Adolescent patients with obesity are at significant risk of developing an eating disorder (ED), yet due to their higher weight status their symptoms often go unrecognized and untreated. Although not widely known, individuals with a weight history in the overweight (BMI-for-age ≥85th percentile but <95th percentile, as defined by Centers for Disease Control and Prevention growth charts) or obese (BMI-for-age ≥95th percentile, as defined by the Centers for Disease Control and Prevention growth charts) range, represent a substantial portion of adolescents presenting for ED treatment. Given research that suggests that early intervention promotes the best chance of recovery, it is imperative that these children’s and adolescents’ ED symptoms are identified and that intervention is offered before the disease progresses. This report presents 2 examples of EDs that developed in the context of obese adolescents’ efforts to reduce their weight. Each case shows specific challenges in the identification of ED behaviors in adolescents with this weight history and the corresponding delay such teenagers experience accessing appropriate treatment.
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October 2013
Case Report|
October 01 2013
Eating Disorders in Adolescents With a History of Obesity
Leslie A. Sim, PhD;
aDepartment of Psychiatry and Psychology, and
Address correspondence to Leslie Sim, PhD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail: [email protected]
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Jocelyn Lebow, PhD;
Jocelyn Lebow, PhD
aDepartment of Psychiatry and Psychology, and
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Marcie Billings, MD
Marcie Billings, MD
bPediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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Address correspondence to Leslie Sim, PhD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail: [email protected]
FINANCIAL DISCLOSURE: The authors indicated they have no financial relationships relevant to this article to disclose.
Pediatrics (2013) 132 (4): e1026–e1030.
Article history
Accepted:
May 29 2013
Citation
Leslie A. Sim, Jocelyn Lebow, Marcie Billings; Eating Disorders in Adolescents With a History of Obesity. Pediatrics October 2013; 132 (4): e1026–e1030. 10.1542/peds.2012-3940
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Comments
Treating eating disorders and obesity in adolescents
In their recent case report entitled, 'Eating disorders in adolescents with a history of obesity', Sim and colleagues present two case studies highlighting the risk of developing an eating disorder (ED) in the context of obesity (Pediatrics. 132(4): e1026-e1030). As adolescent providers, we applaud the authors' recognition that obesity and EDs have many shared risk factors (1). However, we disagree with their warning that weight loss is unusual in adolescents and consequently any weight loss should be viewed with concern. While weight loss can be a causal factor of EDs, it is usually only in the context of a constellation of vulnerabilities that EDs develop. Therefore, we emphasize that the fear of inducing an ED should not discourage adolescent providers from helping overweight and obese adolescents to lose weight. This is of particular importance given that more than 30% of adolescents ages 12-19 years are overweight, more than half of whom are obese (4). Left unaddressed, as many as 63% of obese adolescents will become obese adults (5).
Several large epidemiological studies show that weight loss is possible in adolescents, and in the majority of cases, it is accomplished through healthy behavior change. Analyses of retrospective self-report and measured weights from the National Health and Nutrition Examination Survey, 1999-2001, show that 25% of overweight and obese adolescents successfully reduced their body weight over one year (2). On average, males lost 12% of their body weight, and females reported a 14% weight loss. Using the publicly-available data from the National Longitudinal Study of Adolescent Health (Add Health), we found that in the 10% of overweight and obese adolescents who successfully lost 10 or more pounds (mean of 13.2 pounds) over one year, 56% reported that they had exercised and 25% reported dieting to lose weight, whereas 0% reported vomiting, 1% used diet pills and 1.3% used laxatives to lose weight. Finally, among adolescents enrolled in the Successful Adolescent weight Losers study, there were no significant differences in the proportion of adolescents who endorsed disordered weight control behaviors between those who lost at least 4.5 kg in the past two years and those who did not lose weight (p>0.05) (3), suggesting that successful weight loss per se is not diagnostic of disorder.
It is not our intention to diminish the importance of evaluating ED behaviors among adolescents who are overweight or obese, as we acknowledge that ED co-morbidities are acute and require urgent attention. Instead, we urge adolescent mental and healthcare providers to assess and treat both EDs and obesity as weight-related disorders that require multidisciplinary attention and treatment. We stress that successful weight loss in adolescents is possible using healthy behaviors and urge adolescent providers to treat obesity with the same commitment and vigilance as EDs with confidence that healthy weight loss is achievable and does not in itself cause eating disorders.
REFERENCES
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2. Boutelle K, Hanna P, Neumark-Sztainer D, Himes J. Identification and correlates of weight loss in adolescents in a national sample. Obesity. 2007;15(2):473-82.
3. Boutelle K, Libby H, Neumark-Sztainer D, Story M. Weight control strategies of overweight adolescents who successfully lost weight. J Am Diet Assoc. 2009;109:2029-35.
4. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among us children and adolescents, 1999-2010. J Am Med Assoc. 2012;307(5):483-90.
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Conflict of Interest:
None declared
Further Potential Complexities of Eating Disorders in Adolescents With a History of Obesity: A Commentary on Sim, Lebow & Billings (2013)
Further Potential Complexities of Eating Disorders in Adolescents With a History of Obesity: A Commentary on Sim, Lebow & Billings (2013)
Dr. Stuart B. Murray a, b
a School of Psychology, University of Sydney, Sydney, NSW, Australia b The Redleaf Practice, Wahroonga, Sydney, NSW, Australia
Correspondence: Dr Stuart B. Murray, The Redleaf Practice, 5 Redleaf Ave, Wahroonga, Sydney, Australia, NSW 2076. Tel: +61 420 838734 Email: [email protected]
Sim, Lebow & Billings1 present a compelling case report paper detailing the challenges faced in identifying eating disorders such as anorexia nervosa (AN) in adolescents with a history of obesity. The authors point out the potential scope for misdiagnosis of eating disorders amongst those who don't meet strict weight criteria of previous diagnostic guidelines, which invariably results in lengthy delays in the uptake of specialised eating disorder treatment. Furthermore, the grave dangers of potential misdiagnosis was underscored by the myriad of significant medical risks inherent to restriction based eating disorders, such as AN. To this end, the authors should be commended for their excellent efforts in stimulating professional discussion in this highly important and understudied area.
Whilst in unequivocal agreement with the author's sentiments that adolescents whose dietary restriction and weight loss takes them from the overweight to the 'average' weight range are not exempt from clinical eating disorders, it is possible that the authors may have understated the possible complexities in such cases upon commencing treatment. For instance, ample evidence suggests that perceptual disturbances and body image distortion partly underpins psychopathology in AN2, with further attentional biases and fastidious processing of weight and shape related stimuli3 underscoring the extent to which such disturbances impact the adolescent. As such many treatment approaches typically aim to cognitively restructure distorted perceptions of self-image via the generation of disconfirmatory evidence2.
However, this therapeutic process may become significantly more complex in eating disordered adolescents who do not fall within underweight BMI percentiles, whose perception of themselves as 'bigger than their friends' may in fact be ostensibly accurate. Attentional biases towards accurate feedback loops as to one's body size, relative to peers, may further heighten one's drive for thinness and facilitate the development of more entrenched eating disorder psychopathology and concomitant further medical complications. This may be further intensified upon entering into specialist treatment and contact with other eating disordered patients who may be severely emaciated, with adolescents typically proclaiming that they are 'too fat to be anorexic'.
A further challenge may concern the difficulty therapists face in assisting previously obese eating disordered adolescents in establishing healthy eating patterns, despite pathological eating practices having taken them out of the 'unhealthy' and into the 'healthy' weight range. Symptoms of AN are notoriously ego-syntonic, although this may be particularly potent in instances of this illness having taken away the stigma and negative social experiences associated with adolescent obesity4. Thus, medical practitioners and parents conveying that an adolescent is too medically unwell to continue their dietary practices may, from an adolescent perspective, run counterintuitive to falling within 'healthy' weight ranges on normative weight charts. As such, disrupting disordered eating practices in such instances may become more challenging as increased ego-syntonicity and lower motivation to change are likely.
Thus, in addition to the challenges in the effective early identification of restriction-based eating disorders in teens with a history of obesity1, it may also be the case that such instances require an intensified treatment intervention in recognition of the qualitatively challenges faced by such teens.
References 1 Sim LA, Lebow J, Billings M. Eating disorders in adolescents with a history of obesity. Peadiatrics, 2013, DOI: 10.1542/peds.2012-3940.
2 Waller G, Cordery H, Corstorphine E, Hinrichsen H, Lawson R, Mountfor V, Russell K. Cognitive Behavioral Therapy for Eating Disorders: A Comprehensive Treatment Guide. Cambridge University Press, 2007.
3 Rieger E, Schotte DE, Touyz SW, Beumont PJV, Griffiths R, Russell J. Attentional biases in eating disorders: A visual probe detection procedure. International Journal of Eating Disorders, 1998; 23, 199-205.
4 Pearce MJ, Boergers J, Prinstein MJ. Adolescent obesity, overt and relational peer victimization, and romantic relationships. Obesity, 2002; 10, 386-393.
Conflict of Interest:
None declared