Journal of the American Academy of Child & Adolescent Psychiatry
RESEARCH UPDATE REVIEWPsychiatric Aspects of Child and Adolescent Obesity: A Review of the Past 10 Years
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 1999ā2000 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 (1971ā1974)
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 āinfants 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 OāRahilly (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, parentāoffspring, 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 ābecause 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 āreasonable 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 āWarningsā of the product labeling of antipsychotic medications to include baseline and periodic glucose monitoring. The letter stated, āepidemiological studies suggest an increased risk of treatment emergent hyperglycemia-related adverse events in patients treated with the atypical antipsychoticsā (Rosack, 2003).
REFERENCES (138)
- et al.
Assessment of emotional, externally induced and restrained eating behavior in nine to twelve-year-old obese and non-obese children
Behav Res Ther
(1997) - et al.
Mirror image of environmental deprivation: severe childhood obesity of psychosocial origin
Child Abuse Negl
(1989) Obesity and cancer
Metabolism
(1995)Periods of risk in childhood for the development of adult obesitywhat do we need to learn?
J Nutr
(1997)- et al.
Blount disease (tibia vara): another skeletal disorder associated with childhood obesity
J Pediatr
(1982) - et al.
Taste preferences in human obesity: environmental and familial factors
Am J Clin Nutr
(1991) - et al.
Childhood obesity: public health crisis, common sense cure
Lancet
(2002) - et al.
Behavioral therapy in the treatment of pediatric obesity
Pediatr Clin North Am
(2001) - et al.
Teasing, body image, and self-esteem in a clinical sample of obese women
Addict Behav
(1994) - et al.
Adderall, the atypicals, and weight gain
J Am Acad Child Adolesc Psychiatry
(2001)
Integrating the prevention of eating disorders and obesity: feasible or futile?
Prev Med
Topiramate for reversing atypical antipsychotic weight gain
J Am Acad Child Adolesc Psychiatry
Parental neglect during childhood and increased risk of obesity in young adulthood
Lancet
Childhood and adolescent obesity: the neuroendocrinology of childhood obesity
Pediatr Clin North Am
Sleep-associated breathing disorders in morbidly obese children and adolescents
J Pediatr
Reliability testing of a childrens version of the Eating Attitude Test
J Am Acad Child Adolesc Psychiatry
Influence of parents physical activity levels on activity levels of young children
J Pediatr
40-year follow-up of overweight children
Lancet
Three traditional and three new childhood anxiety questionnaires: their reliability and validity in a normal adolescent sample
Behav Res Ther
Sociodemographic and personal characteristics of adolescents engaged in weight loss and weight/muscle gain behaviors: who is doing what?
Prev Med
Psychosocial differences associated with body weight among female adolescents: the importance of body image
J Adolesc Health
Increased incidence of non-insulin-dependent diabetes mellitus among adolescents
J Pediatr
Weight gain associated with olanzapine and risperidone in adolescent patients: a comparative prospective study
J Am Acad Child Adolesc Psychiatry
Neurocognitive deficits in morbidly obese children with obstructive sleep apnea
J Pediatr
Manual for the Child Behavior Checklist/4-18 and 1991 Profile
The Child Behavior Checklist and related forms for assessing behavioral/emotional problems and competencies
Pediatr Rev
Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)
Bupropion SR enhances weight loss: a 48-week double-blind, placebo-controlled trial
Obes Res
The Childrens Eating Behavior Inventory: reliability and validity results
J Pediatr Psychol
Some common issues in the use of antiepileptic drugs
Semin Neurol
Obesity evaluation and treatment: expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services
Pediatrics
A brief motivational intervention to improve dietary adherence in adolescents. The Dietary Intervention Study in Children (DISC) Research Group
Health Educ Res
The Three-Factor Eating Questionnaire in the evaluation of eating behavior in subjects seeking participation in a dietotherapy programme
Ann Nutr Metab
Asthma and obesity in adolescents: is there an association?
J Asthma
Rates of psychiatric disorders in a clinical study group of adolescents with extreme obesity and in obese adolescents ascertained via a population based study
Int J Obes Relat Metab Disord
Body mass index increase of 58% associated with olanzapine
Am J Psychiatry
Associations between body weight, psychiatric disorders and body image in female adolescents
Psychother Psychosom
Possible risk factors in the development of eating disorders in overweight pre-adolescent girls
Int J Obes Relat Metab Disord
Prescription medications: a modifiable contributor to obesity
South Med J
Can the increase in body mass index explain the rising trend in asthma in children?
Thorax
The validity of the eating disorder examination and its subscales
Br J Psychiatry
Visual loss in pseudotumor cerebri
Arch Neurol
Depressive symptoms among obese children
Eat Weight Disord
Weight status, parent reaction, and self-concept in five-year-old girls
Pediatrics
Obesity: what mental health professionals need to know
Am J Psychiatry
Dopaminergic tone and obesity: an insight from prolactinomas treated with bromocriptine
Eur J Endocrinol
Incidence of pseudotumor cerebri: population studies in Iowa and Louisiana
Arch Neurol
Child and parent factors that influence psychological problems in obese children
Int J Eat Disord
The association of maternal psychopathology and family socioeconomic status with psychological problems in obese children
Obes Res
Cited by (226)
Epidemiology, pathophysiology and etiology of obesity in children and adolescents
2020, Current Problems in Pediatric and Adolescent Health CareThe Relationship Between Body Mass Index and Childrenās Mathematics Performance: A Growth Curve Model
2023, Early Childhood Education JournalRacial and Ethnic Disparities in Childhood Growth Trajectories
2022, Journal of Racial and Ethnic Health DisparitiesBariatric Surgery in Adolescents with Obesity: Long-Term Perspectives and Potential Alternatives
2022, Hormone Research in PaediatricsSurviving Body Shaming: An Auto-ethnography of a Malaysian Indian Woman
2022, A Kaleidoscope of Malaysian Indian Womenās Lived Experiences: Gender-Ethnic Intersectionality and Cultural SocialisationEffect of sleep habits on academic performance in schoolchildren age 6 to 12 years: a cross-sectional observation study
2022, Journal of Clinical Sleep Medicine
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.