Obesity and eating disorders (EDs) are both prevalent in adolescents. There are concerns that obesity prevention efforts may lead to the development of an ED. Most adolescents who develop an ED did not have obesity previously, but some teenagers, in an attempt to lose weight, may develop an ED. This clinical report addresses the interaction between obesity prevention and EDs in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs.

The prevalence of childhood obesity has increased dramatically over the past few decades in the United States and other countries, and obesity during adolescence is associated with significant medical morbidity during adulthood.1 Eating disorders (EDs) are the third most common chronic condition in adolescents, after obesity and asthma.2 Most adolescents who develop an ED did not have obesity previously, but some adolescents may misinterpret what “healthy eating” is and engage in unhealthy behaviors, such as skipping meals or using fad diets in an attempt to “be healthier,” the result of which could be the development of an ED.3 Messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling.4 

This clinical report complements existing American Academy of Pediatrics (AAP) reports on EDs5 and obesity prevention.6 The aim is to address the interaction between obesity prevention and EDs in teenagers and to stress that obesity prevention does not promote the development of EDs in adolescents. This report provides the pediatrician with office-based, evidence-informed tools to identify behaviors that predispose to both obesity and EDs and to provide guidance about obesity and ED prevention messages.

Data from the NHANES on adolescent obesity prevalence revealed that, in 2011–2012, 20.5% of 12- to 19-year-olds were obese (BMI ≥95th percentile according to the 2000 sex-specific BMI-for-age growth charts of the Centers for Disease Control and Prevention).7,8 Combining the definitions of overweight (BMI between the 85th and 95th percentiles) and obesity, according to the NHANES 2011–2012 data, 34.5% of 12- to 19-year-olds were overweight or obese.7,8 Disparities exist in obesity rates among minority youth, with Hispanic, American Indian, and African-American adolescents having the highest prevalence of obesity. Over the past 30 years, the rate of childhood obesity has more than doubled, and the rate of adolescent obesity has quadrupled. However, more recent data over the past 9 years between 2003–2004 and 2011–2012 have revealed no significant changes in obesity prevalence in youth or adults. Although halting the increase in the rate of obesity is a step in the right direction, the prevalence of obesity remains high, and its health care burden and costs remain significant.9 

Most studies have found that children and adolescents who are obese, especially those in the higher range of BMI percentiles, are more likely to be obese as adults.10,12 The health consequences of obesity can manifest during childhood, but the longer a person is obese, the more at risk he or she is for adult health problems. A high adolescent BMI increases adult diabetes and coronary artery disease risks by nearly threefold and fivefold, respectively.13 Type 2 diabetes is one of the most serious complications of childhood obesity. Risks of other common comorbid conditions, such as hypertension, abnormal lipid profiles, nonalcoholic fatty liver disease, gallstones, gastroesophageal reflux, polycystic ovary syndrome, obstructive sleep apnea, asthma, and bone and joint problems, are significantly increased in both obese adolescents and adults who were obese as adolescents.1,14,16 In addition, the psychosocial morbidities associated with childhood obesity, such as depression, poor self-esteem, and poor quality of life, are of significant concern.17,19 

The onset of EDs usually is during adolescence, with the highest prevalence in adolescent girls, but EDs increasingly are being recognized in children as young as 5 to 12 years.20,22 Increased prevalence rates also have been noted in males and minority youth.23 The peak age of onset for anorexia nervosa (AN) is early to mid-adolescence, and the peak age of onset for bulimia nervosa (BN) is late adolescence. Although overall incidence rates have been stable, there has been a notable increase in the incidence of AN in 15- to 19-year-old girls.24 In the United States from 1999 to 2006, hospitalizations for EDs increased 119% for children younger than 12 years.25 The lifetime prevalences of AN, BN, and binge eating disorder in adolescent females are 0.3%, 0.9%, and 1.6%, respectively.26 The reported female-to-male ratio is 9:1, but increasing numbers of males with EDs are being recognized, especially among younger age groups.20,22 

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for EDs are listed in Table 1.27 The diagnostic criteria for both AN and BN in the DSM-5 are less stringent than in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, so the numbers of reported cases likely will increase. For AN, the 85% expected body weight threshold and the amenorrhea criterion from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, both have been eliminated in the DSM-5. For BN, DSM-5 modifications from the previous edition include reducing the threshold of the frequency of binge eating and inappropriate compensatory behaviors (self-induced vomiting, periods of starvation, compulsive exercising or the use of laxatives, diuretics, or diet pills) from twice a week for 3 months to once a week for 3 months. Binge eating disorder now is officially recognized in the DSM-5 as a distinct disorder characterized by recurrent episodes of bingeing at least once a week for 3 months, but without compensatory behaviors, and is associated with the development of obesity.28 “Atypical AN” describes a subset of patients who lost a significant amount of weight and then returned to normal weight but who continue to have preoccupations with body shape and weight, comparable to patients with “classic” AN.

TABLE 1

Key Features of DSM-5 Diagnostic Criteria for Feeding Disorders and EDs

AN 
 • Restriction of food eaten leading to lower than expected body weight 
 • Intense fear of weight gain or being fat 
 • Body image distortion 
 Types: restricting or binge eating/purging 
BN 
 • Binge eating in which 
  o a larger amount of food is eaten within a 2-hour period compared with peers; and 
  o there is a perceived lack of control during the time of the binge 
 • Repeated use of unhealthy behaviors after a binge to prevent weight gain: (vomiting; abuse of laxatives, diuretics, or other medications; food restriction; or excessive exercise) 
 • Behaviors occur at least once a week for 3 months 
 • Self-worth is overly based on body shape and weight 
 • Behaviors occur distinctly apart from AN 
Binge-eating disorder 
 • Recurrent episodes of binge eating in which 
  o a larger amount of food is eaten within a 2-hour period compared with peers; and 
  o there is a perceived lack of control during the time of the binge 
 Bingeing episodes are associated with at least 3 of the following: 
  o eating faster than normal; 
  o eating until overly full; 
  o eating large quantities of food when not hungry; 
  o eating alone because of embarrassment about the quantity of food eaten; and 
  o feeling badly emotionally after eating 
 • Upset about bingeing 
 • Bingeing behavior occurs at least once a week for 3 months 
 • Bingeing is not followed by the use of unhealthy behaviors to purge and does not occur during AN or BN 
Avoidant/restrictive food intake disorder 
 • A feeding problem that results in at least one of the following: 
  o significant weight loss or failure to meet the expected weight or height gain in children; 
  o significant nutritional deficiency; 
  o dependence on nonfood nutrition, such as nasogastric feedings or oral nutritional supplements; or 
  o marked interference with psychosocial functioning 
 • The problem is not attributable to food availability or cultural ideas 
 • The problem is 
  o not attributable to AN, and there is no distortion in body image; and 
  o not attributable to another condition, medical or mental 
Other specified feeding disorder or ED 
 Atypical AN: all criteria for anorexia, but weight is normal 
 BN (of low frequency and/or limited duration): all criteria except for frequency 
 Binge-eating disorder (of low frequency and/or limited duration): all criteria except for frequency 
 Purging disorder: recurrent purging in an effort to lose weight without bingeing 
AN 
 • Restriction of food eaten leading to lower than expected body weight 
 • Intense fear of weight gain or being fat 
 • Body image distortion 
 Types: restricting or binge eating/purging 
BN 
 • Binge eating in which 
  o a larger amount of food is eaten within a 2-hour period compared with peers; and 
  o there is a perceived lack of control during the time of the binge 
 • Repeated use of unhealthy behaviors after a binge to prevent weight gain: (vomiting; abuse of laxatives, diuretics, or other medications; food restriction; or excessive exercise) 
 • Behaviors occur at least once a week for 3 months 
 • Self-worth is overly based on body shape and weight 
 • Behaviors occur distinctly apart from AN 
Binge-eating disorder 
 • Recurrent episodes of binge eating in which 
  o a larger amount of food is eaten within a 2-hour period compared with peers; and 
  o there is a perceived lack of control during the time of the binge 
 Bingeing episodes are associated with at least 3 of the following: 
  o eating faster than normal; 
  o eating until overly full; 
  o eating large quantities of food when not hungry; 
  o eating alone because of embarrassment about the quantity of food eaten; and 
  o feeling badly emotionally after eating 
 • Upset about bingeing 
 • Bingeing behavior occurs at least once a week for 3 months 
 • Bingeing is not followed by the use of unhealthy behaviors to purge and does not occur during AN or BN 
Avoidant/restrictive food intake disorder 
 • A feeding problem that results in at least one of the following: 
  o significant weight loss or failure to meet the expected weight or height gain in children; 
  o significant nutritional deficiency; 
  o dependence on nonfood nutrition, such as nasogastric feedings or oral nutritional supplements; or 
  o marked interference with psychosocial functioning 
 • The problem is not attributable to food availability or cultural ideas 
 • The problem is 
  o not attributable to AN, and there is no distortion in body image; and 
  o not attributable to another condition, medical or mental 
Other specified feeding disorder or ED 
 Atypical AN: all criteria for anorexia, but weight is normal 
 BN (of low frequency and/or limited duration): all criteria except for frequency 
 Binge-eating disorder (of low frequency and/or limited duration): all criteria except for frequency 
 Purging disorder: recurrent purging in an effort to lose weight without bingeing 

Source: DSM-5.27 

The medical complications of EDs have been well described elsewhere.5 In general, medical complications are either the result of physiologic adaptations to the effects of malnutrition or a consequence of unhealthy weight-control behaviors. Young people who have lost large amounts of weight or lost weight too rapidly can develop hypothermia, bradycardia, hypotension, and orthostasis even if their current weight is in the normal range.29,30 Rapid weight loss can be associated with acute pancreatitis and gallstone formation. Electrolyte disturbances can occur secondary to self-induced vomiting or the use of laxatives or diuretics or can develop when food is reintroduced after prolonged periods of dietary restriction (the so-called refeeding syndrome). Dietary restriction can lead to primary or secondary amenorrhea in adolescent girls of even normal weight as a result of the suppression of the hypothalamic-pituitary-ovarian axis, which is mediated in part by leptin.31 Prolonged amenorrhea results in a low-estrogen state, which can contribute to osteoporosis.23 

Most adolescents who develop an ED were not previously overweight. However, it is not unusual for an ED to begin with a teenager “trying to eat healthy.”32 Some adolescents and their parents misinterpret obesity prevention messages and begin eliminating foods they consider to be “bad” or “unhealthy.”32 US Food and Drug Administration–mandated nutrition facts on food labels list percent daily values based on a 2000-kcal diet. Moderately active adolescent girls require approximately 2200 kcal/day, and moderately active adolescent boys require 2800 kcal/day for normal growth and development. Teenagers who are athletes require even higher caloric intakes.33 Strict adherence to a 2000-kcal/day diet may lead to an energy deficit and weight loss for many growing teenagers.

Adolescents who are overweight may adopt disordered eating behaviors while attempting to lose weight. In cross-sectional studies, adolescents who are overweight have been shown to engage in self-induced vomiting or laxative use more frequently than their normal-weight peers.34,35 Some adolescents who were overweight or obese previously can go on to develop a full ED.3,30,32 In 1 study in adolescents seeking treatment of an ED, 36.7% had a previous weight greater than the 85th percentile for age and sex.3 Initial attempts to lose weight by eating in a healthy manner may progress to severe dietary restriction, skipping of meals, prolonged periods of starvation, or the use of self-induced vomiting, diet pills, or laxatives. Initial attempts to increase physical activity may progress to compulsive and excessive exercise, even to the point at which the teenager awakens at night to exercise or continues excess exercise despite injury. EDs that develop in the context of previous obesity can present with challenges that delay treatment of the ED.32 At first, weight loss is praised and reinforced by family members, friends, and health care providers, but ongoing excessive preoccupation with weight loss can lead to social isolation, irritability, difficulty concentrating, profound fear of gaining the lost weight back, and body image distortion. If the pediatrician only focuses on weight loss without identifying the associated concerning symptoms and signs, an underlying ED may be missed.

Cross-sectional and longitudinal observational studies have identified the following certain behaviors associated with both obesity and EDs in adolescents:

  1. Dieting. Dieting, defined as caloric restriction with the goal of weight loss, is a risk factor for both obesity and EDs. In a large prospective cohort study in 9- to 14-year-olds (N = 16 882) followed for 2 years, dieting was associated with greater weight gain and increased rates of binge eating in both boys and girls.36 Similarly, in a prospective observational study in 2516 adolescents enrolled in Project Eating Among Teens (Project EAT) followed for 5 years, dieting behaviors were associated with a twofold increased risk of becoming overweight and a 1.5-fold increased risk of binge eating at 5-year follow-up after adjusting for weight status at baseline.37 Stice et al38 showed that girls without obesity who dieted in the ninth grade were 3 times more likely to be overweight in the 12th grade compared with nondieters. These findings and others36,38,39 suggest that dieting is counterproductive to weight-management efforts. Dieting also can predispose to EDs. In a large prospective cohort study in students 14 to 15 years of age followed for 3 years, dieting was the most important predictor of a developing ED. Students who severely restricted their energy intake and skipped meals were 18 times more likely to develop an ED than those who did not diet; those who dieted at a moderate level had a fivefold increased risk.40 

  2. Family meals. Family meals have been associated with improved dietary intake and provide opportunities for modeling behavior by parents, even though family meals have not been shown to prevent obesity across ethnic groups.41,43 A higher frequency of family meals is associated with improved dietary quality, as evidenced by increased consumption of fruits, vegetables, grains, and calcium-rich foods and fiber and reduced consumption of carbonated beverages.44 Eating family meals together 7 or more times per week resulted in families consuming 1 serving more of fruits and vegetables per day compared with families who had no meals together. These improvements in dietary intake were sustained 5 years later during young adulthood.45 Family meals also have been shown to protect girls from disordered eating behaviors.46,48 Most recently, a prospective study in more than 13 000 preadolescents and adolescents found that eating family dinners most days or every day during the previous year was protective against purging behaviors, binge eating, and frequent dieting. The trend was similar in both females and males, although not statistically significant in males.48 In girls, family meals perceived to be enjoyable were protective from extreme weight-control behaviors.46 Postulates for why family meals are protective include the following: families will consume healthier foods than teenagers would choose on their own; parents can model healthy food choices; family meals provide a time for teenagers and parents to interact; and parents can monitor their child’s eating and address issues earlier when they are aware of their child’s eating behavior.49 

  3. Weight talk. Weight talk by family members refers to comments made by family members about their own weight or comments made to the child by parents to encourage weight loss. Even well-intended comments can be perceived as hurtful by the child or adolescent. Several studies have found that parental weight talk, whether it involves encouraging their children to diet or talking about their own dieting, is linked to overweight37,50 and EDs.51 Project EAT linked weight talk to higher rates of overweight 5 years later. Loth et al51 interviewed patients in recovery from EDs and found that weight talk affected them negatively. Parents who had conversations about weight had adolescents who were more likely to engage in dieting, unhealthy weight-control behaviors, and binge eating. However, if the focus of the conversation was only on healthful eating behaviors, overweight adolescents were less likely to diet and to use unhealthy weight-control behaviors.52 

  4. Weight teasing. In overweight adolescents, weight teasing by peers or family members is experienced by 40% of early adolescent females (mean age: 12.8 ± 0.7 years), 28.2% of middle adolescent females (mean age: 15.9 ± 0.8 years), 37% of early adolescent males, and 29% of middle adolescent males.53 Family weight teasing predicts the development of overweight status, binge eating, and extreme weight-control behaviors in girls and overweight status in boys. Adolescent girls who were teased about their weight at baseline were at approximately twice the risk of being overweight 5 years later.37 A 10-year longitudinal study found that the prevalence of weight teasing did not decrease as children matured into young adults, despite the fact that the relationship between bullying and obesity had received a great deal of attention in the news.53 A group of subjects who were studied in their young teenage years were studied again in young adulthood to evaluate the role of hurtful weight-related comments and eating behaviors (n = 1902; mean age: 25 years). For both males and females, hurtful weight-related comments from family members and significant others were associated with the use of unhealthy weight-control behaviors and binge eating in both males and females.54 

  5. Healthy body image. Approximately half of teenage girls and one-quarter of teenage boys are dissatisfied with their bodies; these numbers are higher in overweight teenagers.55 Body dissatisfaction is a known risk factor for both EDs and disordered eating; higher scores of body dissatisfaction are associated with more dieting and unhealthy weight-control behaviors in both boys and girls, reduced physical activity in girls, and more binge eating in boys.56 Body dissatisfaction and disordered eating occur in minority populations and are not limited to white girls and boys.57 Adolescents who were more satisfied with their bodies were more likely to report parental and peer attitudes that encouraged healthful eating and exercising to be fit, rather than dieting; they were less likely to report personal weight-related concerns and behaviors.58 

MI was developed by Miller and Rollnick in 1991 to treat patients with addiction. Although MI has been well studied in adults with addictions and obesity, fewer studies have evaluated the effect of MI on patients with EDs and the use of MI in children and adolescents.59,61 Studies to date on the use of MI for patients with EDs60,61 and for children and adolescents with obesity have been promising.62,65 The most recent book on MI by Miller and Rollnick defines MI as “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”66 This counseling approach involves 4 broad processes listed in Table 2.67 

TABLE 2

The Counseling Processes of MI

• Engaging 
 Establishing a working relationship with the patient 
• Focusing 
 Identifying how change is being discussed in the conversation 
• Evoking 
 Encouraging the patient to explore and discuss the need to change 
• Planning for change 
 Planning for change with the patient once the patient demonstrates the readiness to change 
• Engaging 
 Establishing a working relationship with the patient 
• Focusing 
 Identifying how change is being discussed in the conversation 
• Evoking 
 Encouraging the patient to explore and discuss the need to change 
• Planning for change 
 Planning for change with the patient once the patient demonstrates the readiness to change 

A study conducted through the AAP Pediatric Research in Office Settings (PROS) network assessed the effect of MI delivered by pediatricians and found that pediatricians and dietitians who used MI to counsel families with overweight children were successful in reducing children’s BMI percentile by 3.1 more points than a control group in which MI was not used.68 The AAP Web and mobile app called “Change Talk: Childhood Obesity” (http://ihcw.aap.org/resources) uses an interactive virtual practice environment to train pediatricians about the basics of MI. Pediatricians can successfully facilitate their patients’ lifestyle behavior changes. Concerns from pediatricians and parents that obesity counseling can lead to an ED can be addressed by understanding the effectiveness of family-centered MI to promote healthy behaviors.

The pediatrician often is the first professional consulted by a parent or the school when there is a concern about a possible ED. Height, weight, and BMI should be plotted on the 2000 growth charts available from the Centers for Disease Control and Prevention (www.cdc.gov/growthcharts), and the current data should be compared with as many previous data points as possible. A BMI below the fifth percentile is underweight and may indicate an ED. Other possible indicators of an ED include missed menstrual periods in girls, an unusually rapid decline in BMI, or engaging in disordered eating behaviors by normal-weight and overweight adolescents who are dissatisfied with their body image. Early diagnosis and intervention are associated with improved outcome.69 EDs are best evaluated and managed by a multidisciplinary health care team, with the pediatrician as an important member of that team.70 A thorough physical examination and review of systems can help to identify any underlying medical and psychiatric causes for weight loss. This comprehensive clinical assessment has been described in detail elsewhere.5 High-risk eating and activity behaviors and clinical findings of concern are outlined in Table 3. The pediatrician may feel comfortable performing this evaluation or may prefer to refer the patient to a specialized ED center, if one is available in the local community. A psychological assessment by a mental health professional can assist with the evaluation for comorbid psychiatric illnesses (eg, affective or anxiety disorders).

TABLE 3

High-Risk Eating and Activity Behaviors and Clinical Findings of Concern

High-risk eating and activity behaviors 
 • Severe dietary restriction (<500 kcal/d) 
 • Skipping of meals to lose weight 
 • Prolonged periods of starvation 
 • Self-induced vomiting 
 • Use of diet pills, laxatives, or diuretics 
 • Compulsive and excessive exercise 
 • Social isolation, irritability, profound fear of gaining weight, body image distortion 
Clinical findings of concern 
 • Rapid weight loss 
 • Falling off percentiles for weight and BMI 
 • Amenorrhea in girls 
 • Presence of vital sign instability 
  o Bradycardia (heart rate <50 beats/minute during the day) 
  o Hypotension (<90/45 mm Hg) 
  o Hypothermia (body temperature <96°F [<35.6°C]) 
  o Orthostasis (increase in pulse >20 beats/min) or decrease in blood pressure (>20 mm Hg systolic or >10 mm Hg diastolic) on standing 
High-risk eating and activity behaviors 
 • Severe dietary restriction (<500 kcal/d) 
 • Skipping of meals to lose weight 
 • Prolonged periods of starvation 
 • Self-induced vomiting 
 • Use of diet pills, laxatives, or diuretics 
 • Compulsive and excessive exercise 
 • Social isolation, irritability, profound fear of gaining weight, body image distortion 
Clinical findings of concern 
 • Rapid weight loss 
 • Falling off percentiles for weight and BMI 
 • Amenorrhea in girls 
 • Presence of vital sign instability 
  o Bradycardia (heart rate <50 beats/minute during the day) 
  o Hypotension (<90/45 mm Hg) 
  o Hypothermia (body temperature <96°F [<35.6°C]) 
  o Orthostasis (increase in pulse >20 beats/min) or decrease in blood pressure (>20 mm Hg systolic or >10 mm Hg diastolic) on standing 

In children and adolescents with AN and BN, family-based therapy (FBT), in which the parents control the refeeding process, has been shown to be an effective first-line method of treatment.71,72 With FBT, the pediatrician can assist with monitoring the patient for weight gain and vital sign stability and can communicate with the patient, family, and therapist. Becoming familiar with the general principles of FBT can assist the pediatrician in understanding his or her role in this form of treatment (Table 4).73 

TABLE 4

Principles of Family-Based Treatment of EDs and Role of the Pediatrician

Principles of treatment 
 • Parents are not to blame 
 • Parents are vital to therapeutic success 
 • Parents are responsible for weight restoration 
 • Separate the child from the illness 
 • Nonauthoritarian approach 
Three phases of treatment 
 • Phase 1: parents restore patient’s weight 
 • Phase 2: control transferred back to the child or adolescent 
 • Phase 3: focuses on adolescent developmental issues and termination of treatment 
Examples of the role the pediatrician can play 
 • Act as a consultant to the parents and therapist 
 • Explain the medical seriousness of the ED 
 • Monitor and manage the medical status of the adolescent 
 • Empower the parents in decision-making 
 • Communicate with the patient, family, and therapist 
Principles of treatment 
 • Parents are not to blame 
 • Parents are vital to therapeutic success 
 • Parents are responsible for weight restoration 
 • Separate the child from the illness 
 • Nonauthoritarian approach 
Three phases of treatment 
 • Phase 1: parents restore patient’s weight 
 • Phase 2: control transferred back to the child or adolescent 
 • Phase 3: focuses on adolescent developmental issues and termination of treatment 
Examples of the role the pediatrician can play 
 • Act as a consultant to the parents and therapist 
 • Explain the medical seriousness of the ED 
 • Monitor and manage the medical status of the adolescent 
 • Empower the parents in decision-making 
 • Communicate with the patient, family, and therapist 

Obesity prevention and treatment, if conducted correctly, does not predispose to EDs. On the contrary, randomized controlled trials of obesity prevention programs have shown a reduction in the use of self-induced vomiting or diet pill use to control weight74 and a decrease in concerns about weight in the intervention groups.75 

Family involvement in the treatment of both adolescent obesity and EDs has been determined to be more effective than an adolescent-only focus.73,76 An integrated approach to the prevention of obesity and EDs focuses less on weight and more on healthy family-based lifestyle modification that can be sustained. Pediatricians can encourage parents to be healthy role models and supportively manage the food environment by creating easy accessibility to healthy foods (eg, fruits, vegetables, whole grains, beans and other legumes, and water) and by limiting the availability of sweetened beverages, including those containing artificial sweeteners, and other foods containing refined carbohydrates. Discussions between pediatricians and parents about increasing physical activity and limiting the amount of total entertainment screen time to less than 2 hours/day are important and may lead to changes in family behavior.77 Another area of prevention is avoiding the presence of a television in the teenager’s bedroom, because having a television in the room predicts significantly less physical activity as well as poorer dietary intakes compared with not having a television in the room.78,79 Other evidence-based approaches encourage parents to include more family meals, home-prepared meals, and meals with less distractions as well as fewer discussions about weight and about dieting.6,80 Understanding that poor body image can lead to an ED, parents should avoid comments about body weight and discourage dieting efforts that may inadvertently result in EDs and body dissatisfaction.

Observations that can be concluded from current research summarized in this report to help prevent weight-related problems including both obesity and EDs include the following:

  1. Discourage dieting, skipping of meals, or the use of diet pills; instead, encourage and support the implementation of healthy eating and physical activity behaviors that can be maintained on an ongoing basis. The focus should be on healthy living and healthy habits rather than on weight.

  2. Promote a positive body image among adolescents. Do not encourage body dissatisfaction or focus on body dissatisfaction as a reason for dieting.

  3. Encourage more frequent family meals.

  4. Encourage families not to talk about weight but rather to talk about healthy eating and being active to stay healthy. Do more at home to facilitate healthy eating and physical activity.

  5. Inquire about a history of mistreatment or bullying in overweight and obese teenagers and address this issue with patients and their families.

  6. Carefully monitor weight loss in an adolescent who needs to lose weight to ensure the adolescent does not develop the medical complications of semistarvation.

Time constraints in a busy pediatric practice are significant. Weight issues can be a topic of sensitivity and therefore can be time consuming. The evidence-based suggestions in this report can be implemented in relatively brief encounters and can be an excellent first step for teenagers and families to promote a healthy lifestyle.

     
  • AAP

    American Academy of Pediatrics

  •  
  • AN

    anorexia nervosa

  •  
  • BN

    bulimia nervosa

  •  
  • DSM-5

    Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

  •  
  • ED

    eating disorder

  •  
  • FBT

    family-based therapy

  •  
  • MI

    motivational interviewing

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

1
Inge
TH
,
King
WC
,
Jenkins
TM
, et al
.
The effect of obesity in adolescence on adult health status.
Pediatrics
.
2013
;
132
(
6
):
1098
1104
[PubMed]
2
Fisher
M
,
Golden
NH
,
Katzman
DK
, et al
.
Eating disorders in adolescents: a background paper.
J Adolesc Health
.
1995
;
16
(
6
):
420
437
[PubMed]
3
Lebow
J
,
Sim
LA
,
Kransdorf
LN
.
Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders.
J Adolesc Health
.
2015
;
56
(
1
):
19
24
[PubMed]
4
Puhl
RM
,
Peterson
JL
,
Luedicke
J
.
Parental perceptions of weight terminology that providers use with youth.
Pediatrics
.
2011
;
128
(
4
). Available at: www.pediatrics.org/cgi/content/full/128/4/e786
[PubMed]
5
Rosen
DS
;
American Academy of Pediatrics Committee on Adolescence
.
Identification and management of eating disorders in children and adolescents.
Pediatrics
.
2010
;
126
(
6
):
1240
1253
[PubMed]
6
Daniels
SR
,
Hassink
SG
;
Committee on Nutrition
.
The role of the pediatrician in primary prevention of obesity.
Pediatrics
.
2015
;
136
(
1
). Available at: www.pediatrics.org/cgi/content/full/136/1/e275
[PubMed]
7
Ogden
CL
,
Carroll
MD
,
Kit
BK
,
Flegal
KM
.
Prevalence of childhood and adult obesity in the United States, 2011-2012.
JAMA
.
2014
;
311
(
8
):
806
814
[PubMed]
8
National Center for Health Statistics
. Health, United States, 2011: with special features on socioeconomic status and health. Hyattsville, MD: US Department of Health and Human Services;
2012
. Available at: www.cdc.gov/nchs/data/hus/hus11.pdf. Accessed November 10, 2015
9
Trasande
L
,
Elbel
B
.
The economic burden placed on healthcare systems by childhood obesity.
Expert Rev Pharmacoecon Outcomes Res
.
2012
;
12
(
1
):
39
45
[PubMed]
10
The
NS
,
Suchindran
C
,
North
KE
,
Popkin
BM
,
Gordon-Larsen
P
.
Association of adolescent obesity with risk of severe obesity in adulthood.
JAMA
.
2010
;
304
(
18
):
2042
2047
[PubMed]
11
Whitaker
RC
,
Wright
JA
,
Pepe
MS
,
Seidel
KD
,
Dietz
WH
.
Predicting obesity in young adulthood from childhood and parental obesity.
N Engl J Med
.
1997
;
337
(
13
):
869
873
[PubMed]
12
Guo
SS
,
Chumlea
WC
.
Tracking of body mass index in children in relation to overweight in adulthood.
Am J Clin Nutr
.
1999
;
70
(
1
):
145S
148S
13
Tirosh
A
,
Shai
I
,
Afek
A
, et al
.
Adolescent BMI trajectory and risk of diabetes versus coronary disease.
N Engl J Med
.
2011
;
364
(
14
):
1315
1325
[PubMed]
14
Freedman
DS
,
Khan
LK
,
Serdula
MK
,
Dietz
WH
,
Srinivasan
SR
,
Berenson
GS
.
The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study.
Pediatrics
.
2005
;
115
(
1
):
22
27
[PubMed]
15
Li
C
,
Ford
ES
,
Zhao
G
,
Mokdad
AH
.
Prevalence of pre-diabetes and its association with clustering of cardiometabolic risk factors and hyperinsulinemia among U.S. adolescents: National Health and Nutrition Examination Survey 2005-2006.
Diabetes Care
.
2009
;
32
(
2
):
342
347
[PubMed]
16
Whitlock
EP
,
Williams
SB
,
Gold
R
,
Smith
PR
,
Shipman
SA
.
Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force.
Pediatrics
.
2005
;
116
(
1
). Available at: www.pediatrics.org/cgi/content/full/116/1/e125
[PubMed]
17
French
SA
,
Story
M
,
Perry
CL
.
Self-esteem and obesity in children and adolescents: a literature review.
Obes Res
.
1995
;
3
(
5
):
479
490
[PubMed]
18
Strauss
RS
.
Childhood obesity and self-esteem.
Pediatrics
.
2000
;
105
(
1
). Available at: www.pediatrics.org/cgi/content/full/105/1/e15
[PubMed]
19
Strauss
RS
,
Pollack
HA
.
Social marginalization of overweight children.
Arch Pediatr Adolesc Med
.
2003
;
157
(
8
):
746
752
[PubMed]
20
Madden
S
,
Morris
A
,
Zurynski
YA
,
Kohn
M
,
Elliot
EJ
.
Burden of eating disorders in 5-13-year-old children in Australia.
Med J Aust
.
2009
;
190
(
8
):
410
414
[PubMed]
21
Nicholls
DE
,
Lynn
R
,
Viner
RM
.
Childhood eating disorders: British national surveillance study.
Br J Psychiatry
.
2011
;
198
(
4
):
295
301
[PubMed]
22
Pinhas
L
,
Morris
A
,
Crosby
RD
,
Katzman
DK
.
Incidence and age-specific presentation of restrictive eating disorders in children: a Canadian Paediatric Surveillance Program study.
Arch Pediatr Adolesc Med
.
2011
;
165
(
10
):
895
899
[PubMed]
23
Golden
NH
,
Katzman
DK
,
Sawyer
SM
, et al
.
Update on the medical management of eating disorders in adolescents.
J Adolesc Health
.
2015
;
56
(
4
):
370
375
[PubMed]
24
van Son
GE
,
van Hoeken
D
,
Bartelds
AI
,
van Furth
EF
,
Hoek
HW
.
Time trends in the incidence of eating disorders: a primary care study in The Netherlands.
Int J Eat Disord
.
2006
;
39
(
7
):
565
569
[PubMed]
25
Zhao
Y
,
Escinosa
W
.
An Update on Hospitalizations for Eating Disorders, 1999 to 2009
.
Rockville, MD
:
Agency for Health Care Policy and Research
;
2011
. Statistical Brief No. 120
26
Swanson
SA
,
Crow
SJ
,
Le Grange
D
,
Swendsen
J
,
Merikangas
KR
.
Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement.
Arch Gen Psychiatry
.
2011
;
68
(
7
):
714
723
[PubMed]
27
American Psychiatric Association
.
Diagnostic and Statistical Manual of Mental Disorders
, Fifth Edition.
Washington, DC
:
American Psychiatric Association
;
2013
28
Sonneville
KR
,
Horton
NJ
,
Micali
N
, et al
.
Longitudinal associations between binge eating and overeating and adverse outcomes among adolescents and young adults: does loss of control matter?
JAMA Pediatr
.
2013
;
167
(
2
):
149
155
[PubMed]
29
Peebles
R
,
Hardy
KK
,
Wilson
JL
,
Lock
JD
.
Are diagnostic criteria for eating disorders markers of medical severity?
Pediatrics
.
2010
;
125
(
5
). Available at: www.pediatrics.org/cgi/content/full/125/5/e1193
[PubMed]
30
Whitelaw
M
,
Gilbertson
H
,
Lee
KJ
,
Sawyer
SM
.
Restrictive eating disorders among adolescent inpatients.
Pediatrics
.
2014
;
134
(
3
). Available at: www.pediatrics.org/cgi/content/full/134/3/e758
[PubMed]
31
Golden
NH
,
Carlson
JL
.
The pathophysiology of amenorrhea in the adolescent.
Ann N Y Acad Sci
.
2008
;
1135
:
163
178
[PubMed]
32
Sim
LA
,
Lebow
J
,
Billings
M
.
Eating disorders in adolescents with a history of obesity.
Pediatrics
.
2013
;
132
(
4
). Available at: www.pediatrics.org/cgi/content/full/132/4/e1026
[PubMed]
33
American Academy of Pediatrics Committee on Nutrition
.
Pediatric Nutrition
. 7th Edition: Adolescent Nutrition.
Elk Grove Village, IL
:
American Academy of Pediatrics
;
2014
34
Field
AE
,
Camargo
CA
 Jr
,
Taylor
CB
, et al
.
Overweight, weight concerns, and bulimic behaviors among girls and boys.
J Am Acad Child Adolesc Psychiatry
.
1999
;
38
(
6
):
754
760
[PubMed]
35
Neumark-Sztainer
D
,
Hannan
PJ
.
Weight-related behaviors among adolescent girls and boys: results from a national survey.
Arch Pediatr Adolesc Med
.
2000
;
154
(
6
):
569
577
[PubMed]
36
Field
AE
,
Austin
SB
,
Taylor
CB
, et al
.
Relation between dieting and weight change among preadolescents and adolescents.
Pediatrics
.
2003
;
112
(
4
):
900
906
[PubMed]
37
Neumark-Sztainer
DR
,
Wall
MM
,
Haines
JI
,
Story
MT
,
Sherwood
NE
,
van den Berg
PA
.
Shared risk and protective factors for overweight and disordered eating in adolescents.
Am J Prev Med
.
2007
;
33
(
5
):
359
369
[PubMed]
38
Stice
E
,
Cameron
RP
,
Killen
JD
,
Hayward
C
,
Taylor
CB
.
Naturalistic weight-reduction efforts prospectively predict growth in relative weight and onset of obesity among female adolescents.
J Consult Clin Psychol
.
1999
;
67
(
6
):
967
974
[PubMed]
39
Stice
E
,
Presnell
K
,
Shaw
H
,
Rohde
P
.
Psychological and behavioral risk factors for obesity onset in adolescent girls: a prospective study.
J Consult Clin Psychol
.
2005
;
73
(
2
):
195
202
[PubMed]
40
Patton
GC
,
Selzer
R
,
Coffey
C
,
Carlin
JB
,
Wolfe
R
.
Onset of adolescent eating disorders: population based cohort study over 3 years.
BMJ
.
1999
;
318
(
7186
):
765
768
[PubMed]
41
Fulkerson
JA
,
Neumark-Sztainer
D
,
Hannan
PJ
,
Story
M
.
Family meal frequency and weight status among adolescents: cross-sectional and 5-year longitudinal associations.
Obesity (Silver Spring)
.
2008
;
16
(
11
):
2529
2534
[PubMed]
42
Taveras
EM
,
Rifas-Shiman
SL
,
Berkey
CS
, et al
.
Family dinner and adolescent overweight.
Obes Res
.
2005
;
13
(
5
):
900
906
[PubMed]
43
Sen
B
.
Frequency of family dinner and adolescent body weight status: evidence from the national longitudinal survey of youth, 1997.
Obesity (Silver Spring)
.
2006
;
14
(
12
):
2266
2276
[PubMed]
44
Neumark-Sztainer
D
,
Hannan
PJ
,
Story
M
,
Croll
J
,
Perry
C
.
Family meal patterns: associations with sociodemographic characteristics and improved dietary intake among adolescents.
J Am Diet Assoc
.
2003
;
103
(
3
):
317
322
[PubMed]
45
Larson
NI
,
Neumark-Sztainer
D
,
Hannan
PJ
,
Story
M
.
Family meals during adolescence are associated with higher diet quality and healthful meal patterns during young adulthood.
J Am Diet Assoc
.
2007
;
107
(
9
):
1502
1510
[PubMed]
46
Neumark-Sztainer
D
,
Wall
M
,
Story
M
,
Fulkerson
JA
.
Are family meal patterns associated with disordered eating behaviors among adolescents?
J Adolesc Health
.
2004
;
35
(
5
):
350
359
[PubMed]
47
Neumark-Sztainer
D
,
Eisenberg
ME
,
Fulkerson
JA
,
Story
M
,
Larson
NI
.
Family meals and disordered eating in adolescents: longitudinal findings from Project EAT.
Arch Pediatr Adolesc Med
.
2008
;
162
(
1
):
17
22
[PubMed]
48
Haines
J
,
Gillman
MW
,
Rifas-Shiman
S
,
Field
AE
,
Austin
SB
.
Family dinner and disordered eating behaviors in a large cohort of adolescents.
Eat Disord
.
2010
;
18
(
1
):
10
24
[PubMed]
49
Neumark-Sztainer
D
.
Preventing obesity and eating disorders in adolescents: what can health care providers do?
J Adolesc Health
.
2009
;
44
(
3
):
206
213
[PubMed]
50
Berge
JM
,
MacLehose
RF
,
Loth
KA
,
Eisenberg
ME
,
Fulkerson
JA
,
Neumark-Sztainer
D
.
Parent-adolescent conversations about eating, physical activity and weight: prevalence across sociodemographic characteristics and associations with adolescent weight and weight-related behaviors.
J Behav Med
.
2015
;
38
(
1
):
122
135
[PubMed]
51
Loth
KA
,
Neumark-Sztainer
D
,
Croll
JK
.
Informing family approaches to eating disorder prevention: perspectives of those who have been there.
Int J Eat Disord
.
2009
;
42
(
2
):
146
152
[PubMed]
52
Berge
JM
,
Maclehose
R
,
Loth
KA
,
Eisenberg
M
,
Bucchianeri
MM
,
Neumark-Sztainer
D
.
Parent conversations about healthful eating and weight: associations with adolescent disordered eating behaviors.
JAMA Pediatr
.
2013
;
167
(
8
):
746
753
[PubMed]
53
Haines
J
,
Hannan
PJ
,
van den Berg
P
,
Eisenberg
ME
,
Neumark-Sztainer
D
.
Weight-related teasing from adolescence to young adulthood: longitudinal and secular trends between 1999 and 2010.
Obesity (Silver Spring)
.
2013
;
21
(
9
):
E428
E434
[PubMed]
54
Eisenberg
ME
,
Berge
JM
,
Fulkerson
JA
,
Neumark-Sztainer
D
.
Associations between hurtful weight-related comments by family and significant other and the development of disordered eating behaviors in young adults.
J Behav Med
.
2012
;
35
(
5
):
500
508
[PubMed]
55
Neumark-Sztainer
D
,
Story
M
,
Hannan
PJ
,
Perry
CL
,
Irving
LM
.
Weight-related concerns and behaviors among overweight and nonoverweight adolescents: implications for preventing weight-related disorders.
Arch Pediatr Adolesc Med
.
2002
;
156
(
2
):
171
178
[PubMed]
56
Neumark-Sztainer
D
,
Paxton
SJ
,
Hannan
PJ
,
Haines
J
,
Story
M
.
Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males.
J Adolesc Health
.
2006
;
39
(
2
):
244
251
[PubMed]
57
Neumark-Sztainer
D
,
Croll
J
,
Story
M
,
Hannan
PJ
,
French
SA
,
Perry
C
.
Ethnic/racial differences in weight-related concerns and behaviors among adolescent girls and boys: findings from Project EAT.
J Psychosom Res
.
2002
;
53
(
5
):
963
974
[PubMed]
58
Kelly
AM
,
Wall
M
,
Eisenberg
ME
,
Story
M
,
Neumark-Sztainer
D
.
Adolescent girls with high body satisfaction: who are they and what can they teach us?
J Adolesc Health
.
2005
;
37
(
5
):
391
396
[PubMed]
59
Flattum
C
,
Friend
S
,
Neumark-Sztainer
D
,
Story
M
.
Motivational interviewing as a component of a school-based obesity prevention program for adolescent girls.
J Am Diet Assoc
.
2009
;
109
(
1
):
91
94
[PubMed]
60
Sepulveda
AR
,
Wise
C
,
Zabala
M
,
Todd
G
,
Treasure
J
.
Development and reliability of a Motivational Interviewing Scenarios Tool for Eating Disorders (MIST-ED) using a skills-based intervention among caregivers.
Eat Behav
.
2013
;
14
(
4
):
432
436
[PubMed]
61
Macdonald
P
,
Hibbs
R
,
Corfield
F
,
Treasure
J
.
The use of motivational interviewing in eating disorders: a systematic review.
Psychiatry Res
.
2012
;
200
(
1
):
1
11
[PubMed]
62
Carcone
AI
,
Naar-King
S
,
Brogan
KE
, et al
.
Provider communication behaviors that predict motivation to change in black adolescents with obesity.
J Dev Behav Pediatr
.
2013
;
34
(
8
):
599
608
[PubMed]
63
Resnicow
K
,
Davis
R
,
Rollnick
S
.
Motivational interviewing for pediatric obesity: conceptual issues and evidence review.
J Am Diet Assoc
.
2006
;
106
(
12
):
2024
2033
[PubMed]
64
Schwartz
RP
,
Hamre
R
,
Dietz
WH
, et al
.
Office-based motivational interviewing to prevent childhood obesity: a feasibility study.
Arch Pediatr Adolesc Med
.
2007
;
161
(
5
):
495
501
[PubMed]
65
Resnicow
K
,
McMaster
F
,
Bocian
A
, et al
.
Motivational interviewing and dietary counseling for obesity in primary care: an RCT.
Pediatrics
.
2015
;
135
(
4
):
649
657
[PubMed]
66
Miller
WR
,
Rollnick
S
.
Motivational Interviewing. Helping People Change
. 3rd ed.
New York, NY
:
The Guilford Press
;
2013
67
American Academy of Pediatrics
. Motivational interviewing. Healthy Active Living for Families Implementation Guide. Available at: www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/HALF-Implementation-Guide/communicating-with-families/Pages/Motivational-Interviewing.aspx. Accessed November 10, 2015
68
Resnicow
K
,
Harris
D
,
Schwartz
R
, et al
.
Can brief motivational interviewing in practice reduce child body mass index?
Results of a 2-year randomized controlled trial [abstr]. Presented at:
Pediatric Academic Societies Annual Meeting
;
Vancouver, British Columbia, Canada
; May 4,
2014
69
Forman
SF
,
Grodin
LF
,
Graham
DA
, et al;
National Eating Disorder QI Collaborative
.
An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses.
J Adolesc Health
.
2011
;
49
(
6
):
594
600
[PubMed]
70
Golden
NH
,
Katzman
DK
,
Sawyer
SM
, et al;
Society for Adolescent Health and Medicine
.
Position paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults.
J Adolesc Health
.
2015
;
56
(
1
):
121
125
[PubMed]
71
Lock
J
,
Le Grange
D
,
Agras
WS
,
Moye
A
,
Bryson
SW
,
Jo
B
.
Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa.
Arch Gen Psychiatry
.
2010
;
67
(
10
):
1025
1032
[PubMed]
72
Le Grange
D
,
Crosby
RD
,
Rathouz
PJ
,
Leventhal
BL
.
A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa.
Arch Gen Psychiatry
.
2007
;
64
(
9
):
1049
1056
[PubMed]
73
Katzman
DK
,
Peebles
R
,
Sawyer
SM
,
Lock
J
,
Le Grange
D
.
The role of the pediatrician in family-based treatment for adolescent eating disorders: opportunities and challenges.
J Adolesc Health
.
2013
;
53
(
4
):
433
440
[PubMed]
74
Austin
SB
,
Field
AE
,
Wiecha
J
,
Peterson
KE
,
Gortmaker
SL
.
The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls.
Arch Pediatr Adolesc Med
.
2005
;
159
(
3
):
225
230
[PubMed]
75
Robinson
TN
,
Killen
JD
,
Kraemer
HC
, et al
.
Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study.
Ethn Dis
.
2003
;
13
(
1
,
suppl 1
):
S65
S77
[PubMed]
76
Shrewsbury
VA
,
Steinbeck
KS
,
Torvaldsen
S
,
Baur
LA
.
The role of parents in pre-adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations.
Obes Rev
.
2011
;
12
(
10
):
759
769
[PubMed]
77
Strasburger
VC
;
Council on Communications and Media
.
Children, adolescents, obesity, and the media.
Pediatrics
.
2011
;
128
(
1
):
201
208
[PubMed]
78
Barr-Anderson
DJ
,
van den Berg
P
,
Neumark-Sztainer
D
,
Story
M
.
Characteristics associated with older adolescents who have a television in their bedrooms.
Pediatrics
.
2008
;
121
(
4
):
718
724
[PubMed]
79
Bauer
KW
,
Neumark-Sztainer
D
,
Fulkerson
JA
,
Hannan
PJ
,
Story
M
.
Familial correlates of adolescent girls’ physical activity, television use, dietary intake, weight, and body composition.
Int J Behav Nutr Phys Act
.
2011
;
8
:
25
[PubMed]
80
Barlow
SE
;
Expert Committee
.
Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics
.
2007
;
120
(
suppl 4
):
S164
S192
[PubMed]

Neville H. Golden, MD, FAAP

Marcie Schneider, MD, FAAP

Christine Wood, MD, FAAP

Stephen Daniels, MD, PhD, FAAP, Chairperson

Steven Abrams, MD, FAAP

Mark Corkins, MD, FAAP

Sarah de Ferranti, MD, FAAP

Neville H. Golden, MD, FAAP

Sheela N. Magge, MD, MSCE, FAAP

Sarah Schwarzenberg, MD, FAAP

Jeff Critch, MD – Canadian Pediatric Society

Van Hubbard, MD, PhD, FAAP – National Institutes of Health

Kelley Scanlon, PhD – Centers for Disease Control and Prevention

Valery Soto, MS, RD, LD – US Department of Agriculture

Debra Burrowes, MHA

Tamar Haro

Paula K. Braverman, MD, FAAP, Chairperson

William Adelman, MD, FAAP

Elizabeth M. Alderman, MD, FAAP, FSAHM

Cora C. Breuner, MD, MPH, FAAP

David A. Levine, MD, FAAP

Arik V. Marcell, MD, MPH, FAAP

Rebecca O’Brien, MD, FAAP

Margo Lane, MD, FAAP, FRCPC – Canadian Pediatric Society

Julie Strickland, MD – American College of Obstetricians and Gynecologists

Benjamin Shain, MD, PhD – American Academy of Child and Adolescent Psychiatry

Karen Smith

James Baumberger, MPP

Stephen Pont, MD, MPH, FAAP, Chairperson

Christopher Bolling, MD, FAAP

Stephen Cook, MD, MPH, FAAP

Lenna Liu, MD, MPH, FAAP

Robert Schwartz, MD, FAAP

Wendelin Slusser, MD, MS, FAAP

Mala Thapar, MPH

Jeanne Lindros, MPH

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose.