Eating Disorders in Adolescents With a Historyof Obesity

abstractAdolescent patients with obesity are at significant risk of developingan eating disorder (ED), yet due to their higher weight status theirsymptoms often go unrecognized and untreated. Although not widelyknown, individuals with a weight history in the overweight (BMI-for-age $85th percentile but ,95th percentile, as defined by Centers forDisease Control and Prevention growth charts) or obese (BMI-for-age$95th percentile, as defined by the Centers for Disease Control andPrevention growth charts) range, represent a substantial portion ofadolescents presenting for ED treatment. Given research that sug-gests that early intervention promotes the best chance of recovery,it is imperative that these children’s and adolescents’ ED symptomsare identified and that intervention is offered before the diseaseprogresses. This report presents 2 examples of EDs that developedin the context of obese adolescents’ efforts to reduce their weight.Each case shows specific challenges in the identification of ED behav-iors in adolescents with this weight history and the correspondingdelay such teenagers experience accessing appropriate treatment.Pediatrics 2013;132:e1026–e1030

AUTHORS: Leslie A. Sim, PhD,a Jocelyn Lebow, PhD,a andMarcie Billings, MDb

aDepartment of Psychiatry and Psychology, and bPediatric andAdolescent Medicine, Mayo Clinic College of Medicine, Rochester,Minnesota

KEY WORDSeating disorders, obesity

ABBREVIATIONSAN—anorexia nervosaED—eating disorderPCP—primary care provider

Dr Sim conceptualized and designed the review, drafteda manuscript outline, prepared the 2 cases, wrote the abstract,and reviewed and revised the manuscript; Dr Lebow wrote thefirst draft of the introduction and discussion sections, providedreferences in the manuscript, and reviewed and revised themanuscript; Dr Billings reviewed and revised the manuscriptand added suggestions for health care providers in thediscussion section, and critically reviewed the manuscript; andall authors approved the final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-3940

doi:10.1542/peds.2012-3940

Accepted for publication May 29, 2013

Address correspondence to Leslie Sim, PhD, Mayo Clinic, 200 FirstSt SW, Rochester, MN 55905. E-mail: sim.leslie@mayo.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors indicated they have nofinancial relationships relevant to this article to disclose.

FUNDING: No external support.

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

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The “childhood obesity epidemic” hasbecome a familiar slogan disseminatedwith the intention of raising awarenessof risks posed to youth by sedentarybehaviors and inadequate nutrition.These campaigns are based on the sig-nificant medical comorbidities associ-ated with pediatric obesity,1 as well asrising prevalence estimates that suggestthat that 17% of children and adoles-cents meet criteria for this condition.2

Although pediatric eating disorders(EDs) have not received the same degreeof public health attention, they are alsoserious conditions afflicting a sizablenumber of children and adolescents. Atleast 6% of youth suffer from EDs,3 and.55% of high school girls and 30% ofboys report disordered eating symptoms,including engaging in $1 maladaptivebehaviors (fasting, diet pills, vomiting,laxatives, binge-eating) to induce weightloss.4 Of concern, EDs are associated witha chronic course, high relapse rates, andsignificant impairment, along with a hostof medical comorbidities that are oftenlife-threatening.3

Somewhat counterintuitively, patientswith a weight history in the overweight(BMI-for-age$85th percentile but,95thpercentile, as defined by the Centers forand Disease Control and Preventiongrowth charts4) or obese (BMI-for-age$95th percentile, as defined by theCenters for Disease Control and Pre-vention growth charts4) range representa substantial portion of patients pre-senting for ED treatment. Symptoms inthese patients are not limited to binge-eating or bulimic behaviors. In 1 study in.100 patients with anorexia nervosa(AN), the majority had a history of obe-sity.5 Another study revealed that nearlyhalf of patients presenting for adolescentED treatment had a history of obesity andthat it took significantly longer forthese patients to be identified as com-pared with patients without this weighthistory (L.A.S., unpublished data). Althoughformer diagnostic criteria classified

individuals with AN as those who lost.25% of their baseline weight, irre-spective of absolute body weight,7 thecurrent diagnostic system’s inclusion ofan absolute weight requirement8 hasallowedmany seriously ill patients to goundetected or to receive a diagnosis ofeating disorder not otherwise specified,whichmight not convey the seriousnessof the patient’s weight loss to otherpractitioners. This situation is particu-larly troubling given research that,compared with adolescents with AN, asample of overweight teenagers whohad lost.25%of their premorbidweightwere more medically compromised.9

The following cases highlight EDs thatdeveloped in the context of obese ado-lescents’ efforts to lose weight. Theseexamples show specific challenges inidentification and treatment of EDs inyoung patients with an obesity history.

CASE 1

Daniel is a 14-year-old boy who pre-sented to an ED evaluation with a 2-yearhistory of significant weight loss (39.5kg) that developed in the context ofa history of obesity. Daniel reached hishighestBMIof 33.6whenhewas12yearsold. At that time, Daniel weighed 40 kgabove the50thpercentile forBMI-for-agefor boys. Throughout development,Daniel’s BMI had always trended wellabove his same age and gender peersand appeared to be moving steadilyupward from the 90th percentile at age3 to well beyond the 97th percentile.(See Fig 1 for weight history.)

Daniel’s weight-loss efforts began withattempts to eat healthily and exercise butquickly developed into severe restriction:he reported eating no more than 600kcal per day while running high schoolcross country. He eliminated sweets, fats,and carbohydrates from meals andwould only eat “diet food.” Daniel alsoexhibited many physical and emotionalsequelae of low weight including diffi-culties concentrating, worsening mood

and irritability, extreme social with-drawal, as well as cold intolerance,significant fatigue, bloating, and con-stipation. Similar to many individualswith AN, Daniel had little insight intothe seriousness of his problem.

Daniel’s weight loss came to the at-tention of his medical providers in thecontext of a pediatric gastroenterologyevaluation for concerns regarding con-stipation, bloating, and intermittentpostprandial chest pain. Results of thegastroenterology evaluation, includingscreening for celiac sprue, Giardia, andHelicobacter pylori, a hydrogen breathtest, thyroid testing, and a brain MRI,were unremarkable. However, Danielexhibited marked sinus bradycardia,and laboratory results were consistentwith significant dehydration. In spite ofhaving lost over half of his body weight,the medical documentation associatedwith the evaluation stated, “there is noelement to suggest that he has an eatingdisorder at this particular time.” At therequest of his mother, however, Danielwas referred for an ED evaluation. Ofnote, Daniel’s weight was a focus ofdiscussion at all medical appointmentsthroughout his childhood. However,during the 13 medical encounters thattook place when he was losing weight,there was no discussion of concernsregarding weight loss.(See Fig 1 forweight history.)

CASE 2

Kristin is an 18-year-old girl who pre-sented to an ED evaluation for signifi-cant fear of weight gain, restrictiveeating, excessive exercise, and binge-eating. At the time of the evaluation,Kristin was experiencing physical se-quelaeof lowweightandpoornutritionalstatus, including secondary amenor-rhea, cold intolerance, and fatigue. Shealso had developed persistent back painand stress fractures.

Kristin’s weight loss also began in thecontext of obesity. When she was

CASE REPORT

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12 years old, her obesity was identifiedand addressed by her primary carephysician (PCP) through a review ofhealthy eating and exercise habits.Consequently, Kristin attempted severaldiets with little success. At age 14, shereached her highest weight of 85 kg,corresponding to a BMI of 32. At thistime, Kristin committed to a dietaryregimen of 1500 kcal per day and beganrunning 7 miles per day. Within 3 years,she lost 38 kg, going from beyond the97th percentile to the 10th percentile.(See Fig 2 for weight history.)

After the first year of her weight loss,she presented to a physical examina-tion with secondary amenorrhea, diz-ziness, and orthostatic intolerance. At

that appointment, her provider rec-ommended that Kristin drink morewater and prescribed oral contra-ceptives for Kristin’s amenorrhea. Oneyear later, after losing an additional 18kg, she returned for follow-up withcontinued orthostatic symptoms. Al-though her mother expressed con-cerns about Kristin’s restrictive eatingand minimal dietary fat intake, theseconcerns were overlooked. At her nextvisit 6 months later, Kristin again pre-sented with amenorrhea. Her PCP thenrecommended an evaluation for poly-cystic ovary syndrome, which Kristindeclined. Documentation associatedwith the visit stated that it was likelythat her amenorrhea was related toher running regimen.

Six months later, Kristin developed se-vere right distal shin pain and wasreferred to a sports medicine physi-cian, who remarked on her weight loss,amenorrhea,stressfractures,andbinge-eating and expressed concerns thatshe had developed the female athletetriad. Consequently, she was referredfor a sports nutritional consultation.The dietitian expressed no concernsregarding her minimal dietary fat in-take or significant weight loss and in-stead recommended that she maintainher current weight and eating pattern.Around the same time, Kristin pre-sented to her PCP for a general medicalevaluation. In spite of her mother’sconcern that she may have an ED, herPCP documented, “given that her BMI is

FIGURE 1BMI history for case 1.

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currently appropriate, it is reasonable todo a trial off thebirth control pill and see ifher menses resume.”

DISCUSSION

These cases highlight EDs that de-veloped in the context of obesity and thecorresponding challenges in identifi-cation and consequent delay in treat-ment. In both cases, despite regularmedical check-ups and obvious signs ofmalnutrition, EDswere not identified assuch and consequently worsened.Symptoms were instead attributedto rarer disorders such as polycysticovary syndrome or gastrointestinalconditions. It is important to note thatthese patients’ weight histories and

severe physical and psychologicalsymptoms are not unique. In total, 45%of the patients seen in our ED clinic inthe past year were adolescents witha history of obesity.6

These caseswere selected because theyhighlight important issues for medicalproviders to keep in mind in theirencounters with patients with obesityhistories. In particular, children andadolescents whose weights fall in thenormal,overweight,orevenobeserangeare not exempt from having or de-velopinganED.Physical complicationsofsemistarvation and weight loss, whichare red flags in a low-weight individual,are oftenmisdiagnosed in thesepatients.Becauseof thismisdiagnosis, referral for

ED treatment is often delayed until the EDsymptoms have progressed and physicaland psychological sequelae are severe.6

PCPs need to be aware that youth withsignificant EDs can present at anyweight. ED concerns shouldbebasedondeviations from a child’s pattern ofgrowth and not simply the percentile atwhich they present for treatment. It isimportant to keep in mind that weightloss is a fairly unusual and difficult taskfor adults, and more so for adoles-cents,10 and any weight loss, even if ittakes a child from overweight to the“average” range, should prompt EDscreening. Furthermore, ED identifica-tion should not hinge solely on weightstatus. Even in the absence of low

FIGURE 2BMI history for case 2.

CASE REPORT

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weight, evidence of eating-disorderedbehaviors (eg, driven exercise, rapidweight loss, extreme dietary restriction,binge-eating, compensatory behaviorssuch as purging), cognitions (eg, un-healthy emphasis on the importance ofweight/shape, skewed or negative bodyimage), psychological features (eg, so-cial withdrawal, irritability, rigidity), andphysical sequelae of starvation should

prompt immediate intervention and re-ferral to appropriate services. Earlyidentification of EDs is associated withthe most positive prognosis for teen-agers and, as such, PCPs are oftenuniquely placed to ensure that patients’symptoms are addressed with maxi-mum effectiveness.

In summary, with the goal of early de-tection and intervention, it is essential

that ED symptoms are on every practi-tioner’s radar, regardless of the pa-tient’s weight. Disordered behaviorsmust be identified as early as possible,and patients referred for appropriateintervention. By maintaining awarenessthat EDs and obesity are, in fact, heavilyoverlapping, and not distinct, classes ofdisorders, health care professionalscan improve overall patient health.

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9. Peebles R, Hardy KK, Wilson JL, Lock JD. Arediagnostic criteria for eating disordersmarkers of medical severity? Pediatrics.2010;125(5). Available at: www.pediatrics.org/cgi/content/full/125/5/e1193

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DOI: 10.1542/peds.2012-3940 originally published online September 9, 2013; 2013;132;e1026Pediatrics 

Leslie A. Sim, Jocelyn Lebow and Marcie BillingsEating Disorders in Adolescents With a History of Obesity

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