Obesity in Children and Adolescents:

Identifying Eating Disorders

ABSTRACT: The hallmarks of an eating disorder are disturbed eating behaviors (eg, binge eating, compulsive eating, and purging), dissatisfaction
with body image, and medical or psychiatric comorbidities. Certain
factors such as dieting, parental weight-related teasing, and family meal
frequency influence the emergence of disordered eating. Depressive and
anxious symptoms also contribute to eating disorder pathology. Nutrition
and medical evaluation is of equal importance to psychological assessment. Routine screening of children and teens of varying sizes will increase
recognition of eating disorders and improve clinical skills and confidence.
Collaboration with additional providers early on is essential for effective
treatment of obese children.
DOMINIQUE R. WILLIAMS, MD
Childrens Hospital of
The Kings Daughters

Dr Williams is assistant professor of

pediatrics at Eastern Virginia Medical
School in Norfolk, fellow of the American
Academy of Pediatrics, and medical
director of the Healthy You for Life Program at Childrens Hospital of The Kings
Daughters in Norfolk, Va. She is also an
MPH in Nutrition candidate at the
University of Massachusetts at Amherst.
Dr Williams has no financial disclosures
or conflicts of interest.
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ories in and calories out. What follows

is a brief review of the complexity of
problems that may coexist with overweight and obesity in both children
and teens. It focuses on 2 studies that
address the prevalence of eating disorder symptoms and other psychopathology in this age group. These studies, along with other valuable studies
on obesity, support the concern that
problems contributing to obesity are
not being addressed and children are
not receiving adequate diagnosis and
care.9-12

ddressing the obesity

epidemic in America is a
complex undertaking. To
simplify it by saying that
it is just an intake of too
many calories ignores the impact of
the food industry, neighborhood developers, and a convenience-driven
society. All of these issues probably
contribute to the problem, but it is
also essential to consider a disordered relationship with food as one
of the underlying causes of overweight and obesity.
Primary care clinicians are responsible for the screening and
treatment of eating disorders and
obesity. Eating disorders are psychological conditions with physical
manifestations.1,2 Anorexia nervosa
(AN) and bulimia nervosa (BN) are
the most recognizable eating disorders. Increasingly, investigators are
looking at the disordered eating
habits of overweight and obese children and considering whether overweight and obesity are physical
manifestations of binge eating disorder (BED).3 Many of these children
have the same disturbed eating behaviors, dissatisfaction with body
image, and medical or psychiatric
comorbidities commonly found in
patients with AN or BN.4-8
A lack of understanding of the
varying manifestations and possible
comorbidities of eating disorders and
obesity may lead to a disproportionate focus on the balance between cal-

DIAGNOSTIC CRITERIA
FOR EATING DISORDERS

The current Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition, Text Revision (DSMIV-TR) includes diagnostic criteria
for AN, BN, and eating disorder not
otherwise specified (EDNOS).1,2 The
Eating Disorders Workgroup for the
fifth edition of the DSM is considering classifying BED as a free-standing eating disorder. 3 Table 1 includes the diagnostic criteria for eating disorders associated with
overweight and obesity.
Patients with AN weigh less
than 85% of their expected weight
and have a distorted body image, an
intense fear of gaining weight or becoming fat, and amenorrhea. In contrast, patients with BN are of normal
weight or may be over weight. Patients with BN, like those with
EDNOS, engage in inappropriate
compensator y behaviors (self-induced vomiting, misuse of laxatives,
diuretics, enemas, fasting, excessive
exercising). EDNOS describes a disorder of eating that does not meet
the criteria for either AN or BN and
consists of a subset of disorders that
includes BED and night eating syndrome. Much like BN, patients with
BED engage in uncontrolled binge
eating; however, they do not vomit,
purge, or abuse laxatives. Patients

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Obesity in Children and Adolescents:

Identifying Eating Disorders

Table 1 DSM-IV-TR criteria for eating disorders associated

with 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 least
twice 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 nervosa

or bulimia nervosa

Female patient has regular menses

Current weight is at least >85% expected
Uses inappropriate compensatory behavior after eating small amounts
of 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 Syndrome

Morning 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.

with BED are often over weight or

obese. Diagnostic criteria for eating
disorders are not mutually exclusive. At diagnosis, most patients
have characteristics of more than
one eating disorder.
FACTORS THAT INFLUENCE
DISORDERED EATING

Haines and coworkers 7 conducted a prospective cohort study

to identify shared risk and protective factors for purging, binge eating, and over weight. The authors
used questionnaires of US children
and adolescents aged 11 to 17 years
enrolled in the Growing Up Today
Study (the offspring of participants
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february 2012

in the second Nurses Health

Study). Over 3 years, more than
10,000 boys and girls answered
questions about purging behaviors,
binge eating, and weight. Other behaviors assessed during that time
include weight concerns, dieting,
fast-food intake, breakfast frequency, physical activity, and television
viewing. The average age of the cohor t was about 14 years; par ticipants were predominantly white
(93%) and female (57%). Researchers also inquired about socioenvironmental factors, such as maternal
dieting, parental weight-related
teasing, peer concern with thinness,
desire to look like same-sex media

figure, and family meal frequency.

Table 2 shows the outcomes related to weight and disordered eating
and selected predictors.
At the end of the study, 331 girls
(7.8%) began purging; 503 girls
(11.8%) and 132 boys (4.5%) started
binge eating. Also of note, 424 girls
(10%) and 382 boys (13.6%) became
overweight. The results of the study
suggested that concern for weight
had a direct relationship to binge eating, purging, and becoming overweight. In girls, factors such as dieting, parental weight-related teasing,
and family meal frequency influenced the emergence of overweight
and disordered eating.
EATING DISORDERS AND
DEPRESSION AND ANXIETY

In a smaller study, Eddy and colleagues6 investigated disordered eating and mental illness in children and
adolescents seeking treatment in the
Optimal Weight for Life pediatric
weight management program at Childrens Hospital Boston. Exclusion
criteria were psychotic disorders, developmental disorders with cognitive
impairment, and obesity-related disorders associated with mental retardation. After 18 months of recruiting,
122 participants met the inclusion criteria. Participants and their parents
received compensation for their time
and participation.
Researchers used multiple inter views, inventories, scales, and
questionnaires to evaluate patients
for eating disorders, mood and anxiety disorders, psychopathology, and
other risk factors. The results of the
questionnaires and statistical analysis revealed a positive association
between eating disorder pathology
and depressive and anxious symptoms (ie, depression, generalized
anxiety, and separation anxiety). A
teasing experience, thin-ideal internalization, and decreased per fectionism all increased the possibility
of an eating disorder, having an elevated negative af fect. Of special
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note, 10 patients (8.2%) met the criteria for an eating disorder while at
least one-third disclosed recent
binge eating. Researchers also suggested that over weight patients
with disordered eating or binge eating have a poorer prognosis for
treatment.
ASSESSMENTS FOR
OVERWEIGHT AND OBESITY

Both of the studies described

above highlight the importance of
performing psychological assessments in overweight and obese children and adolescents.13 Of equal impor tance are the nutritional and
medical assessments that help to
identify causes and consequences of
being overweight.
Nutritional and medical evaluation. Table 3 includes key compo-

nents of the history, physical examination, and laboratory evaluations. A

complete blood cell count and metabolic panel can help determine nutritional status. Measurement of the
glycosylated hemoglobin level and a
lipid panel helps screen for complications of overweight and obesity.14
In the presence of obesity and arrested linear growth, checking thyroid function may be helpful. A 12lead ECG, which is simple and inexpensive, can provide a great deal of
information in the case of obesity
(eg, identify ventricular hypertrophy
as a result of hyper tension). An
ECG can also help identify arrhythmias and ventricular or atrial hypertrophies that are possible adverse
effects of laxatives, diuretics, or appetite suppressants.
Psychological screening.

There are 2 main obstacles that can

make it difficult to screen for obesity or disordered eating. First, use of
questionnaires to determine the
presence of disordered eating behavior and mood disorders may not
be conducive to the time constraints
of a busy physician in private practice. However, dietitians, psychologists, or other clinical providers
may have more expertise and time
to administer these tools after the
physician per for ms the initial
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screen. In some communities, onsite dietitions and psychologists can

expedite this assessment and transfer of information.
Often patients present for issues
unrelated to disordered eating, mood
disorders, or obesity. As such, the appointment schedule may not allow
time to screen or inquire about binge
eating. After children complete the
primary series of vaccines and the
frequency of well child assessments
decreases, there are fewer opportunities to assess growth and thus fewer
plots on the growth curve to assess
linear, weight, and body mass index
velocity. Even when a clinician identifies an eating disorder, there is no
guarantee the family will return for
follow-up, especially because an eating disorder is usually not on the list
of family concerns. Second, how to
code a follow-up appointment and the
risk of not being reimbursed for time
spent is always a concern.
In addition to the issues of time
and reimbursement are the challeng-

es of patient nondisclosure and parental influence. The Haines7 and

Eddy6 studies highlight that at least
1 of 4 overweight or obese patients
has either binge eating behaviors or
symptoms of a mood disorder.6,7 Patients tend to withhold information
or downplay the severity of their disordered behaviors. Clinicians should
consider interviewing patients, especially adolescents, without their parents in the room.
Some parents str uggle with
their own subclinical (or overt) eating disorders. Other parents are not
aware of the signs of an eating or
mood disorder. Sadly, some parents
chide and lecture the child about
making better food choices, and
overlook the tearfulness, withdrawal,
and signs of depression. The child
sneaks food not because of hunger
but because of feelings of sadness or
anxiety. Parents may not mention
that they recently separated or divorced. Military families may not realize that every time a parent is de-

Table 2 Outcomes related to weight and disordered

eating and selected predictors

Adolescent girls
(n = 6022)

Adolescent boys
(n = 4518)

Purging

219 (3.6)

30 (0.7)

Binge eating

426 (7.1)

90 (2.0)

Obese or overweight

1019 (17.4)

1040 (24.6)

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)

Responded yes to dieting

2316 (38.5)

719 (15.9)

Maternal dieting

4104 (68.2)

2746 (60.8)

Outcomes, No (%)

Selected predictors, mean (SD)

Selected predictors, No (%)

Data from Haines J et al. Arch Pediatr Adolesc Med. 2010.7

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Obesity in Children and Adolescents:

Identifying Eating Disorders

ployed, the child withdraws, changes

eating habits, and gains weight.
During the psychological assessment, it is impor tant to also
consider whether being corpulent is
a sign of wealth or health in various
cultures.5 Neither clinicians nor parents may view consumption of food
during celebrations, bereavement,
or days of worship as binging. In
some cultures, friends and family
go out to dinner after church or
Sunday worship. In the midst of all
of the fellowship, is someone binge
eating? In other cultures, using food
to mute feelings of pain, depression,
or low self-esteem is more acceptable than talking about the feelings.
Many families do not like to discuss
feelings or uncomfortable events.
As long as everyone remains quiet
either by not speaking or keeping
their mouth full, then ever ything
is okay.
Tools of assessment. Interviews,
inventories, scales, and questionnaires used to evaluate patients for
eating disorders, mood and anxiety
disorders, psychopathology, and
other risk factors are listed in Table
4. Routine psychological screening
of children of varying sizes for eating disorders will increase recognition of eating disorders and improve
clinical skills and confidence. Along
with screening questions typical for
over weight and obesity, ask about
skipping meals and sneaking or
stealing food. Patients may disclose
that they often feel as though they
cannot stop eating or that their eating is out of control; parents may describe a child who likes to eat so
much that it is hard to stop the child
from overeating.15
Ask parents about the frequency of family meals and how often
they find hidden spoiled food and
food wrappers. In addition to obtaining a family history for weight-related chronic diseases, inquire about a
family histor y of substance abuse,
mood disorders, and eating disorders or obesity. A personal history of
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february 2012

Table 3 Key components

of the nutritional and
medical assessment
History

Past medical history

Medications, supplements,
over-the-counter drugs
Changes in clothes and
shoe sizes
Sleep patterns
Changes in household
or social dynamics
Developmental history
Grade level, school
performance
Peer groups, bullying
Physical examination

Height, weight, blood pressure,

BMI
Note of velocity
Compare to age, gender norms
Skin
Acanthosis 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 A1c
Fasting 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, g-glutamyl
transferase; FT4, free thyroxine;
TSH, thyroid-stimulating hormone.

mental illness; sexual, physical, or

verbal abuse; or parental weight-related teasing should prompt further
questions about binge eating. Many
of these are risk factors for both obesity and eating disorders.16
TREATMENT
AND REFERRAL

Obese patients with known or

suspected binge eating and those
with a possible mood disorder
should be fur ther evaluated by a
mental health professional. The
American Academy of Pediatrics
recommended approach to obesity
treatment follows 4 stages. Stage 1
(Prevention Plus) and Stage 2
(Structured Weight Management)
can be completed in a primary care
setting, often with the support of a
dietitian, counselor or other mental
health professional. Recent evidence
suggests that obesity management
in primar y care settings can work
when physicians collaborate with
other health professionals.17 Stage 3
(Comprehensive Multidisciplinar y
Intervention) and Stage 4 (Tertiary
Care Inter vention) are characterized by multidisciplinary teams specializing in treatment of obese children and adolescents. Many of these
teams include clinical social workers
and psychologists familiar with disordered eating in obese patients.
These providers play an important
role in assessing readiness for
change and in identifying specific
family needs. Treatment plans may
include behavioral weight management, mental health or developmental consult, family therapy, or a combination of these options to increase
the likelihood of success.18
Evaluation and treatment of
childhood obesity is difficult enough
without adding eating disorders to
the equation. Traditionally, treatment of obesity focuses on energy
balance. However, focusing on calories and weight loss without resolving the underlying body image or
psychiatric problems represents parwww.Consultant360.com

Table 4 Psychological assessment tools

Tool

Use

Child Behavior Checklist (CBCL)

Screen for problem behaviors,

6 - 18 y
emotional difficulties,
and social problems

10 - 15 min
Completed by parent

Pediatric Symptom Checklist-17

Screen for emotional and

4 - 18 y
behavioral problems

Less than 5 min

Completed by parent

Screen for Anxiety and

Related Disorders (SCARED)

Screen for childhood anxiety

8 - 18 y
disorders, including school phobia

10 min
Completed by parent, child

Child Binge Eating Disorder Scale (C-BEDS)b

Age rangea

5 - 7 y

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

Time to administera

10 min
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?
a

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

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

tial treatment and is likely to lead to

relapse. If the fifth edition of the
DSM includes BED as a free-standing diagnosis, it may improve the
ability to track its prevalence.3 This
addition will not only improve insurance coverage for over weight or
obesity but also lead to classification
of obesity as different types of BEDs.
In the meantime, clinicians can increase screening, become more informed about the manifestations of
disordered eating, and have a low
threshold for adding a mental health
professional to the team at the beginning of treatment of overweight and
obesity.
n
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Dr Williams invites your comments
about her article. You are welcome
to visit our official Web site,
www.Consultant360.com, and post your
comments and questions.
The Editors

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