Eating disorders often begin when an adolescent tries to lose weight. New AAP guidance provides tools to address the unhealthy eating behaviors that put teens at risk.
Reviewed by Neville H Golden, MD, MPH
Among the top most common chronic conditions in adolescents, obesity and eating disorders rank in the top 3. Data from the National Health and Nutrition Examination Survey (NHANES) show that between 2011 and 2012, 34.5% of adolescents aged 12 to 19 years were overweight or obese. The prevalence of eating disorders, which typically begin during adolescence, is highest among adolescent girls and growing among male and minority adolescents. It is estimated that adolescent females have a lifetime prevalence of anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder of 0.3%, 0.9%, and 1.6%, respectively.1
The need to more effectively address these chronic conditions in adolescents is underscored by the associated physical and psychosocial morbidity of these conditions that often extend into adulthood. If not adequately addressed, overweight and obese adolescents are at increased risk of developing a host of difficult-to-manage physical morbidities in adulthood, such as adult diabetes, coronary artery disease, fatty liver disease, and bone and joint problems, as well as enduring ongoing struggles with psychosocial difficulties such as depression.1
In recognition of the need to help pediatricians address some of the key issues about these conditions, the American Academy of Pediatrics (AAP) published clinical guidance in 2010 on identifying and managing eating disorders in children and adolescents,2 and in 2015 published guidance on the role of the pediatrician in the primary prevention of obesity.3
In a more recent publication, the AAP pulls together these 2 conditions to show the interaction between them and to highlight that an eating disorder in adolescence often begins when an adolescent is trying to lose weight or become more healthy. The 2016 published clinical report titled “Preventing obesity and eating disorders in adolescents” is meant to complement the prior clinical reports and provides pediatricians with tools to identify behaviors that predispose adolescents to both obesity and eating disorders.1
Lead author of the report, Neville H. Golden, MD, chief, Division of Adolescent Medicine, and Marron and Mary Elizabeth Kendrick Professor in Pediatrics, Stanford University, Palo Alto, California, highlights that the report “alerts the pediatrician to the increasing number of young people who were previously overweight or obese and who develop an eating disorder while trying to become healthy.”
The name given the condition for adolescents who develop an eating disorder while trying to lose weight is known as “atypical anorexia nervosa,” according to Golden, who says that adolescents who develop this type of eating disorder while trying to lose weight suffer from medical and psychological complications that are very similar to those associated with patients with more classical AN.
This article provides a brief summary of key findings of the AAP clinical report to provide a quick guide for pediatricians on how to identify behaviors that place adolescents at increased risk of becoming obese or developing an eating disorder. The report highlights that some behaviors, such as dieting, can lead to both obesity and eating disorders, while other behaviors, such as family meals, can protect against the development of either disorder, says Golden.
Importantly, the clinical report provides pediatricians with guidance about how to talk to children and adolescents about obesity prevention and eating disorders, underscoring the critical importance of giving these young people the right messages about healthy and effective weight loss.
Although the clinical report points out that most adolescents who develop eating disorders are not previously overweight or obese, the intent of the clinical report is to focus on the adolescents who do develop an eating disorder in an attempt to lose weight. Often an eating disorder will develop in these teenagers through what they (and their parents) misinterpret as “eating healthy,” which often focuses on calorie restriction that can lead to skipping meals; severely restricting dietary intake to fewer than 500 kcal/day; use of diet pills or laxatives; prolonged periods of starvation; and self-induced vomiting.1
Adolescents who engage in these behaviors may present with clinical findings of rapid weight loss, falling off percentiles for weight or body mass index, amenorrhea (girls), and presence of vital sign instability (ie, bradycardia, hypotension, hypothermia, and orthostasis).1
Of first importance for these teenagers and their parents to understand is that caloric intakes required for normal growth and development vary among adolescents depending on gender and activity level (Table 1). Adhering to a strict 2000 kcal/day diet-the caloric intake used by food labels to list percent daily values of nutrition facts as mandated by the US Food and Drug Administration-is not the appropriate way for teenager to eat healthy or lose weight.
To help adolescents and their parents better understand ways that actually do promote healthy eating and prevent obesity, without risking the development of an eating disorder, pediatricians are encouraged to use an integrated approach to obesity and eating disorder prevention that focuses on healthy lifestyle modification. Critical to this approach is the inclusion of the family, and to ensure that parents participate as healthy role models and support their teenagers to help them adopt healthy lifestyle behaviors (Table 2).
Specific evidence-based lifestyle modification behaviors and strategies that pediatricians are encouraged to discuss with their patients are listed in Table 3.
Golden stresses that pediatricians should not use body dissatisfaction as a motivator for weight loss in an obese child or adolescent, and should discourage such behaviors as dieting, skipping meals, using diet pills, and engaging in conversation about weight. Family meals, however, are encouraged.
“Most importantly, if a young person does need to lose weight, provide guidance as to healthy ways to losing weight and monitor the progress to ensure that he or she does not develop an eating disorder,” he says, suggesting that patients should return every 3 to 4 weeks to get their weight and vital signs monitored.
“Sustainable weight loss is best achieved by life style modification,” Golden says, which means healthy eating and being physically active.
Critical to the success of getting teenagers to adopt healthy lifestyle modifications to prevent obesity and eating disorders is being aware of the power of language, Golden emphasizes.
Pediatricians are encouraged to avoid weight-based language and instead use motivational interviewing (MI) techniques designed to strengthen the adolescent’s motivation for and commitment to achieving his or her goal in a collaborative framework with the pediatrician. Table 4 lists 4 broad MI processes that promote collaboration and compassionate engagement with teenagers and their parents, and that have been shown to be effective in helping adolescents lose weight.1
For more specific guidance on using MI in practice, the AAP offers a mobile app called “Change Talk: Childhood Obesity” that that can be accessed at bit.ly/AAP-MI.
Obesity and eating disorders are among the most prevalent chronic conditions in adolescents. These 2 conditions often overlap in adolescents who develop an eating disorder in their attempt to lose weight. In recognition of this interaction between obesity and eating disorders, the AAP clinical report provides pediatricians with an integrated approach to preventing both conditions using evidence-based management strategies focused on healthy, family-based lifestyle modification.
1. Golden NH, Schneider M, Wood C; Committee on Nutrition; Committee on Adolescence; Section on Obesity. preventing obesity and eating disorders in adolescents. Pediatrics. 2016;138(3:e20161649.
2. Rosen DS, American Academy of pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126(6):1240-1253.
3. Daniels SR, Hassink SG; Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275-e292.