Eating Disorders in Adolescents With a History of

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CASE REPORT
Eating Disorders in Adolescents With a History
of Obesity
AUTHORS: Leslie A. Sim, PhD,a Jocelyn Lebow, PhD,a and
Marcie Billings, MDb
abstract
aDepartment
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-forage $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.
Pediatrics 2013;132:e1–e5
bPediatric
of Psychiatry and Psychology, and
and
Adolescent Medicine, Mayo Clinic College of Medicine, Rochester,
Minnesota
KEY WORDS
eating disorders, obesity
ABBREVIATIONS
AN—anorexia nervosa
ED—eating disorder
PCP—primary care provider
Dr Sim conceptualized and designed the review, drafted
a manuscript outline, prepared the 2 cases, wrote the abstract,
and reviewed and revised the manuscript; Dr Lebow wrote the
first draft of the introduction and discussion sections, provided
references in the manuscript, and reviewed and revised the
manuscript; Dr Billings reviewed and revised the manuscript
and added suggestions for health care providers in the
discussion section, and critically reviewed the manuscript; and
all 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 First
St SW, Rochester, MN 55905. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors indicated they have no
financial relationships relevant to this article to disclose.
FUNDING: No external support.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conflicts of interest to disclose.
PEDIATRICS Volume 132, Number 4, October 2013
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e1
The “childhood obesity epidemic” has
become a familiar slogan disseminated
with the intention of raising awareness
of risks posed to youth by sedentary
behaviors and inadequate nutrition.
These campaigns are based on the significant medical comorbidities associated with pediatric obesity,1 as well as
rising prevalence estimates that suggest
that that 17% of children and adolescents meet criteria for this condition.2
Although pediatric eating disorders
(EDs) have not received the same degree
of public health attention, they are also
serious conditions afflicting a sizable
number of children and adolescents. At
least 6% of youth suffer from EDs,3 and
.55% of high school girls and 30% of
boys report disordered eating symptoms,
including engaging in $1 maladaptive
behaviors (fasting, diet pills, vomiting,
laxatives, binge-eating) to induce weight
loss.4 Of concern, EDs are associated with
a chronic course, high relapse rates, and
significant impairment, along with a host
of medical comorbidities that are often
life-threatening.3
Somewhat counterintuitively, patients
with a weight history in the overweight
(BMI-for-age $85th percentile but ,95th
percentile, as defined by the Centers for
and Disease Control and Prevention
growth charts4) or obese (BMI-for-age
$95th percentile, as defined by the
Centers for Disease Control and Prevention growth charts4) range represent
a substantial portion of patients presenting for ED treatment. Symptoms in
these patients are not limited to bingeeating or bulimic behaviors. In 1 study in
.100 patients with anorexia nervosa
(AN), the majority had a history of obesity.5 Another study revealed that nearly
half of patients presenting for adolescent
ED treatment had a history of obesity and
that it took significantly longer for
these patients to be identified as compared with patients without this weight
history (L.A.S., unpublished data). Although
former diagnostic criteria classified
e2
individuals with AN as those who lost
.25% of their baseline weight, irrespective of absolute body weight,7 the
current diagnostic system’s inclusion of
an absolute weight requirement8 has
allowed many seriously ill patients to go
undetected or to receive a diagnosis of
eating disorder not otherwise specified,
which might not convey the seriousness
of the patient’s weight loss to other
practitioners. This situation is particularly troubling given research that,
compared with adolescents with AN, a
sample of overweight teenagers who
had lost .25% of their premorbid weight
were more medically compromised.9
The following cases highlight EDs that
developed in the context of obese adolescents’ efforts to lose weight. These
examples show specific challenges in
identification and treatment of EDs in
young patients with an obesity history.
CASE 1
Daniel is a 14-year-old boy who presented to an ED evaluation with a 2-year
history of significant weight loss (39.5
kg) that developed in the context of
a history of obesity. Daniel reached his
highest BMI of 33.6 when he was 12 years
old. At that time, Daniel weighed 40 kg
above the 50th percentile for BMI-for-age
for boys. Throughout development,
Daniel’s BMI had always trended well
above his same age and gender peers
and appeared to be moving steadily
upward from the 90th percentile at age
3 to well beyond the 97th percentile.
(See Fig 1 for weight history.)
Daniel’s weight-loss efforts began with
attempts to eat healthily and exercise but
quickly developed into severe restriction:
he reported eating no more than 600
kcal per day while running high school
cross country. He eliminated sweets, fats,
and carbohydrates from meals and
would only eat “diet food.” Daniel also
exhibited many physical and emotional
sequelae of low weight including difficulties concentrating, worsening mood
SIM et al
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and irritability, extreme social withdrawal, as well as cold intolerance,
significant fatigue, bloating, and constipation. Similar to many individuals
with AN, Daniel had little insight into
the seriousness of his problem.
Daniel’s weight loss came to the attention of his medical providers in the
context of a pediatric gastroenterology
evaluation for concerns regarding constipation, bloating, and intermittent
postprandial chest pain. Results of the
gastroenterology evaluation, including
screening for celiac sprue, Giardia, and
Helicobacter pylori, a hydrogen breath
test, thyroid testing, and a brain MRI,
were unremarkable. However, Daniel
exhibited marked sinus bradycardia,
and laboratory results were consistent
with significant dehydration. In spite of
having lost over half of his body weight,
the medical documentation associated
with the evaluation stated, “there is no
element to suggest that he has an eating
disorder at this particular time.” At the
request of his mother, however, Daniel
was referred for an ED evaluation. Of
note, Daniel’s weight was a focus of
discussion at all medical appointments
throughout his childhood. However,
during the 13 medical encounters that
took place when he was losing weight,
there was no discussion of concerns
regarding weight loss.(See Fig 1 for
weight history.)
CASE 2
Kristin is an 18-year-old girl who presented to an ED evaluation for significant fear of weight gain, restrictive
eating, excessive exercise, and bingeeating. At the time of the evaluation,
Kristin was experiencing physical sequelae of low weight and poor nutritional
status, including secondary amenorrhea, cold intolerance, and fatigue. She
also had developed persistent back pain
and stress fractures.
Kristin’s weight loss also began in the
context of obesity. When she was
CASE REPORT
FIGURE 1
BMI history for case 1.
12 years old, her obesity was identified
and addressed by her primary care
physician (PCP) through a review of
healthy eating and exercise habits.
Consequently, Kristin attempted several
diets with little success. At age 14, she
reached her highest weight of 85 kg,
corresponding to a BMI of 32. At this
time, Kristin committed to a dietary
regimen of 1500 kcal per day and began
running 7 miles per day. Within 3 years,
she lost 38 kg, going from beyond the
97th percentile to the 10th percentile.
(See Fig 2 for weight history.)
After the first year of her weight loss,
she presented to a physical examination with secondary amenorrhea, dizziness, and orthostatic intolerance. At
that appointment, her provider recommended that Kristin drink more
water and prescribed oral contraceptives for Kristin’s amenorrhea. One
year later, after losing an additional 18
kg, she returned for follow-up with
continued orthostatic symptoms. Although her mother expressed concerns about Kristin’s restrictive eating
and minimal dietary fat intake, these
concerns were overlooked. At her next
visit 6 months later, Kristin again presented with amenorrhea. Her PCP then
recommended an evaluation for polycystic ovary syndrome, which Kristin
declined. Documentation associated
with the visit stated that it was likely
that her amenorrhea was related to
her running regimen.
PEDIATRICS Volume 132, Number 4, October 2013
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Six months later, Kristin developed severe right distal shin pain and was
referred to a sports medicine physician, who remarked on her weight loss,
amenorrhea, stressfractures, and bingeeating and expressed concerns that
she had developed the female athlete
triad. Consequently, she was referred
for a sports nutritional consultation.
The dietitian expressed no concerns
regarding her minimal dietary fat intake or significant weight loss and instead recommended that she maintain
her current weight and eating pattern.
Around the same time, Kristin presented to her PCP for a general medical
evaluation. In spite of her mother’s
concern that she may have an ED, her
PCP documented, “given that her BMI is
e3
FIGURE 2
BMI history for case 2.
currently appropriate, it is reasonable to
do a trial off the birth control pill and see if
her menses resume.”
DISCUSSION
severe physical and psychological
symptoms are not unique. In total, 45%
of the patients seen in our ED clinic in
the past year were adolescents with
a history of obesity.6
These cases highlight EDs that developed in the context of obesity and the
corresponding challenges in identification and consequent delay in treatment. In both cases, despite regular
medical check-ups and obvious signs of
malnutrition, EDs were not identified as
such and consequently worsened.
Symptoms were instead attributed
to rarer disorders such as polycystic
ovary syndrome or gastrointestinal
conditions. It is important to note that
these patients’ weight histories and
These cases were selected because they
highlight important issues for medical
providers to keep in mind in their
encounters with patients with obesity
histories. In particular, children and
adolescents whose weights fall in the
normal, overweight, or even obese range
are not exempt from having or developing an ED. Physical complications of
semistarvation and weight loss, which
are red flags in a low-weight individual,
are often misdiagnosed in these patients.
Because of this misdiagnosis, referral for
e4
SIM et al
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ED treatment is often delayed until the ED
symptoms have progressed and physical
and psychological sequelae are severe.6
PCPs need to be aware that youth with
significant EDs can present at any
weight. ED concerns should be based on
deviations from a child’s pattern of
growth and not simply the percentile at
which they present for treatment. It is
important to keep in mind that weight
loss is a fairly unusual and difficult task
for adults, and more so for adolescents,10 and any weight loss, even if it
takes a child from overweight to the
“average” range, should prompt ED
screening. Furthermore, ED identification should not hinge solely on weight
status. Even in the absence of low
CASE REPORT
weight, evidence of eating-disordered
behaviors (eg, driven exercise, rapid
weight loss, extreme dietary restriction,
binge-eating, compensatory behaviors
such as purging), cognitions (eg, unhealthy emphasis on the importance of
weight/shape, skewed or negative body
image), psychological features (eg, social withdrawal, irritability, rigidity), and
physical sequelae of starvation should
prompt immediate intervention and referral to appropriate services. Early
identification of EDs is associated with
the most positive prognosis for teenagers and, as such, PCPs are often
uniquely placed to ensure that patients’
symptoms are addressed with maximum effectiveness.
In summary, with the goal of early detection and intervention, it is essential
that ED symptoms are on every practitioner’s radar, regardless of the patient’s weight. Disordered behaviors
must be identified as early as possible,
and patients referred for appropriate
intervention. By maintaining awareness
that EDs and obesity are, in fact, heavily
overlapping, and not distinct, classes of
disorders, health care professionals
can improve overall patient health.
and development. Vital Health Stat 11. 2002:
(246):1–190
5. Croll J, Neumark-Sztainer D, Story M, Ireland
M. Prevalence and risk and protective factors related to disordered eating behaviors
among adolescents: relationship to gender
and ethnicity. J Adolesc Health. 2002;31(2):
166–175
6. Crisp AH, Hsu LK, Harding B, Hartshorn J.
Clinical features of anorexia nervosa: a study
of a consecutive series of 102 female patients.
J Psychosom Res. 1980;24(3–4):179–191
7. American Psychiatric Association, ed. Diagnostic and Statistical Manual of Mental
Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980
8. American Psychiatric Association, ed. Diagnostic and Statistical Manual of Mental
Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000
9. 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
10. 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
REFERENCES
1. Deckelbaum RJ, Williams CL. Childhood
obesity: the health issue. Obes Res. 2001;9
(suppl 4):239S–243S
2. Ogden CL, Carroll MD, Kit BK, Flegal KM.
Prevalence of obesity and trends in body
mass index among US children and adolescents, 1999-2010. JAMA. 2012;307(5):483–490
3. Swanson SA, Crow SJ, Le Grange D,
Swendsen J, Merikangas KR. Prevalence and
correlates of eating disorders in adolescents: results from the national comorbidity
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Arch Gen Psychiatry. 2011;68(7):714–723
4. Kuczmarski RJ, Ogden CL, Guo SS, GrummerStrawn LM, Flegal KM, Mei Z, et al. 2000 CDC
growth charts for the United States: methods
PEDIATRICS Volume 132, Number 4, October 2013
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e5
Eating Disorders in Adolescents With a History of Obesity
Leslie A. Sim, Jocelyn Lebow and Marcie Billings
Pediatrics; originally published online September 9, 2013;
DOI: 10.1542/peds.2012-3940
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on June 18, 2017
Eating Disorders in Adolescents With a History of Obesity
Leslie A. Sim, Jocelyn Lebow and Marcie Billings
Pediatrics; originally published online September 9, 2013;
DOI: 10.1542/peds.2012-3940
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/early/2013/09/04/peds.2012-3940
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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