Pediatric Annals

Special Issue Article 

Identifying and Preventing Eating Disorders in Adolescent Patients with Obesity

Sharonda Alston Taylor, MD, FAAP, FSAHM; Sarah Ditch, MD, FAAP; Shana Hansen, MD, FAAP, FSAHM

Abstract

Adolescents with obesity are not immune to developing disordered eating and eating disorders. They most commonly present with atypical or subthreshold criterion due to excess body weight or questions regarding the presence of a distorted body image. Patients with premorbid overweight/obesity and subsequent achievement of weight loss may lead to delays in the recognition and treatment of disordered eating and eating disorders. In fact, disordered eating and eating disorders tend to be higher in those undergoing weight management. This article describes risk factors for the development of eating disorders, common features of eating disorders in adolescents with obesity, and provides recommendations for prevention strategies. [Pediatr Ann. 2018;47(6):e232–e237.]

Abstract

Adolescents with obesity are not immune to developing disordered eating and eating disorders. They most commonly present with atypical or subthreshold criterion due to excess body weight or questions regarding the presence of a distorted body image. Patients with premorbid overweight/obesity and subsequent achievement of weight loss may lead to delays in the recognition and treatment of disordered eating and eating disorders. In fact, disordered eating and eating disorders tend to be higher in those undergoing weight management. This article describes risk factors for the development of eating disorders, common features of eating disorders in adolescents with obesity, and provides recommendations for prevention strategies. [Pediatr Ann. 2018;47(6):e232–e237.]

Obesity is the most common chronic illness seen in pediatrics. As of 2014, 20.5% of youth age 12 to 19 years in the United States were obese (body mass index [BMI] ≥95th percentile for age and gender) and 9.1% were extremely obese (BMI ≥120% of the 95th percentile for age and gender).1 Adolescents desiring to lose weight may employ unhealthy behaviors to accomplish this goal. According to 2013 Youth Risk Behavior Surveillance Survey high school data, 13% engaged in meal skipping to lose weight, 5% took diet pills or other nonprescription weight loss supplements, and 4.4% vomited or used laxatives to lose weight.2 The National Longitudinal Study of Adolescent to Adult Health noted an even higher prevalence of disordered weight control behaviors in those who self-identified as overweight; they engaged in fasting/meal skipping (19.5% adolescent girls, 12.9% adolescent boys), purging/diet pills (9.4% adolescent girls, 2% adolescent boys), and overeating/loss of control (LOC) eating (11.1% adolescent girls, 6.6% adolescent boys).3 Additional research shows that disordered weight control behaviors are greater in people who are overweight or with obesity than in people who are average weight4,5 as well as in those actively seeking treatment.6 Over 40% of adolescents undergoing a lifestyle intervention for obesity screened positive for an eating disorder. The most prevalent features were LOC overeating and body image disturbance.7

Obesity and eating disorders are not mutually exclusive conditions. Often, patients with obesity are not considered at risk for disordered eating or eating disorders. It is important that clinicians are aware of common symptomatology and screen for disordered eating and eating disorders in patients with overweight or obese BMIs.

Identifying Eating Disorder Risk Factors

Adolescents with obesity are not immune to developing disordered eating and eating disorders. Patients present with atypical or subthreshold criteria due to the presence of excess body weight or to the perceived validity of their body weight and shape concerns. Many patients who are diagnosed with anorexia nervosa (AN) initially were obese and may experience a treatment delay of 10 months compared to those beginning at a healthy body weight prior to eating disorder development.8

Patients with obesity who are developing an eating disorder often display stereotypical disordered eating behaviors similar to their counterparts with a healthy body weight or low BMI. These include hiding food, eating in secret, binging, purging, exercising excessively, and taking frequent bathroom breaks. In addition to these stereotypical behaviors, there are risk factors to assess for in patients who may be developing both obesity and an eating disorder. These may be similar to those with AN and bulimia nervosa (BN),9 and include environmental and social factors such as weight-based teasing by family or peers,10 an overemphasis by family on body weight and shape, household environment/family dynamics, media use, and dieting.10

Adolescents with obesity are often victims of weight-related teasing, and this can lead to binge eating and other disordered eating behaviors, which can increase the risk for both further weight gain and eating disorders.11 Studies have shown that media use is positively associated with both a higher BMI and the development of disordered weight control practices. Media perpetuates a thin beauty ideal and internalization of this unattainable belief leads to body dissatisfaction, which is a risk factor for binge eating and dieting behaviors. Despite its perceived role in treating obesity, dieting is not effective at preventing weight gain and may put adolescents at risk for obesity. Most people with eating disorders admit to dieting prior to developing disordered eating.12

Patient-specific risk factors include severe childhood obesity,9 overestimation of weight,5 patient personal body dissatisfaction,10,13 history of adverse childhood event/trauma,14 lower interpersonal functioning, and cognitive rigidity.5 Additionally, there is evidence of attention-deficit/hyperactivity disorder as being a risk factor for binge-eating disorder (BED).15 A parental history of BED as well as parental BED restrictive feeding practices are associated with adolescent binge eating and overeating.16 See Table 1 for additional risk factors.

Risk Factors for Binge Eating and Overeating by Eating Disorder Type

Table 1:

Risk Factors for Binge Eating and Overeating by Eating Disorder Type

Common Eating Disorders in Patients with Obesity

Binge-Eating Disorder/Loss of Control Eating

The core features of BED include eating more in a discrete amount of time than most people would and experiencing LOC eating during this time. The binge eating episode causes significant shame, disgust with oneself, and can lead to psychological distress. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), criteria are listed in Table 2.17Table 3 lists questions to consider when defining a BED in children. BED is distinguishable from BN by the absence of compensatory behaviors such as vomiting, compulsive exercise, or abuse of laxatives. Prevalence of BED varies widely, with community surveys of the general population having estimates between 1.8% and 3.5% and increasing to between 9% and 47% in patients who are obese as well as in patients who had bariatric surgery.18–20 BED affects 1% to 5% of adolescents.18–20 Patients often report that their binge eating began during childhood and adolescence.21,22

Binge-Eating Disorder Diagnostic Criteria

Table 2:

Binge-Eating Disorder Diagnostic Criteria

Recommended Questions to Assess Binge-Eating Behaviors

Table 3:

Recommended Questions to Assess Binge-Eating Behaviors

BED may be underrecognized in children given that the diagnostic feature of eating “a large amount” of food may be difficult to define in this age group.23 Researchers have proposed the term LOC, rather than considering a measured quantity eaten.24 LOC is best described as eating without being able to control the amount of food, regardless of the meal size. LOC is characterized by overeating in any situation that can lead to physical discomfort. Unlike the episodes of binging involved in BED or BN, there may not be significant psychological distress or true awareness of the event. LOC eating often precedes BED and other disorders of disinhibited eating patterns.24 Recent literature has noted that LOC, rather than overeating, is predictive of future obesity and depression.25

Compared with non-BED obese controls, those with BED have more severe obesity, earlier onset of overweight, and early onset of dieting.26

Bulimia Nervosa

The key feature of BN is uncontrolled eating of large quantities followed by a compensatory behavior to rid oneself of the calories consumed. The official DSM-5 criteria for BN are in Table 4.

Bulimia Nervosa Diagnostic Criteria

Table 4:

Bulimia Nervosa Diagnostic Criteria

Flament et al.4 noted that full-criteria and subthreshold cases of BN increase in both men and women as BMI increases. The odds of having BN are 7.86 and 3.27 for men and women with obesity, respectively.

Binge-eating episodes in BN are identifiable as truly excessive food intake and are associated with the sense of lack of control and significant distress after the event. In the setting of obesity, binges must still occur in a discrete period of time; snacking throughout the day does not qualify as binge eating. Binge episodes should be put into cultural context; for example, consuming large amounts of food at culturally sanctioned events (holidays, celebrations) or the normalization of larger portion sizes may not represent a binge.27

The astute clinician should ask about a variety of purging methods, obtaining as much detail as possible. Start by asking, “After you binge, do you do anything to get rid of the calories or food?” Specific purging questions are included in Table 5.

Questions to Assess Purging Behaviors

Table 5:

Questions to Assess Purging Behaviors

Purging Disorder

Purging disorder is an example of “other specified eating disorder.” It is characterized using purging (as described above in the compensatory mechanisms used in BN) as a means of controlling body weight and/or shape but is not associated with binge eating. Research shows that meal-skipping and vomiting are commonly used compensatory mechanisms in patients with obesity.15 When compared to BED, those with purging disorder report more dietary restraint and greater body dissatisfaction.28

Night-Eating Syndrome

Night-eating syndrome (NES) is characterized by a circadian phase delay in food intake. Proposed standardized diagnostic criteria for NES are listed in Table 6.29,30 People with NES take in a high proportion (25%) of their daily calories after dinner, many of which come from breads and sweets. NES is differentiated from sleep-related eating disorder in that patients with NES are aware and can recall their nocturnal eating episodes.

Night-Eating Syndrome Proposed Diagnostic Criteria

Table 6:

Night-Eating Syndrome Proposed Diagnostic Criteria

Prevalence varies by study population with the rate in the general population being 1.5% and increasing from 9% to 15% in overweight samples and from 10% to 42% in bariatric patients. NES often has its onset in early adulthood, is chronic, and waxes and wanes with life circumstances. In fact, 75% of people with NES relate the onset of their night eating to a specific life stressor.26 People with a healthy body weight with NES tend to be younger than those who are overweight, which suggests that NES may contribute to the development of future obesity. This idea is further supported by the fact that >50% of night eaters with obesity report that their night eating preceded obesity development.31

Prevention

The high prevalence of body dissatisfaction, disordered eating behaviors, and clinical eating disorders in patients with obesity complicates efforts to prevent and treat the disease.12 Primary care providers play a key role in the prevention of eating disorders by encouraging proper nutrition and physical activity while avoiding unhealthy emphasis on weight and dieting.

Appropriate Weight Goals

It is important for providers to set appropriate weight goals for children and adolescent patients with an elevated BMI. For children younger than age 11 years, weight management goals focus on slowing weight gain (if overweight) or weight maintenance (if obese). If weight loss occurs, it should not exceed 1 pound per month; however, more rapid weight loss (up to 2 pounds per week) can be tolerated if BMI is >99th percentile. For adolescents with an overweight BMI, the goal is weight maintenance or a slowing of weight gain. For adolescents with obesity, the goal is weight loss at a rate of no more than 2 pounds per week. If faster weight loss occurs, close attention should be paid to signs of other causes of weight loss (both organic and disordered eating behaviors).32 We recommend that providers review risk factors for and features of eating disorders so early intervention can occur. In general, praising healthy behavior change rather than the weight loss may lessen disordered weight control behaviors.

In addition, rapid weight gain may be a sign of BED/LOC and NES. Reviewing eating patterns and timing, especially early day food restriction, meal skipping, late day meals/snacks, or emotional eating may aid in the diagnosis of these lesser known conditions. Provider assistance with developing healthy meal time habits can reduce the likelihood that a patient develops BED/LOC or NES.

There are five evidence-based management topics for the prevention of obesity and eating disorders (Table 7). The framework provided by these management recommendations can help prevent not only obesity and eating disorders but also other weight-related problems.12,33

Recommendations for Preventing Obesity and Eating Disorders

Table 7:

Recommendations for Preventing Obesity and Eating Disorders

Family's Role in Preventing Eating Disorders

Behaviors modeled by parents are important in shaping a child's eating habits. Having family meals leads to healthier dietary intake such as including more fruits, vegetables, grains, and calcium-rich food and less soft drink intake. Possible mechanisms for this include availability of healthier foods, parental modeling of healthy eating patterns, improved parent-teen relationship, and opportunity for parents to monitor the adolescent's eating behavior and overall emotional health.12

Both at the table and throughout the day, families should be encouraged to avoid weight talk. This includes commenting about their own weight and dieting, discussing other people's weight, encouraging the adolescent to diet or lose weight, and weight teasing. Family weight talk at home increases the risk of eating disorders in adolescents and does not facilitate weight management. Approximately 40% of early adolescent boys and girls report experiencing weight teasing by peers or family members.12 The presence of family weight teasing is correlated with overweight status in both girls and boys, and binge eating and extreme weight-control behaviors in girls.12,33 Parents should create a home environment that encourages healthy eating and physical activity and model these activities for their children.12,33

Provider's Role in Preventing Eating Disorder

Many adolescents engage in dieting to lose weight, but these behaviors may be counterproductive and are associated with long-term weight gain. Patients may be referring to a variety of eating habits, so it is important to ask what they mean by “dieting.” Providers can discourage unhealthy dieting and instead support positive eating and physical activity. Positive eating includes eating more fruits and vegetables and paying attention to portion size and signs of hunger and satiety. It is important that providers encourage children to develop a healthy relationship with their bodies by focusing on wanting to nurture their bodies, rather than body dissatisfaction, as a motivator for change.12,33 Among all adolescents, 50% of girls and 30% of boys express body dissatisfaction;11 the proportion is increased in adolescents with higher BMIs. Adolescents need support from providers to adopt these healthy eating behaviors. In clinic, this support can be provided by motivational interviewing and individual and family counseling services.12,33

It is important that children know that they do not deserve to be the victim of weight teasing and family members should be educated that weight teasing cannot be tolerated at home, even if it is in a playful or joking manner. Weight teasing is not only associated with overweight status and body dissatisfaction but also with low self-esteem, depressive symptoms, and problematic eating behaviors. Although health care providers may be reluctant to bring up weight management because they do not want to make the children uncomfortable, it is important to provide a safe place for patients to disclose weight mistreatment and talk about their experiences.12,33

Conclusion

Clinicians should promptly screen for the risk factors and early signs of disordered eating in people who are overweight/obese. If not adequately addressed, people who are overweight/obese are vulnerable to the development of eating disorders, often while they are trying to lose weight or become healthier. Prevention of eating disorders and appropriate treatment efforts are important due to the significant distress and dysfunction associated with these disorders. Clinicians can use an integrated prevention approach that includes incorporating both healthy individual and family-based lifestyle modifications.

References

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Risk Factors for Binge Eating and Overeating by Eating Disorder Type

All eating disorders <list-item>

Negative affect

</list-item><list-item>

Perfectionism

</list-item><list-item>

Family dieting

</list-item><list-item>

Family overeating

</list-item><list-item>

Problem parenting

</list-item><list-item>

Family discord

</list-item><list-item>

High parental demands

</list-item><list-item>

Parental substance abuse

</list-item><list-item>

Physical abuse

</list-item>
Bulimia nervosa and binge-eating disorder <list-item>

Conduct problems

</list-item><list-item>

Severe childhood obesity

</list-item><list-item>

Bullying and teasing

</list-item><list-item>

Family history of bulimia nervosa

</list-item><list-item>

Separation from parent

</list-item><list-item>

Sexual abuse

</list-item>
Binge-eating disorder <list-item>

Substance abuse

</list-item><list-item>

Pregnancy history

</list-item><list-item>

Disruptions and deprivation

</list-item><list-item>

Parental absence or death

</list-item><list-item>

Parental depression

</list-item>
Night-eating disorder <list-item>

Family history of night-eating disorder

</list-item><list-item>

Elevated stress levels

</list-item><list-item>

Depressed mood

</list-item>

Binge-Eating Disorder Diagnostic Criteria

<list-item>

Recurrent episodes of binge eating

</list-item><list-item>

Binge-eating episode is associated with eating rapidly, eating until feeling uncomfortably full, eating when not feeling hungry, eating alone due to being embarrassed, or feeling disgusted or depressed

</list-item><list-item>

Marked distress because of the binge eating

</list-item><list-item>

Frequency at least once per week for 3 months

</list-item><list-item>

Symptoms are not followed by compensatory behavior and do not occur in the context of bulimia nervosa or anorexia

</list-item>

Recommended Questions to Assess Binge-Eating Behaviors

<list-item>

Do you ever eat when you are not hungry?

</list-item><list-item>

Do you ever feel that when you start eating you cannot stop?

</list-item><list-item>

Do you ever eat because you feel bad, sad, bored, or any other mood?

</list-item><list-item>

Do you ever want food as a reward for doing something?

</list-item><list-item>

Do you ever feel embarrassed or guilty after you eat?

</list-item><list-item>

Do you ever sneak or hide food?

</list-item>

Bulimia Nervosa Diagnostic Criteria

Recurrent episodes of binge eating. An episode of binge eating is characterized by the following: <list-item>

Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

</list-item><list-item>

A sense of lack of control about eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)

</list-item><list-item>

Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise

</list-item><list-item>

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once per week for 3 months

</list-item><list-item>

Self-evaluation is unduly influenced by body shape and weight

</list-item><list-item>

The disturbance does not occur exclusively during episodes of anorexia nervosa

</list-item>

Questions to Assess Purging Behaviors

<list-item>

Vomiting: how often do you make yourself vomit; how many episodes of vomiting per session; how do you know when to stop; have you ever noticed blood in your vomit; has it ever been bright green?

</list-item><list-item>

Diuretics, diet pills, and laxatives: what is the name of the medication; where do you get it from (physician, natural food store, Internet, family); what is the dose; how many do you take; how often do you use it; what happens when you take it (diarrhea, frequent urination, palpitation)?

</list-item><list-item>

Exercise: walk me through your physical activity/exercise routine (ask for specific exercises); how many repetitions; how many sets; how many times a day?

</list-item><list-item>

Restriction/meal skipping: when do you eat your next meal or snack after you binge; do you skip meals to make up for the overeating; how many meals will you skip?

</list-item>

Night-Eating Syndrome Proposed Diagnostic Criteria

<list-item>

Daily eating pattern of evening/night-time hyperphagia of one or both of the following: <list-item>

At least 25% caloric intake after the evening meal

</list-item><list-item>

At least two episodes of nocturnal eating per week

</list-item>

</list-item><list-item>

Awareness and recall of evening- and nocturnal-eating episodes

</list-item><list-item>

At least three of the following must be present: <list-item>

Morning anorexia and/or skipped breakfast four or more mornings per week

</list-item><list-item>

Presence of a strong urge to eat between dinner and sleep onset and/or during the night

</list-item><list-item>

Sleep onset and/or sleep maintenance insomnia four or more nights per week

</list-item><list-item>

Presence of a belief that one must eat to return to sleep

</list-item><list-item>

Mood is frequently depressed and/or mood worsens in the evening

</list-item>

</list-item><list-item>

The disorder is associated with significant distress and/or impairment in functioning

</list-item><list-item>

The disordered pattern of eating is maintained for at least 3 months

</list-item><list-item>

The disorder is not secondary to substance abuse or dependence, medical disorder, medication, or another psychiatric disorder

</list-item>

Recommendations for Preventing Obesity and Eating Disorders

<list-item>

Inform adolescents that dieting, and particularly unhealthy weight control behaviors, may be counterproductive. Instead encourage positive eating and physical behaviors that can be maintained on a regular basis

</list-item><list-item>

Do not use body dissatisfaction as a motivator for change. Instead, help adolescents care for their bodies so they will want to nurture their bodies through healthy eating, physical activity, and positive self-talk

</list-item><list-item>

Encourage families to have regular and enjoyable family meals

</list-item><list-item>

Encourage families to avoid weight talk; talk less about weight and do more to help them achieve a healthy weight

</list-item><list-item>

Assume overweight adolescents have experienced weight mistreatment and address it with both the patient and the family

</list-item>
Authors

Sharonda Alston Taylor, MD, FAAP, FSAHM, is an Associate Professor, Adolescent Medicine and Sports Medicine Section, Department of Pediatrics, Baylor College of Medicine. Sarah Ditch, MD, FAAP, is an Adolescent Medicine Fellow, San Antonio Uniformed Services Health Science Consortium; and an Assistant Professor, Uniformed Services University of the Health Sciences, Brooke Army Medical Center. Shana Hansen, MD, FAAP, FSAHM, is a Clinical Associate Professor, Uniformed Services University of the Health Sciences, Adolescent Medicine Section, Department of Pediatrics, San Antonio Uniformed Services Health Science Consortium, Brooke Army Medical Center.

Address correspondence to Sharonda Alston Taylor, MD, FAAP, FSAHM, Adolescent Medicine and Sports Medicine Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1710.00, Houston, TX 77030; email: sjtaylor@bcm.edu.

Disclaimer: The views expressed do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of Defense, or the U.S. Government.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20180522-01

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