Obesity and Disordered Eating in Children

Chalanda Jones, MD

Dr Jones is a pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD––Series Editor: Dr Pohl is professor of pediatrics and senior associate dean of student affairs and career counseling at Jefferson College in Philadelphia, Pennsylvania.

Adolescents with obesity are at significant risk of developing an eating disorder, yet clinicians often fail to identify symptoms and intervene early.

Restrictive eating and compulsive physical activity levels often are red flags that prompt health care providers to screen for an eating disorder in an adolescent with a low body mass index (BMI). Less often do these behaviors prompt screening for an eating disorder in a child who is obese—after all, dieting and exercise are the very behaviors that weight loss plans encourage.

Sim and colleagues1 recently presented 2 examples of eating disorders in teenagers with obesity that demonstrate how the early warning signs may be overlooked.

Case 1

A 14-year-old boy had reached a peak BMI of 33.6 kg/m2 at 12 years of age but had experienced rapid weight loss of 39.5 kg since then. He had begun losing weight by eating healthily and exercising but quickly progressed to severe calorie restricting and cross-country running. He began to have difficulty concentrating, irritability, extreme social withdrawal, cold intolerance, fatigue, and constipation.

He was seen by a pediatric gastroenterologist who documented in the medical record that “there is no element to suggest that he has an eating disorder.” The extensive gastroenterology workup identified only sinus bradycardia and dehydration.

It was not until the mother requested an eating disorder workup that the possibility was addressed. He had had 13 previous medical encounters documenting dramatic weight loss, none of which included a discussion about an eating disorder.

Case 2

An 18-year-old girl’s weight had fallen 38 kg, from above the 97th percentile to the 10th percentile, in 3 years. She presented to an eating disorder evaluation for fear of weight gain, restrictive eating and bingeing, and excessive exercise. She had been diagnosed with obesity at 12 years of age. Her maximum weight had been 85 kg (BMI 32 kg/m2) at 14 years of age.

After her first year of weight loss, she presented to primary care with secondary amenorrhea, dizziness, and orthostatic intolerance; she was prescribed oral contraceptives and advised to drink more water. At a checkup 18 months later, her primary care provider attributed her amenorrhea to her daily 7-mile running regimen.

Six months later, shin pain prompted referral to a sports medicine physician, who noted stress fractures, weight loss, bingeing, and amenorrhea, and suggested the possibility of the female athlete triad. She was referred to a sports nutritionist who voiced no concerns and advised her to maintain her weight and eating pattern.

When the patient saw her primary care physician again, her mother expressed concern about an eating disorder. The physician discontinued oral contraceptives to address the amenorrhea, noting that “her BMI is currently appropriate.”

Clinical Vigilance

The authors note that 45% of patients seen in their eating disorder clinic are adolescents with obesity. They emphasize the importance of monitoring teens for signs of an eating disorder as they are guided through healthy weight loss plans.

The authors recommend that primary care providers pay more attention to deviations from a child’s pattern of growth than to absolute weight percentiles. Losing weight is difficult and fairly unusual in adolescents, and perhaps even more so in young patients with obesity. The authors recommend vigilance for the hallmarks of disordered eating, such as driven exercise, rapid weight loss, extreme dietary restriction, and bulimic behaviors. Adolescents with an unhealthy focus on weight and body shape; with skewed or negative body image; with social withdrawal, irritability, and rigidity; and with the physical consequences of starvation should receive immediate intervention and referral. n


1. Sim LA, Lebow J, Billings M. Eating disorders in adolescents with a history of obesity. Pediatrics. 2013;132(4):e1026-e1030. http://pediatrics.
aappublications.org/content/132/4/e1026.long. Accessed November 13, 2013.