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Andes pediatrica

versão On-line ISSN 2452-6053

Andes pediatr. vol.92 no.4 Santiago ago. 2021

http://dx.doi.org/10.32641/andespediatr.v92i4.3539 

REVIEW ARTICLE

Eating disorders and obesity in adolescents: Another challenge of our times

Rosa Behar1  * 

Verónica Marín2 

1 Departamento de Psiquiatría, Facultad de Medicina, Universidad de Valparaíso. Valparaíso, Chile.

2 Servicio de Pediatría, Clínica Ciudad del Mar. Viña del Mar, Chile.

Abstract:

Obesity (OB) and feeding and eating disorders (FED) are complex and prevalent pathologies in adolescents. OB has been shown to be a risk factor for developing binge eating disorder and buli mia nervosa, and vice versa, these FED also develop OB. However, obese adolescents may present atypical or sub-threshold criteria for FED. The objective of this review is to describe the epidemio logical, clinical, and therapeutic relationship between FED and OB in adolescents, with emphasis on the urgent need for research and collaboration among professionals in the fields of mental health and nutrition.

Keywords: Obesity; Feeding and Eating Disorders; Adolescent; Bariatric Surgery

What do we know about the subject matter of this study?

In adolescence, due to biopsychosocial changes, there is an incre asing risk of developing an eating disorder, however, patients with overweight/obesity are generally not accurately diagnosed, often ignoring the significant overlap between both pathologies, with their consequent complications.

What does this study contribute to what is already known?

This review advances the understanding of the complex associa tions between obesity and eating disorders and the urgent need for exploration of these issues, emphasizing the close and essential contribution between mental health and nutritional professionals.

Introduction

Obesity (OB) and eating disorders (ED) are com plex and prevalent pathologies1-3. Although both share biopsychosocial etiopathogenic aspects, they are gene rally focused separately and partially, ignoring a signi ficant co-occurrence between them4-6.

Before starting treatment7, dietary restriction, and weight and shape concerns are frequent in overweight/ OB youths, more often displaying unhealthy weight control behaviors7, which constitute risk factors for developing ED; nevertheless, because they are overweight/OB patients, they are generally underdiag nosed and public health programmes have often igno red the significant overlap between OB and ED.

The aim of this article is to describe the epidemio logical, clinical, and therapeutic relationship between ED and OB in adolescents and to propose strategies for a simultaneous prevention and treatment.

Epidemiological aspects

In Latin America, the percentages of binge eating disorder in obese people aged 14 to 52.9 years, who attend weight loss programmes range from 16% to 51.6%ix. In adult Americans, they fluctuate from 4% to 49%x and in adolescents from 15.4% to 41.7%. Also, the rate at which both pathologies jointly increase is significantly higher (4.5 times) than the increase in people with OB only (1.6 times) or with ED without OB (3.1 times)12.

In Chile, a study of obese adolescents who started treatment reported that 19.6% of females and 12.2% of males developed ED, with higher rates in those with a higher body mass index (20.5%)13.

Obesity and eating disorders

Obese adolescents usually display atypical or sub threshold criteria for ED, due to excess body weight, and despite a significant weight loss, their diagnosis and treatment are delayed because they do not reach a state of malnutrition14.

Meierer et al15 verified that in adolescents with ano rexia nervosa and a history of overweight, the drop in weight was much greater than in those without a background of overweight (7 vs 3.8 points). They also showed that more than one-third had a history of being overweight, resulting in a delay between the recognition of anorexia nervosa and its full diagnosis. Kennedy et al16 observed a higher percentage of weight loss (27.4% vs 16.2%) in patients with typical or atypi cal anorexia nervosa, overweight or premorbid obesity, and a longer duration of the disease than in patients without such a condition.

It should also be noted that binge eating disorder is the most frequent ED associated with overweight/OB, found in 10% to 25% of patients, so its systematic de tection is essential.

Eating habits

He et al19 estimated the prevalence of binge ea ting and uncontrolled eating in 22.2% and 31.2% of overweight/OB children and adolescents, respectively.

Food addiction has been associated with greater psychopathology in people with ED and OB, identifying three groups: 1) dysfunctional (higher prevalen ce of other ED and bulimia nervosa, greater severity of eating pathology, and more dysfunctional personality traits); 2) moderate (high prevalence of bulimia nervo sa, personality disorder and moderate levels of eating psychopathology); and 3) adaptive (high prevalence of OB, binge eating disorder, low levels of eating psycho pathology, and more functional personality traits)20.

Stojek et al21 clasified adolescents with an uncon trolled emotional eating pattern as a subgroup with a particularly high risk of exacerbation of an ED and excessive weight gain. Rose et al22 found that adolescents with severe OB, with more difficulties in impulsive control during negative mood states, exhibited mostly emotional eating and food addiction, related with lower quality of life. Interventions aimed at reducing negative affections, impulsivity, and reinforcing non food-based coping skills, may contribute to optimizing the quality of life and they deserve an in-depth study.

Kass et al23, found that overweight/OB youth who were secret eaters were more prone to depression, die tary restraint, and binging and purging, foreseeing a higher risk of weight gain and ED.

Predictors of risk

ED and OB share biological, environmental, and behavioral risk factors, as well as intermediate neuro- cognitive phenotypes. OB is a specific risk factor for both binge eating disorder and bulimia nervosa; also patients with these EDs often are OB26. A controversial theory postulates that both conditions belong to the same spectrum of eating and weight disorders25. Obese patients with EDs, mainly binge eating disorder, show more eating proneness26, and general27 and personali ty psychopathology28, aspects considered predisposing factors to trigger EDs in overweight/OB individuals.

Opinions about weight and diet in the family, even if well-intentioned, may be perceived as hurt ful by the adolescent and contribute to trigger both conditions29-31. In children, both family teasing and body dissatisfaction also predict the development of overweight, binge eating, and inadequate weight con trol behaviours32,33.

An analysis from birth concluded that maternal chaotic eating, body dissatisfaction, and history of overweight, predicted an occurrence of secret eating in the child during the first 5 years of life, which although not equivalent to a binge eating disorder, consists of eating alone due to the shame caused by the lack of control, and is therefore proposed as a risk index34.

Child abuse is another predisposing factor for both pathologies. Victims may turn to food to relieve stress, manage trauma, block unwanted feelings and emo tions, or express hatred towards their own body35. It would also play a protective role, as obese children would be less attractive to a potential abuser36. In fema le adolescents, abuse has been associated with depres sion, EDs, and low self-esteem. Some survivors of se xual abuse struggle to lose weight to deny their sexuali ty. Others become obsessed with dieting or purging to achieve bodily perfection, feel more powerful, invulne rable, and regain self-esteem37. Binge eating, purging, and starvation would imply self-punishment to miti gate their guilt. Consequently, the possibility of sexual abuse should be evaluated and included regularly in the study of patients with ED and/or overweight/OB, especially in the female gender38.

Obesity, eating disorders, bariatric surgery, and post-surgical evolution

In adolescents, medical management of OB is the treatment of choice, but in severe conditions accompa nied by comorbidity that do not respond to therapeu tic measures, bariatric surgery is an option39. However, not everyone would benefit from it; therefore, selec tion, training for a lifestyle change, and long-term pre- and post surgery follow-up are essential.

Individuals seeking bariatric surgery usually show elevated rates of binge eating and other ED40. Although consumption of objectively large amounts of food is difficult post-surgery, those who persisted with uncon trolled eating, experience suboptimal weight loss or even weight regain. Currently, there are no conclusive studies on predictors of success post-surgery; however, patients with binge eating disorders could benefit from the addition of an emotion regulation intervention in the pre and post surgical periods41.

There are almost no cases of anorexia nervosa pre surgery, but there is some evidence for its develop ment after the surgery42-44. Bulimia nervosa is relatively rare pre-surgery, reaching 3%, and there is little data on post-surgery changes. A possible reason may be its under-reporting due to the fear of being ineligible for this procedure10. Binge eating disorder is the most common pathology before surgery, with rates ranging from 4% to 49%11 in adults and 15.4% to 41.7% in adolescents; with a short-term post-surgical decrease in all ages41. In a national follow-up, 3 years after gas tric bypass surgery in adults, it was observed that the re was no difference in the frequency of binge eating disorder among patients who underwent surgery and those who did not. Low quality of life post-surgery was also observed regarding mental health, particularly as sociated with mood and sexuality42.

Initial improvements in binge eating have been de monstrated at 7 years post gastric bypass or banding surgery, but the proportion of patients with long-term binge eating disorder increases: 4.8% reported the onset of binge eating disorder that they did not have previously, 3.8% had a recurrence of this pre-existing condition, and 9.2% reached remission; nevertheless, in this group, 46.6% maintained uncontrolled eating, which may lead to a negative or suboptimal surgical outcome41.

Another 5-year post-surgery analysis found that mental health problems persist in adolescents despite considerable weight loss, and while this may improve many physical parameters, the relief of psychological complications is unclear, and the bariatric team must offer long-term post-surgery support40.

Prevention and inclusive treatment of both pathologies

Understanding the knowledge and beliefs of those interested in the prevention and treatment of OB and ED, it is crucial to developing effective interventions in addition to integrated health promotion efforts that focus on shared risk (low self-esteem and body dis satisfaction) and build on protective factors (healthy eating and regular exercise), targeting young children, adolescents, and parents, which can show positive results5.

Most adolescents with ED were not previously OB, nonetheless, in some obese patients, they may emerge in an attempt to lose weight. The focus should be on a healthy lifestyle rather than weight. Available evidence suggests that OB prevention and treatment, properly implemented, do not predispose to ED41, demonstra ting that structured, professionally administered OB treatment is associated with a reduction in the preva lence, risk, and symptoms of ED. Recent data shows that family and cognitive-behavioral therapies for child and adolescent OB are effective in reducing weight and body shape concerns, and discouraging an ED42,43.

Analysis and conclusions

This review highlights the relevance of a multidis ciplinary approach, mainly from the mental health and nutritional perspectives, and a combined diagnosis of binge eating, emotional and personality disorders in obese adolescents, for better prevention and outco me of both pathologies. The need to include early detection of an ED (especially binge eating disorder), along with the implementation of integrated thera peutic programmes, are essential for a better outcome, though, health professionals tend not to identify them in obese people, and their symptoms are more difficult to recognize if they are not routinely and specifically checked for.

If OB prevention and treatment are successfully ac complished, OB does not predispose to EDs42; on the contrary, such programmes, which include the family, show a reduction in self-induced vomiting and other pathological compensatory strategies of weight control43.

Other approaches based on clinical experience that encourage parents to include greater availability of nourishing and beneficial foods, less screen time, more family home-cooked meals, with fewer distractions, and conversations about weight, shape, and diet, can promote a healthy body image41.

In adolescents, medical treatment of OB is recom mended, but in severe cases in which serious medical complications co-exist and do not respond adequately to lifestyle interventions, they may benefit from surgi cal treatment. However, not everyone would improve from surgery, so its selection and long-term pre- and post-surgical follow-up are essential to obtain good therapeutic results52. If an obese adolescent has nee ded to undergo surgery, it is imperative to take into account the principles and foundations of the “Chilean Consensus on Mental Health for Patients Undergoing Bariatric Surgery”53, aimed at ensuring the success of the intervention.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

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Received: November 30, 2020; Accepted: April 15, 2021

* Correspondence: Rosa Behar. E-mail: rositabehara@gmail.com.

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