Eating Disorders in Adolescents With a History of Obesity

Case 1

Daniel is a 14-year-old boy who presented to an ED evaluation with a 2-year history of significant weight loss (39.5 kg) that developed in the context of a history of obesity. Daniel reached his highest BMI of 33.6 when he was 12 years old. At that time, Daniel weighed 40 kg above the 50th percentile for BMI-for-age for boys. Throughout development, Daniel’s BMI had always trended well above his same age and gender peers and appeared to be moving steadily upward from the 90th percentile at age 3 to well beyond the 97th percentile. (See Fig 1 for weight history.)

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FIGURE 1

BMI history for case 1.

Daniel’s weight-loss efforts began with attempts to eat healthily and exercise but quickly developed into severe restriction: he reported eating no more than 600 kcal per day while running high school cross country. He eliminated sweets, fats, and carbohydrates from meals and would only eat “diet food.” Daniel also exhibited many physical and emotional sequelae of low weight including difficulties concentrating, worsening mood and irritability, extreme social withdrawal, as well as cold intolerance, significant fatigue, bloating, and constipation. Similar to many individuals with AN, Daniel had little insight into the seriousness of his problem.

Daniel’s weight loss came to the attention of his medical providers in the context of a pediatric gastroenterology evaluation for concerns regarding constipation, bloating, and intermittent postprandial chest pain. Results of the gastroenterology evaluation, including screening for celiac sprue, Giardia, and Helicobacterpylori, a hydrogen breath test, thyroid testing, and a brain MRI, were unremarkable. However, Daniel exhibited marked sinus bradycardia, and laboratory results were consistent with significant dehydration. In spite of having lost over half of his body weight, the medical documentation associated with the evaluation stated, “there is no element to suggest that he has an eating disorder at this particular time.” At the request of his mother, however, Daniel was referred for an ED evaluation. Of note, Daniel’s weight was a focus of discussion at all medical appointments throughout his childhood. However, during the 13 medical encounters that took place when he was losing weight, there was no discussion of concerns regarding weight loss.(See Fig 1 for weight history.)

Case 2

Kristin is an 18-year-old girl who presented to an ED evaluation for significant fear of weight gain, restrictive eating, excessive exercise, and binge-eating. At the time of the evaluation, Kristin was experiencing physical sequelae of low weight and poor nutritional status, including secondary amenorrhea, cold intolerance, and fatigue. She also had developed persistent back pain and stress fractures.

Kristin’s weight loss also began in the context of obesity. When she was 12 years old, her obesity was identified and addressed by her primary care physician (PCP) through a review of healthy eating and exercise habits. Consequently, Kristin attempted several diets with little success. At age 14, she reached her highest weight of 85 kg, corresponding to a BMI of 32. At this time, Kristin committed to a dietary regimen of 1500 kcal per day and began running 7 miles per day. Within 3 years, she lost 38 kg, going from beyond the 97th percentile to the 10th percentile. (See Fig 2 for weight history.)

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FIGURE 2

BMI history for case 2.

After the first year of her weight loss, she presented to a physical examination with secondary amenorrhea, dizziness, and orthostatic intolerance. At that appointment, her provider recommended that Kristin drink more water and prescribed oral contraceptives for Kristin’s amenorrhea. One year later, after losing an additional 18 kg, she returned for follow-up with continued orthostatic symptoms. Although her mother expressed concerns about Kristin’s restrictive eating and minimal dietary fat intake, these concerns were overlooked. At her next visit 6 months later, Kristin again presented with amenorrhea. Her PCP then recommended an evaluation for polycystic ovary syndrome, which Kristin declined. Documentation associated with the visit stated that it was likely that her amenorrhea was related to her running regimen.

Six months later, Kristin developed severe right distal shin pain and was referred to a sports medicine physician, who remarked on her weight loss, amenorrhea, stress fractures, and binge-eating and expressed concerns that she had developed the female athlete triad. Consequently, she was referred for a sports nutritional consultation. The dietitian expressed no concerns regarding her minimal dietary fat intake or significant weight loss and instead recommended that she maintain her current weight and eating pattern. Around the same time, Kristin presented to her PCP for a general medical evaluation. In spite of her mother’s concern that she may have an ED, her PCP documented, “given that her BMI is currently appropriate, it is reasonable to do a trial off the birth control pill and see if her menses resume.”