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Addressing the obesityepidemic in America is acomplex undertaking. Tosimplify it by saying thatit is just an intake of too

many calories ignores the impact ofthe food industry, neighborhood de-velopers, and a convenience-drivensociety. All of these issues probablycontribute to the problem, but it isalso essential to consider a disor-dered relationship with food as one

of the underlying causes of over-weight and obesity.

Primary care clinicians are re-sponsible for the screening andtreatment of eating disorders andobesity. Eating disorders are psy-chological conditions with physicalmanifestations.1,2Anorexia nervosa(AN) and bulimia nervosa (BN) arethe most recognizable eating disor-ders. Increasingly, investigators arelooking at the disordered eatinghabits of overweight and obese chil-dren and considering whether over-weight and obesity are physicalmanifestations of binge eating disor-der (BED).3Many of these childrenhave the same disturbed eating be-haviors, dissatisfaction with bodyimage, and medical or psychiatriccomorbidities commonly found inpatients with AN or BN.4-8

A lack of understanding of the

varying manifestations and possiblecomorbidities of eating disorders andobesity may lead to a disproportion-ate focus on the balance between cal-

ories in and calories out. What followsis a brief review of the complexity ofproblems that may coexist with over-weight and obesity in both childrenand teens. It focuses on 2 studies thataddress the prevalence of eating dis-order symptoms and other psychopa-thology in this age group. These stud-ies, along with other valuable studieson obesity, support the concern thatproblems contributing to obesity arenot being addressed and children are

not receiving adequate diagnosis andcare.9-12

DIAGNOSTIC CRITERIA

FOR EATING DISORDERS

The currentDiagnostic and Sta-tistical Manual of Mental Disorders,

Fourth Edition, Text Revision (DSM-IV-TR) includes diagnostic criteriafor AN, BN, and eating disorder nototherwise specified (EDNOS).1,2TheEating Disorders Workgroup for the

fifth edition of the DSM is consider-ing classifying BED as a free-stand-ing eating disorder.3Table 1 in-cludes the diagnostic criteria for eat-ing disorders associated withoverweight and obesity.

Patients with AN weigh lessthan 85% of their expected weightand have a distorted body image, anintense fear of gaining weight or be-coming fat, and amenorrhea. In con-trast, patients with BN are of normalweight or may be over weight. Pa-tients with BN, like those withEDNOS, engage in inappropriatecompensatory behaviors (self-in-duced vomiting, misuse of laxatives,diuretics, enemas, fasting, excessiveexercising). EDNOS describes a dis-order of eating that does not meetthe criteria for either AN or BN andconsists of a subset of disorders thatincludes BED and night eating syn-

drome. Much like BN, patients withBED engage in uncontrolled bingeeating; however, they do not vomit,purge, or abuse laxatives. Patients

Obesity in Children and Adolescents:Identifying Eating Disorders

DOMINIQUE R. WILLIAMS, MDChildrens Hospital ofThe Kings Daughters

ABSTRACT:The hallmarks of an eating disorder are disturbed eating behav-iors (eg, binge eating, compulsive eating, and purging), dissatisfactionwith body image, and medical or psychiatric comorbidities. Certainfactors such as dieting, parental weight-related teasing, and family mealfrequency influence the emergence of disordered eating. Depressive andanxious symptoms also contribute to eating disorder pathology. Nutritionand medical evaluation is of equal importance to psychological assess-ment. Routine screening of children and teens of varying sizes will increaserecognition of eating disorders and improve clinical skills and confidence.Collaboration with additional providers early on is essential for effectivetreatment of obese children.

FEBRUARY 2012 CONSULTANT 155www.Consultant360.com

Dr Williams is assistant professor ofpediatrics at Eastern Virginia MedicalSchool in Norfolk, fellow of the AmericanAcademy of Pediatrics, and medicaldirector of the Healthy You for Life Pro-gram at Childrens Hospital of The Kings

Daughters in Norfolk, Va. She is also anMPH in Nutrition candidate at theUniversity of Massachusetts at Amherst.Dr Williams has no financial disclosuresor conflicts of interest.


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with BED are often over weight orobese. Diagnostic criteria for eatingdisorders are not mutually exclu-sive. At diagnosis, most patientshave characteristics of more thanone eating disorder.

FACTORS THAT INFLUENCE

DISORDERED EATING

Haines and coworkers7 con-ducted a prospective cohort studyto identify shared risk and protec-tive factors for purging, binge eat-ing, and overweight. The authors

used questionnaires of US childrenand adolescents aged 11 to 17 yearsenrolled in the Growing Up TodayStudy (the offspring of participants

in the second Nurses HealthStudy). Over 3 years, more than10,000 boys and girls answeredquestions about purging behaviors,binge eating, and weight. Other be-haviors assessed during that timeinclude weight concerns, dieting,fast-food intake, breakfast frequen-cy, physical activity, and televisionviewing. The average age of the co-hort was about 14 years; partici-pants were predominantly white(93%) and female (57%). Research-ers also inquired about socioenvi-

ronmental factors, such as maternaldieting, parental weight-relatedteasing, peer concern with thinness,desire to look like same-sex media

figure, and family meal frequency.Table 2shows the outcomes relat-ed to weight and disordered eatingand selected predictors.

At the end of the study, 331 girls(7.8%) began purging; 503 girls(11.8%) and 132 boys (4.5%) startedbinge eating. Also of note, 424 girls(10%) and 382 boys (13.6%) becameoverweight. The results of the studysuggested that concern for weighthad a direct relationship to binge eat-ing, purging, and becoming over-weight. In girls, factors such as diet-ing, parental weight-related teasing,

and family meal frequency influ-enced the emergence of overweightand disordered eating.

EATING DISORDERS AND

DEPRESSION AND ANXIETY

In a smaller study, Eddy and col-leagues6investigated disordered eat-ing and mental illness in children andadolescents seeking treatment in theOptimal Weight for Life pediatricweight management program at Chil-

drens Hospital Boston. Exclusioncriteria were psychotic disorders, de-velopmental disorders with cognitiveimpairment, and obesity-related dis-orders associated with mental retar-dation. After 18 months of recruiting,122 participants met the inclusion cri-teria. Participants and their parentsreceived compensation for their timeand participation.

Researchers used multiple in-terviews, inventories, scales, andquestionnaires to evaluate patientsfor eating disorders, mood and anxi-ety disorders, psychopathology, andother risk factors. The results of thequestionnaires and statistical analy-sis revealed a positive associationbetween eating disorder pathologyand depressive and anxious symp-toms (ie, depression, generalizedanxiety, and separation anxiety). Ateasing experience, thin-ideal inter-

nalization, and decreased perfec-tionism all increased the possibilityof an eating disorder, having an ele-vated negative af fect. Of special

Obesity in Children and Adolescents:

Identifying Eating Disorders

Table 1 DSM-IV-TR criteria for eating disorders associatedwith overweight and obesity

Bulimia Nervosa (types: purging, nonpurging)

Recurrent episodes of binge eating

Recurrent inappropriate compensatory behaviors to prevent weight gain

Binge eating and inappropriate compensatory behavior occur at leasttwice a week for 3 months

Self-evaluation unduly influenced by body shape and weight

Eating Disorder Not Otherwise Specified

Disorders of eating that do not meet criteria for anorexia nervosaor bulimia nervosa

Female patient has regular menses

Current weight is at least >85% expected

Uses inappropriate compensatory behavior after eating small amountsof food

Repeatedly chews and spits out large amounts of foods

Binge Eating Disorder

Recurrent episodes of binge eating without vomiting or laxative abuse

Often associated with obesity

Currently listed in appendix of DSM-IV-TR

Night Eating SyndromeMorning anorexia

Increased appetite in the evening

Difficulty in falling asleep

Patients can have amnesia for night eating

DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision.


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note, 10 patients (8.2%) met the cri-teria for an eating disorder while atleast one-third disclosed recentbinge eating. Researchers also sug-gested that overweight patientswith disordered eating or binge eat-ing have a poorer prognosis fortreatment.

ASSESSMENTS FOR

OVERWEIGHT AND OBESITY

Both of the studies describedabove highlight the importance ofperforming psychological assess-ments in overweight and obese chil-dren and adolescents.13Of equal im-portance are the nutritional andmedical assessments that help to

identify causes and consequences ofbeing overweight.Nutritional and medical evalu-

ation. Table 3includes key compo-nents of the history, physical exami-nation, and laboratory evaluations. Acomplete blood cell count and meta-bolic panel can help determine nutri-tional status. Measurement of theglycosylated hemoglobin level and alipid panel helps screen for compli-cations of overweight and obesity.14

In the presence of obesity and ar-rested linear growth, checking thy-roid function may be helpful. A 12-lead ECG, which is simple and inex-pensive, can provide a great deal ofinformation in the case of obesity(eg, identify ventricular hypertrophyas a result of hypertension). AnECG can also help identify arrhyth-mias and ventricular or atrial hyper-trophies that are possible adverseeffects of laxatives, diuretics, or ap-petite suppressants.

Psychological screening.

There are 2 main obstacles that canmake it difficult to screen for obesi-ty or disordered eating. First, use ofquestionnaires to determine thepresence of disordered eating be-havior and mood disorders may notbe conducive to the time constraintsof a busy physician in private prac-tice. However, dietitians, psycholo-

gists, or other clinical providersmay have more expertise and timeto administer these tools after thephysician performs the initial

screen. In some communities, on-site dietitions and psychologists canexpedite this assessment and trans-fer of information.

Often patients present for issuesunrelated to disordered eating, mooddisorders, or obesity. As such, the ap-pointment schedule may not allowtime to screen or inquire about bingeeating. After children complete theprimary series of vaccines and thefrequency of well child assessmentsdecreases, there are fewer opportuni-ties to assess growth and thus fewerplots on the growth curve to assesslinear, weight, and body mass indexvelocity. Even when a clinician identi-fies an eating disorder, there is no

guarantee the family will return forfollow-up, especially because an eat-ing disorder is usually not on the listof family concerns. Second, how tocode a follow-up appointment and therisk of not being reimbursed for timespent is always a concern.

In addition to the issues of timeand reimbursement are the challeng-

es of patient nondisclosure and pa-rental influence. The Haines7 andEddy6studies highlight that at least1 of 4 overweight or obese patientshas either binge eating behaviors orsymptoms of a mood disorder.6,7Pa-tients tend to withhold informationor downplay the severity of their dis-ordered behaviors. Clinicians shouldconsider interviewing patients, espe-cially adolescents, without their par-ents in the room.

Some parents struggle withtheir own subclinical (or overt) eat-ing disorders. Other parents are notaware of the signs of an eating ormood disorder. Sadly, some parentschide and lecture the child about

making better food choices, andoverlook the tearfulness, withdrawal,and signs of depression. The childsneaks food not because of hungerbut because of feelings of sadness oranxiety. Parents may not mentionthat they recently separated or di-vorced. Military families may not re-alize that every time a parent is de-

Table 2 Outcomes related to weight and disorderedeating and selected predictors

Adolescent girls Adolescent boys(n = 6022) (n = 4518)

Outcomes, No (%)

Purging 219 (3.6) 30 (0.7)

Binge eating 426 (7.1) 90 (2.0)

Obese or overweight 1019 (17.4) 1040 (24.6)

Selected predictors, mean (SD)

Weight concern 2.4 (1.1) 1.6 (0.8)

Importance of thinness to peers 1.9 (0.7) 1.3 (0.5)

Parental weight-related teasing 1.3 (0.6) 1.2 (0.6)

Breakfast, times per week 4.8 (2) 5.2 (1.7)

Family meal frequency 3.1 (0.8) 3.2 (0.8)

Selected predictors, No (%)

Responded yes to dieting 2316 (38.5) 719 (15.9)

Maternal dieting 4104 (68.2) 2746 (60.8)Data from Haines J et al. Arch Pediatr Adolesc Med.2010.7


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ployed, the child withdraws, changeseating habits, and gains weight.

During the psychological as-sessment, it is important to alsoconsider whether being corpulent isa sign of wealth or health in variouscultures.5Neither clinicians nor par-ents may view consumption of foodduring celebrations, bereavement,or days of worship as binging. Insome cultures, friends and familygo out to dinner after church orSunday worship. In the midst of allof the fellowship, is someone bingeeating? In other cultures, using food

to mute feelings of pain, depression,or low self-esteem is more accept-able than talking about the feelings.Many families do not like to discussfeelings or uncomfortable events.As long as everyone remains quieteither by not speaking or keepingtheir mouth full, then everythingis okay.

Tools of assessment.Interviews,inventories, scales, and question-naires used to evaluate patients for

eating disorders, mood and anxietydisorders, psychopathology, andother risk factors are listed inTable4.Routine psychological screeningof children of varying sizes for eat-ing disorders will increase recogni-tion of eating disorders and improveclinical skills and confidence. Alongwith screening questions typical foroverweight and obesity, ask aboutskipping meals and sneaking orstealing food. Patients may disclosethat they often feel as though theycannot stop eating or that their eat-ing is out of control; parents may de-scribe a child who likes to eat somuch that it is hard to stop the childfrom overeating.15

Ask parents about the frequen-cy of family meals and how oftenthey find hidden spoiled food andfood wrappers. In addition to obtain-ing a family history for weight-relat-

ed chronic diseases, inquire about afamily history of substance abuse,mood disorders, and eating disor-ders or obesity. A personal history of

mental illness; sexual, physical, orverbal abuse; or parental weight-re-lated teasing should prompt furtherquestions about binge eating. Manyof these are risk factors for both obe-sity and eating disorders.16

TREATMENT

AND REFERRAL

Obese patients with known orsuspected binge eating and thosewi th a poss ibl e mood di sordershould be further evaluated by amental health professional. TheAmerican Academy of Pediatrics

recommended approach to obesitytreatment follows 4 stages. Stage 1(Prevention Plus) and Stage 2(Structured Weight Management)can be completed in a primary caresetting, often with the support of adietitian, counselor or other mentalhealth professional. Recent evidencesuggests that obesity managementin primary care settings can workwhen physicians collaborate withother health professionals.17Stage 3

(Comprehensive MultidisciplinaryIntervention) and Stage 4(TertiaryCare Intervention) are character-ized by multidisciplinary teams spe-cializing in treatment of obese chil-dren and adolescents. Many of theseteams include clinical social workersand psychologists familiar with dis-ordered eating in obese patients.These providers play an impor tantrole in assessing readiness forchange and in identifying specificfamily needs. Treatment plans mayinclude behavioral weight manage-ment, mental health or developmen-tal consult, family therapy, or a com-bination of these options to increasethe likelihood of success.18

Evaluation and treatment ofchildhood obesity is difficult enoughwithout adding eating disorders tothe equation. Traditionally, treat-ment of obesity focuses on energy

balance. However, focusing on calo-ries and weight loss without resolv-ing the underlying body image orpsychiatric problems represents par-

Obesity in Children and Adolescents:

Identifying Eating Disorders

Table 3 Key componentsof the nutritional and

medical assessment

History

Past medical history

Medications, supplements,over-the-counter drugs

Changes in clothes andshoe sizes

Sleep patterns

Changes in householdor social dynamics

Developmental history

Grade level, schoolperformance

Peer groups, bullying

Physical examination

Height, weight, blood pressure,BMI

Note of velocity

Compare to age, gender norms

SkinAcanthosis nigricans

Striae or stretch marks

Hirsutism or unwanted hair

Extremities

Muscle tone

Edema

Dysmorphic features

Laboratory and diagnostic tests

Comprehensive metabolic panel,including GGT

Hemoglobin A1cFasting lipid panel

Complete blood cell count

Free and total testosterone

FT4/TSH (if growth arrest,or patient is symptomatic)

12-lead ECG

BMI, body mass index; GGT, -glutamyltransferase; FT4, free thyroxine;TSH, thyroid-stimulating hormone.


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tial treatment and is likely to lead to

relapse. If the fifth edition of theDSM includes BED as a free-stand-ing diagnosis, it may improve theability to track its prevalence.3Thisaddition will not only improve insur-ance coverage for overweight orobesity but also lead to classificationof obesity as different types of BEDs.In the meantime, clinicians can in-crease screening, become more in-formed about the manifestations ofdisordered eating, and have a lowthreshold for adding a mental healthprofessional to the team at the begin-ning of treatment of overweight andobesity. n

REFERENCES:1.American Psychiatric Association.Diagnostic andStatistical Manual of Mental Disorders, 4th Edition,Text Revision.Washington DC: American PsychiatricAssociation; 2000.

2.Franco KN. Eating Disorders. Cleveland ClinicCenter for Continuing Education. Available at:http://www.clevelandclinicmeded.com/medical-pubs/diseasemanagement/psychiatry-psychology/eating-disorders/. Accessed November 13, 2011.

3.American Psychiatric Association DSM-5Development. Proposed Draft Revisions to DSMDisorders and Criteria. Available at: http://

www.dsm5.org/ProposedRevisions/Pages/Default.

aspx. Accessed November 13, 2011.4.Decaluw V, Braet C. Assessment of eating disor-der psychopathology in obese children and adoles-cents: interview versus self-report questionnaire.

Behav Res Ther.2004;42:799-811.5.Desocio JE, Otoole JK, Nemirow SJ, et al.Screening for childhood eating disorders in primarycare.Prim Care Companion J Clin Psychiatry.2007;9:16-20.

6.Eddy KT, Tanofsky-Kraff M, Thompson-BrennerH, et al. Eating disorder pathology among over-weight treatment-seeking youth: clinical correlatesand cross-sectional risk modeling.Behav Res Ther.2007;45:2360-2371.

7.Haines J, Kleinman KP, Rifas-Shiman SL, et al.Examination of shared risk and protective factorsfor overweight and disordered eating amongadolescents.

Arch Pediatr Adolesc Med.2010;164:

336-343.

8.Hamilton JD. Eating disorders in preadolescentchildren.Nurse Pract.2007;32:44-48.

9.Bean MK, Stewart K, Olbrisch ME. Obesity inAmerica: implications for clinical and healthpsychologists.J Clin Psychol Med Settings.2008;15:214-224.

10.Haines J, Neumark-Sztainer D. Preventionof obesity and eating disorders: a consideration ofshared risk factors.Health Educ Res.2006;21:770-782.

11.Tanofsky-Kraff M, Yanovski SZ. Eating disor-der or disordered eating? Non-normative eatingpatterns in obese individuals. Obes Res.2004;12:1361-1366.

12.Zametkin AJ, Zoon CK, Klein HW, Munson S.Psychiatric aspects of child and adolescent obesity:a review of the past 10 years. J Am Acad Child

Adolesc Psychiatry.2004;43:134-150.

13.American Academy of Pediatrics. Policy State-ment: identifying and treating eating disorders.

Pediatrics.2003;111:204-214.

14.Ozier AD, Henry BW; American Dietetic Asso-

ciation. Position of the American DieteticAssociation: nutrition intervention in the treatmentof eating disorders.J Am Diet Assoc.2011;111:1236-1241.15.Marcus MD, Kalarchian MA. Binge eating inchildren and adolescents.Int J Eat Disord.2003;34:S47-S57.16.Rome ES, Ammerman S, Rosen DS, et al.Children and adolescents with eating disorders: thestate of the art.Pediatrics. 2003;111:e98-e108.17.Wadden TA, Volger S, Sarwer DB, et al. A two-year randomized trial of obesity treatment in prima-ry care practice [published online ahead of printNovember 14, 2011].N Engl J Med.18.Spear BA, Barlow SE, Ervin C, et al. Recom-mendations for treatment of child and adolescentoverweight and obesity.Pediatrics.2007;120:S254-S288.19.The California Evidence-Based Clearinghousefor Child Welfare Web site. Screening andAssesment Tools for Child Welfare. Available at:www.cebc4cw.org/assessment-tools. AccessedNovember 18, 2011.20.Shapiro JR, Woolson SL, Hamer RM, et al.Evaluating binge eating disorder in children: devel-opment of the childrens binge eating disorder scale(C-BEDS).Int J Eat Disord.2007;40:82-89.

Table 4 Psychological assessment tools

Tool Use Age rangea Time to administera

Child Behavior Checklist (CBCL) Screen for problem behaviors, 6 - 18 y 10 - 15 minemotional difficulties, Completed by parentand social problems

Pediatric Symptom Checklist-17 Screen for emotional and 4 - 18 y Less than 5 minbehavioral problems Completed by parent

Screen for Anxiety and Screen for childhood anxiety 8 - 18 y 10 minRelated Disorders (SCARED) disorders, including school phobia Completed by parent, child

Child Binge Eating Disorder Scale (C-BEDS)b 5 - 7 y 10 min

1. Do you ever want to eat when you are not hungry? Completed by child

2. Do you ever feel that when you start eating you just cant stop?

3. Do you ever eat because you feel bad, sad, bored, or any other mood?4. Do you ever want food as a reward for doing something?

5. Do you ever sneak or hide food?

6. How long have you been doing this?

7. Do you ever do anything to get rid of what you ate?

aFrom The California Evidence-Based Clearinghouse for Child Welfare Web site. Available at: www.cebc4cw.org/assessment-tools.19

bFrom Shapiro JR et al. Int J Eat Disord.2007.20

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