past negative experience with the food. This does not involve a fear of weight gain but leads to significant physical and emotional impairment.1
The physical findings in children and adolescents who have an eating disorder involve almost all organ systems and can include loss of hair, skin changes, constipation, menstrual changes, slow heart rate, dizziness, passing out, heat and cold intolerance, and many other manifestations.
Outcomes of Eating Disorders
Among adolescents with AN, 50% to 70% fully recover, 20% improve but have residual symptoms, and 10% to 20% develop chronic anorexia.11 Among adolescents with BN, with early treatment 50% fully recover in 2 years, and 20% to 50% will have chronic symptoms.11
Eating disorder treatment options are available for children and adolescents as outpatient, intensive outpatient, partial hospitalization, or inpatient. However, most helpful of all is early intervention through a family centered approach, which has the best likelihood of long-term recovery.1
Psychologists can help children with eating disorders cope with negative behaviors, distorted thinking patterns, and any underlying issues that may have triggered the condition. For example, with cognitive-behavioral therapy, patients learn to recognize situations that trigger eating-disorder behaviors and then work to develop positive coping techniques.
Family based treatment (FBT) has the largest evidence base of any treatment of efficacy in adolescent and young adults who have AN.1 The concept is to refeed the child back to health with three phases that include coaching the caregivers to refeed their child to recovery, then once weight is restored, gradually transferring control of eating back to the child or adolescent. It is the essential first step in modern treatment of eating disorders. Food is seen as primary medicine, both for the body and the brain. Refeeding is often carried out through systematic use of behavior motivation techniques. Finally, the child or adolescent works on relapse prevention and treatment termination. Approximately 50% to 60% of patients in FBT achieve full remission within 1 year.1
How Do We Combat Obesity Without Causing an Eating Disorder?
A large percentage of the US population is obese.12 The prevalence of obesity among US youth was 17% between 2011 and 2014.12 The prevalence of obesity among preschool-age children (2–5 years) is 8.9%, for school-age children (6–11 years) it is 17.5%, and for adolescents (age 12–19 years) it is 20.5%.12 As pediatric providers, we should find a balance between counseling children and adolescents on healthy eating options and exercise without causing them to feel that they need to resort to extreme measures to lose weight. We should be mindful to present the information in a way that promotes self-efficacy in making change without causing a detrimental effect in self-image that leads to disordered eating behavior.
The US Centers for Disease Control and Prevention12 has turned increased attention to childhood obesity. However, these efforts can encourage or help to facilitate undesirable eating behaviors in our youth. Children labeled as overweight or obese from a young age may be more likely to experience low body image, a poor relationship with food, or develop an eating disorder. Just because a person is obese does not mean that he or she cannot develop an eating disorder. Someone's eating disorder should not be overlooked (which is sometimes the case) because they are overweight.
The American Academy of Pediatrics has developed an algorithm13 for assessment and management of childhood obesity that promotes an ongoing positive reinforcement approach to healthy behaviors. The approach is empathetic and empowering; it involves motivational interviewing in support of the patient and family. The goal is to lose no more than 1 pound per month for younger children and no more than 2 pounds per week in older children and adolescents.13 Providers as well as parents are encouraged to focus on positive behavioral changes rather than changes in weight or changes in BMI.
In summary, eating disorders are real and can be seen in both children who meet developmental weight goals as well as in children who are overweight and obese. As pediatric professionals, we must ensure that our discussions around healthy eating and exercise are presented to children and adolescents in a manner that is sensitive, supportive, and based in knowledge. Focusing on positive reinforcement for healthy behavioral changes is the key to long-lasting healthy weight management and it helps prevent stigmatizing children and adolescents for their weight, which can cause low self-esteem and mental health concerns that affect the child in various areas of their lives. The goal should be to talk less about weight and do more to help children and teens achieve a weight that is healthy for them.
- Campbell K, Peebles R. Eating disorders in children and adolescents: state of the art review. Pediatrics. 2014;134(3):582–592. doi:10.1542/peds.2014-0194 [CrossRef].
- PBS website. Perfect illusions: eating disorders and the family. http://www.pbs.org/perfectillusions/eatingdisorders/preventing_facts.html. Accessed April 24, 2017.
- Eating Disorder HOPE. Eating Disorder Statistics & Research. https://www.eatingdisorderhope.com/information/statistics-studies. Accessed April 24, 2017.
- Lenhart A. Teens, social media & technology overview 2015. http://www.pewinternet.org/2015/04/09/teens-social-media-technology-2015/. Accessed April 28, 2017.
- Golden NH, Katzman DK, Kreipe RE, et al. Eating disorders in adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health. 2003;33(6):496–503.
- Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep. 2012;14(4):406–414. doi:10.1007/s11920-012-0282-y [CrossRef].
- Centers for Disease Control and Prevention MMWA Surveillance Summaries. Youth risk behavior surveillance, United States, 2015. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015/ss6506_updated.pdf. Accessed April 24, 2017.
- Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724–731. doi:10.1001/archgenpsychiatry.2011.74 [CrossRef].
- Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey replication. Biol Psychiatry. 2007;61(3):348–358. doi:10.1016/j.biopsych.2006.03.040 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Fisher MM, Alderman EM, Kreipe RE, Rosenfeld WD, eds. Textbook of Adolescent Health Care. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; 2001:743–778.
- US Department of Health and Human Services. Prevalence of obesity among adults and youth: United States, 2011–2014. https://www.cdc.gov/nchs/data/databriefs/db219.pdf. Accessed April 24, 2017.
- American Academy of Pediatrics. Institute for Healthy Childhood Weight. Algorithm for the assessment and management of childhood obesity in patients 2 years and older. https://ihcw.aap.org/Documents/Assessment%20%20and%20Management%20of%20Childhood%20Obesity%20Algorithm_FINAL.pdf. Accessed April 24, 2017.