RESEARCH UPDATE REVIEW
Psychiatric Aspects of Child and Adolescent Obesity: A Review of the Past 10 Years

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ABSTRACT

Objective

To review the past 10 years of published research on psychiatric aspects of child and adolescent obesity and highlight information mental health professionals need for preventing obesity in youths and diagnosing and treating it.

Method

Researchers performed computerized and manual searches of the literature and summarized the most relevant articles.

Results

The growing epidemic of child and adolescent obesity deserves attention for its immediate mental health and long-term medical complications. Mental health professionals working with obese youths should be aware of recent advances in neuroscience, genetics, and etiologies associated with obesity. Those who assess and treat obese youth should view obesity as a chronic disease. Currently, no approved pharmacological or surgical approaches exist to treat childhood obesity.

Conclusions

Health care providers should focus on modest weight-loss goals that correlate with significant health benefits. The most effective treatments include substantial parental involvement. Mental health professionals should help obese children build self-esteem to help them lead full lives regardless of weight.

Section snippets

DEFINITION OF OBESITY

Body mass index (BMI) is the simplest and most common assessment tool for categorizing childhood obesity and is calculated by dividing weight (kg) by height (m2). BMI charts for boys and girls can be found at www.cdc.gov/growthcharts. BMI accurately reflects the proportion of excess body fat and correlates with markers of secondary complications of obesity and long-term mortality (Barlow and Dietz, 1998). An expert panel on obesity evaluation and treatment recommends that a BMI greater than the

PREVALENCE

Rates of childhood and adolescent obesity have increased dramatically in the past decade. According to a recent article in the Journal of the American Medical Association based on results from the 1999ā€“2000 National Health and Nutrition Examination Survey (NHANES), more than 15% of youths ages 6 through 19 were obese, and more than 10% of children ages 2 through 5 were obese (Ogden et al., 2002). The percentages of obese children and adolescents were relatively stable over NHANES I (1971ā€“1974)

MEDICAL AND PSYCHOSOCIAL SEQUELAE

Although many of the effects of childhood obesity do not manifest themselves until adulthood, the obese child may suffer immediate consequences from his or her condition. The medical sequelae that threaten the young obese child include cardiovascular disease, endocrine and pulmonary problems, and orthopedic, gastroenterological, and neurological difficulties (Strauss, 1999).

A 40-year follow-up study revealed a twofold increase in the rate of cardiovascular disease and hypertension and a

NATURAL COURSE

Obese children are at great risk for adulthood obesity. Leading predictors are parental weight status and the child's adiposity (amount of fatty tissue) after age 10. Both obese and nonobese children have twice the risk of adulthood obesity when at least one parent is obese (NCHS, 1999; Whitaker et al., 1997). For children ages 3 to 9 years, both their BMIs and their parentsā€™ BMIs are predictors of later obesity. Furthermore, 80% of obese adolescents ages 10 to 14 with at least one obese parent

PEDIATRIC PREDICTORS OF CHILDHOOD OBESITY AND SUBSEQUENT ADULT OBESITY

Gestational events and the adiposity rebound period (see below) may influence childhood-onset obesity leading to adult obesity. Studies have observed that famine during gestation can either increase or decrease later obesity prevalence, and ā€œinfants with higher neonatal amniotic fluid concentrations of insulin show significantly increased obesity at age 6 yearsā€ (Strauss, 1999, p. 8). Infants whose mothers had gestational diabetes have a 50% greater risk of obesity at age 10 (French et al., 1995

NATIONAL HEALTH CARE COST OF CHILD OBESITY

Obesity-associated annual hospital costs, the only U.S. cost data available that isolate childhood obesity, have more than tripled in the past 20 years, from $35 million in 1979 to 1981 to $127 million in 1997 to 1999 (Wang and Dietz, 2002). These data reflect an increase in the percentage of discharges with obesity-related diseases, particularly obesity (197% increase), gallbladder disease (228% increase), and sleep apnea (436% increase). The increased incidence of hospital stays related to

SOCIAL ISSUES AND PRESSURES: STIGMA AND SELF-ESTEEM

Obesity stigmatizes young children even before adolescence, placing them outside the social norms. When shown drawings of children of different sizes, children rank obese classmates as the least desirable playmates.

Studies on self-esteem in obese children report inconsistent results. Many indicate that obese children and adolescents have moderately lower self-esteem than nonobese peers (French et al., 1995; Manus and Killeen, 1995; Pesa et al., 2000; Stradmeijer et al., 2000; Strauss, 2000).

NEUROSCIENCE OF FEEDING AND WEIGHT MAINTENANCE

For a complete review of the neuroscience and neuroendocrinology involved in eating, see Schwartz (2001) and Lustig (2001).

The hypothalamus regulates energy balance and food intake. Leptin, an adipocyte (fat cell) hormone, and insulin, both present in proportion to fat stores in the body, have a high density of receptors in the hypothalamus. The presence of leptin and insulin activates the anorectic branch of the hypothalamus (which decreases food intake) and inhibits the orexigenic branch

GENETICS

Farooqi and Oā€™Rahilly (2000) provide a complete review of the molecular genetics of childhood obesity.

Twin studies estimate that genetic factors account for 50% to 90% of the variance in BMI. Estimates from numerous adoption, parentā€“offspring, and sibling studies indicate that genetic factors account for 20% to 80% of the variance in factors associated with obesity development. Such factors include energy intake and expenditure (Klish, 1998; Maes et al., 1997). Maes et al. (1997) examined more

MEDICAL AND PSYCHOSOCIAL CAUSES OF CHILDHOOD OBESITY

Although rare in the population at large, systemic medical conditions can result in obesity. Table 1 lists most of the medical causes. However, fewer than 10% of the child obesity cases seen have endogenous causes; more than 90% are idiopathic (Moran, 1999). This large idiopathic percentage is responsible for the child obesity epidemic of the past 30 years (Strauss, 1999).

OBESITY: A PSYCHIATRIC OR BEHAVIOR DISORDER?

Overeating, the chronic inability to control how much is eaten, results in obesity and causes suffering, stigmatization, and social cost, but it is not classified as a behavioral or psychiatric disorder. The International Classification of Diseases (ICD) categorizes obesity as a general medical condition. DSM-IV does not characterize it as a psychiatric disorder ā€œbecause it has not been established that obesity is consistently associated with a psychological or behavioral syndromeā€ (American

Psychiatric Disorders: Cause or Consequence?

Many population-based studies have found high rates of psychological disorders in obese children and adolescents, especially in females. Buddeburg-Fisher et al. (1999) found higher rates of such disorders as somatoform, mood, pain, and anxiety in overweight Swiss high school girls. They also reported a correlation between poorer body image and increased psychiatric comorbidity. However, in a study of 3,197 adolescent females, Pesa et al. (2000) found that after controlling for body-image

MEDICAL AND PSYCHIATRIC EVALUATION

Obese patients should be thoroughly evaluated to identify any medical or psychiatric conditions that may affect the course of treatment.

Review Articles

A detailed review of more than 70 randomized controlled studies of child and adolescent obesity treatment programs is beyond the scope of this review of psychiatric aspects of child and adolescent obesity. Two excellent pediatric-based reviews of the literature by Epstein et al. (1998) and Jelalian and Saelens (1999) are highly recommended. It is important for child and adolescent psychiatrists to be familiar with the fundamental findings of that literature.

Despite discouraging results in adult

DIET AND EXERCISE

Increase in Activity and Reduction in Caloric Intake

For weight loss, obese children must expend more energy than they consume, by increasing activity and decreasing caloric intake. This includes limiting time in front of the TV or computer to 1 or 2 hours a day, as recommended by the American Academy of Pediatrics.

Pharmacological Approaches

There are no pharmacological approaches approved by the U.S. Food and Drug Administration to treat childhood obesity. Clinical trials with sibutramine and orlistat in children are under way. Research on the use of leptin is in its preliminary stages, although far from clinical trials (Lustig, 2001). Little is known about pharmacotherapy in children. Therefore, this section will review current and past drug treatments of obesity in adults, because off-label use in children is common.

Typically,

PSYCHOTROPIC MEDICATION: RAMIFICATIONS FOR WEIGHT CHANGE

Weight gain is an adverse side effect of many psychiatric medications and a leading cause of noncompliance in adults taking psychotropics. Psychiatric disorders usually require long-term treatment. Hence, medications that cause weight gain can lead to the serious adverse effects of obesity (Malhi et al., 2001). Little research is available on the ramifications of psychiatric treatment and weight gain in children. However, studies on adults reveal findings that may apply to children.

Psychiatric

ETHICAL DILEMMAS FOR CHILD AND ADOLESCENT PSYCHIATRISTS

Child and adolescent psychiatrists face a range of ethical dilemmas. Some are specific to certain genetic conditions (e.g., Prader-Willi syndrome). Others are more general and pertain to the classification and proper treatment of obesity, which can be especially complicated in cases involving comorbid psychological disorders. Five recent publications address ethical issues and pediatric obesity; two of these (Holland and Wong, 1999; Kodish and Cuttler, 1996) focus on the issues surrounding

FUTURE TRENDS AND RESEARCH GOALS IN UNDERSTANDING AND TREATING CHILD AND ADOLESCENT OBESITY

Targeted research to combat childhood obesity will need to focus on several specific areas. Few empirical data exist regarding prevention. For a comprehensive and extensive prevention literature review, see the Cochrane Review by Campbell et al. (2002). School-based intervention programs have been shown to be ineffective (Story, 1999). Approaches to avoid first episodes of obesity must be developed. High-risk and minority populations need to be oversampled and much earlier interventions need to

CONCLUSION

It has been proposed that we abandon traditional weight-loss goals based on tables in favor of ā€œreasonable weightā€ (Devlin et al., 2000, p. 862). Significant health benefits are associated with modest weight losses that fall short of healthy and aesthetic ideals. Despite the lack of genetic markers or predictors of who will be successful candidates for significant weight-loss maintenance, features to maximize success are known. Obesity will remit in some individuals. Few empirical data exist

NOTE ADDED IN PROOF

In September 2003, the Food and Drug Administration formally requested that the makers of all atypical antipsychotic medications change the ā€œWarningsā€ of the product labeling of antipsychotic medications to include baseline and periodic glucose monitoring. The letter stated, ā€œepidemiological studies suggest an increased risk of treatment emergent hyperglycemia-related adverse events in patients treated with the atypical antipsychoticsā€ (Rosack, 2003).

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  • The authors thank Christine Pace, Avraham Astor, and Sarah Gollust, Bioethics Department, and Erin McClure, Kelly Theim, and Marc Cohen for editorial assistance and medical illustration.

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