Damian Sendler: With their high rates of occurrence and detrimental effects on a child’s physical health as well as their mental well-being, childhood obesity, eating disorders, and other unhealthy eating habits are major public health concerns. We present evidence that the same interventions can be used in pediatrics to treat or prevent obesity and eating disorders. Obesity in children increases the likelihood of developing eating disorders because of the prevalence of disordered eating habits. Bulimia nervosa and binge-eating disorders, both of which are characterized by abnormal eating or weight-control behaviors, are the most common in obese individuals. Numerous underlying mechanisms, both environmental and personal, underlie the interaction, and numerous strategies exist to minimize its negative effects. Treatments for childhood obesity and eating disorders that are based on scientific evidence include weight loss through nutritional management and lifestyle modification through behavioral psychotherapy, as well as treatment of psychiatric comorbidities that are not the result of the eating disorder. Drugs and bariatric surgery should only be used when necessary. Research is needed to identify risk factors for prevention, better understand the mechanisms that underpin these issues, and provide timely treatment in cases where it is necessary. Efforts to reduce disparities in health and improve public health necessitate collaboration between different fields.
Damian Jacob Sendler: With a global population of more than 100 million [1], childhood and adolescent obesity, eating disorders (EDs), and unhealthy eating habits are major public health concerns. Despite the fact that obesity and eating disorders (EDs) have traditionally been treated as distinct conditions, new research shows that they share many similarities, including etiology, comorbidity, risk factors, and prevention methods [2]. EDs may be facilitated by environmental and social factors, such as weight-related teasing by family members or peers, thin beauty ideal perceptions by the social environment or media [3]. Occurring additional EDs in the presence of obesity could worsen current health status and future outcomes [4]. Starting with the definitions, common pathogenesis, and possible treatment outcomes, we outline the rationale for the awareness and recognition of risk factors that increase the vulnerability of obese adolescents to eating disorders. EDs and obesity can be managed or prevented using the same interventions in childhood.
Dr. Sendler: There is ample evidence that obesity affects people of all sexes, all ages, and every region and ethnicity in the world. Body mass index (BMI) is a simple way to estimate body fat indirectly (BMI). Overweight is defined as a body mass index (BMI) score of 85 or higher, while obesity is defined as a BMI score of 95 or higher [5]. [6] The World Health Organization (WHO) has recommended the use of the BMI z-score to define overweight and obesity, respectively. [6] Since the 1990s, there has been a dramatic rise in the number of overweight and obese children around the world. Children and youth between the ages of 5 and 19 years old accounted for 124 million of these obese children and youth in 2016, while 41 million children under the age of 5 were overweight or obese [1]. Obesity in children is more common in developed countries, but it is also on the rise there [1]. The long-term health consequences of obesity, such as an increased risk of chronic disease, should be given more attention. Immediate and long-term effects on mental and emotional well-being, such as low self-esteem and depression, are also possible.
Environmental, behavioral, genetic, and metabolic factors all play a role in the development of obesity [7]. As a result of this complex interaction, a chronic disease with a wide range of symptoms and phenotypes is formed. As a result, management and treatment responses can be difficult [8]. The rise in obesity worldwide is largely due to environmental and behavioral factors. Obesity has been linked to changes in the child’s environment, including the availability of high-calorie fast food, larger portion sizes, increased consumption of sugar-sweetened beverages (SSBs), and a sedentary lifestyle [9].
Dietary habits are a well-known contributor to obesity, with numerous studies supporting this theory. Obesity has been linked to eating habits as early as infancy, according to research. At the age of three, the prevalence of obesity among children of mothers who did not smoke or gain excessive weight during pregnancy was only 6 percent, compared to 29 percent among children of mothers who did the opposite of these four mother/child behaviors, according to an observational study by Gillman et al [10]. Obesity is caused in large part by a person’s eating habits and the food that they consume. It’s important to mention “discretionary food,” which is a significant factor in childhood obesity, when discussing diet. SSBs with a high sugar content are a typical example of this type of food. SSB consumption was linked to an increase in BMI z-scores in a birth cohort studied from the ages of 2 to 17 [12].
Physical activity is essential in addition to a healthy diet. Sedentary behavior among children and adolescents has increased as a result of technological advancements. Time spent in front of a screen includes watching television, using a computer, playing video games, and talking on a cell phone. Even in infancy, screen time has become the most common form of sedentary behavior. The amount of time spent in front of a screen can have a negative impact on a child’s physical and mental health [14]. Numerous studies [15] have documented the negative effects of excessive screen time on physical strength, obesity, and sleep disturbances. In children and adolescents, sleep disturbance is often overlooked as a risk factor for high blood pressure. Poor sleep can be caused by a lack of parental education, a lack of enforcement of rules about caffeine, and the presence of electronics in the child’s bedroom at night. There should also be consideration given to the presence of socioeconomic hardship, family dysfunction, offspring anxiety, and junk food, in addition to the previously mentioned well-known factors [17].
There has been a great deal of investigation into how genes play a role in obesity. Obesity can be genetically influenced by environmental factors, but the likelihood of gaining weight varies among individuals [18]. It is common for multiple genes to make small contributions to the overall phenotype in the majority of cases of obesity. Genetic predisposition to obesity, when considered in conjunction with one’s lifestyle and the environment, may have an impact on one’s ability to maintain a healthy weight. Monogenic obesity, on the other hand, is relatively uncommon, accounting for only 3 to 5 percent of all obese children [18]. The most common gene defect associated with severe, early obesity in children is a mutation in the melanocortin 4 receptor gene (MC4 R) [19].
The link between obesity and adverse childhood experiences (ACEs) has gotten more attention in recent years. Children with higher levels of intrafamilial adversity [20] were found to be more likely to be overweight in a recent study. Meta-analysis of 41 studies looking at the link between child maltreatment and obesity supports these findings [21]. ACE is now recognized as a potentially modifiable obesity risk factor.
A wide range of maladaptive cognitions and behaviors relating to eating and weight are covered by both EDs and disordered eating behaviors, but they differ in their diagnosis [22]. Disorders characterized by abnormal eating or weight-control behaviors are referred to as eating disorders [23]. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) lists anorexia, bulimia, and binge-eating disorder (BE) as specific EDs. [24] If you’re concerned about your health, psychosocial functioning and quality of life, it’s important to know that the prevalence of eating disorders varies depending on study populations and the criteria used to define them [25, 26]. Adolescence is the most common time for EDs to appear, but they can affect children as young as 5 to 12 years old [27]. It is possible that recognizing EDs may help prevent obesity or aid weight loss in cases of long-term obesity. Obesity-related eating disorders can develop in children and adolescents before or after weight-loss surgery or other weight-loss programs.
In an effort to identify possible risk factors for EDs, researchers have tested a wide range of environmental and genetic factors. Childhood sexual abuse has been linked to BN and appearance-related teasing victimization for any ED by an umbrella review of published meta-analyses, which included 50 associations from nine meta-analyses. Due to the small number of large-scale collaborative longitudinal studies examining the relationship between conditions preceding ED onset and their development, there were no ED risk factors with convincing evidence [34].
Food insecurity, characterized by limited or uncertain access to nutrient-dense food in a safe and socially acceptable manner, is now a factor to consider. There is increasing evidence that food insecurity is associated with the adult bulimic spectrum. Adults across the United States were surveyed and found to be in agreement. Diagnoses of bulimic-spectrum disorders, mood disorders, and anxiety disorders were more common among people who had experienced food insecurity over the course of a year than among those who had not. The study found that bulimic-spectrum eating disorders had the greatest impact [35]. In light of these findings, it’s possible that pediatric patients should be considered. In order to better understand this issue, more research is needed.
Because there is a lack of both prospective studies and possible selection bias in clinical samples, it is difficult to determine whether ACEs are a risk factor for developing eating disorders. In the studies that are currently available, there are a lot of discrepancies. According to a population-based research, experiences of life events are linked to specific eating behaviors in children aged 10 years. Emotional overeating is linked to adverse life events [37,38], according to these findings.
Damian Sendler
Disordered eating behaviors are more common in children who are obese, which raises their risk of developing eating disorders (EDs). BN and BE are the most common EDs in obese individuals, both of which are characterized by abnormal eating or weight-control behaviors [39,40]. Binge eating disorder (BED) and binge-eating disorder (BN) are both characterized by recurrent episodes of BE in which the sufferer loses control over the amount of food consumed. For BED, attempts to avoid weight gain through inappropriate compensatory behaviors such as self-inducing vomiting are distinct from those of BN [40,41].
EDs and obesity may share some common risk factors in the context of certain social and environmental factors. Family and peer teasing, perceived social pressure, and frequent criticism or bullying are among the most common forms of bullying. [43] Body dissatisfaction can be exacerbated by images on television or social media that emphasize the ideals of thinness and beauty [44,45]. Additionally, a number of other factors can be linked to family BE behaviors like parental mood, anxiety or substance abuse, as well as family discord, high parental demands or perfectionism, and parental separation, which have been identified as possible causes of obesity and EDs. Negative childhood experiences (including sexual and physical abuse) also raise the stakes [46], as do past life traumas.
For obesity, the strongest known susceptibility locus is the FTO gene [47,48,49]. The role of FTO variants in obesity is not fully understood, but they have been linked to several EDs, including binge eating disorder (BED). There is evidence that the FTO gene plays a role in the development of BED and poor behavioral regulation [50]. By controlling appetite and satiety pathways, as well as the regulation of brain reward systems, genetic factors have a significant impact on the regulation of neural circuits. Genes linked to the hypothalamic appetite and satiety mechanisms may be involved in the emergence of EDs associated with obesity like BED and BN, according to some SNP studies [51].
When it comes to EDs and obesity, the brain plays a critical role in basic research, prevention, and treatment [56]. Neuropsychological mechanisms of EDs and obesity were previously unknown. hedonic hotspots in the brain, specific subregions that can increase the hedonic effect of palatable tastes causally, are one type of mesocorticolimbic mechanism that increases “liking.” However, a larger mesocorticolimbic circuit generates the desire to “want” or “induce” to obtain and eat food rewards [57].
Damian Jacob Markiewicz Sendler: Reward-related regions, including ventral and dorsal striatum, amygdala, orbitofrontal cortex and dopamine release in the dorsal striatum in humans as well as other animals [58], are activated by eating palatable food. Obesity and eating disorders (EDs) like anorexia nervosa and binge eating disorder have been linked to brain abnormalities and neural fragility factors by functional, molecular, and genetic neuroimaging [58]. Having a better understanding of the mechanisms of desire and linkage that are unique to each type of ED and obesity could lead to better treatment strategies and help those who wish to more effectively create stop signals to their own needs.
Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which is a critical part of the neuroendocrine system that regulates eating behavior, has been linked to EDs [61,62].
Damian Jacob Sendler
Inhibitory executive function of serotonin on eating behavior is also known [63]. The noradrenergic system and EDs have been examined in a number of studies. EDs and the noradrenergic system: a recent systematic review uncovered a slew of important findings. Noradrenergic system involvement in various endocrine networks that control human nutrition is not limited to its direct, hypothalamus-based actions on feeding regulation [64]. Neurotransmitter dopamine regulates food’s enticing properties [65]. Neuropeptide Y is a hunger-inducing hormone that also slows down metabolism [66]. Inducing a feeling of satiety is a key role of Leptin’s inhibitory executive function in regulating appetite. Hormone ghrelin is produced in the stomach and upper small intestine, and it stimulates the appetite. When it comes to weight loss, the hormones leptin and ghrelin play a significant role. Anorexia nervosa and BN have been linked to hormones and related executive functions, despite the fact that obesity is commonly associated with these disorders [67,68].
In the case of childhood obesity and EDs, evidence-based treatments include weight loss through nutritional management and lifestyle modification through behavioral psychotherapy as the first line of attack [27]. ED risk profiles may improve or remain unchanged in the majority of children and adolescents receiving supervised obesity treatment [72]. Increased rates of early dropout from the intervention program have been linked to higher baseline dietary restraint scores in obese children, regardless of gender, age, and BMI z-score at baseline, and the education level of the mother [73]. A secondary analysis of an RCT focused on changes in energy intake and diet quality during obesity treatment with post-treatment eating pathology in adolescents found no correlation between intensity of diet and EDs [74].. Dietary restriction and dieting are not linked to an increased risk of erectile dysfunction (ED) in the short term, according to a systematic review [75].
In the fight against childhood obesity, the majority of organizations recommend either weight maintenance or loss as a treatment objective. Adolescents who are overweight or obese can benefit from lifestyle intervention programs that take a multifaceted approach to nutrition and eating habits. Experiencing weight-related teasing as a child or adolescent can lead to emotional eating, which can impede long-term weight loss maintenance [76]. There were significant differences in weight status even when programs aimed at treating shared risk factors resulted in little difference in body dissatisfaction, dieting and weight-control behaviors [22].
Damien Sendler: Cognitive behavioral therapy (CBT) focuses on reshaping negative patterns of behavior that creep into day-to-day life and on altering the attitudes and behaviors that underlie mental health issues. One of the most promising treatments for eating disorders and obesity is cognitive behavioral therapy (CBT). In cases where family-based multicomponent behavioral weight loss treatment (FBT) has failed or cannot be used, CBT may be considered as a backup option [77,78].
Weight loss is more likely to occur with multi-component interventions. FBT is recommended as a treatment option for children with obesity and eating disorders [79]. An intervention aimed at improving the health of families may be more effective than an effort aimed at improving the health of adolescents [27]. After four months of FBT and an additional eight months of weight maintenance, researchers found that the weight loss that occurred as a result of both FBT and maintenance was not influenced by any concurrent physiopathology or eating disorders [80].
Patients may benefit from regular counseling to keep them motivated to lose weight [81]. Motivating the patient to explore and plan the necessary changes is the focus of motivational interviewing (MI), which avoids stigmatizing language about weight that could negatively impact a teen and lead to BE, decreased physical activity, social isolation, avoidance of health care services, and increased weight gain [27]. The use of MI techniques to improve patient-provider communication has been shown to result in positive behavioral changes [5].
Even though a better approach to preventing and treating obesity in children and adolescents is always being sought, current population-based interventions and traditional medical care have failed to produce the desired results. This demonstrates the need for new approaches to the fight against obesity. “Personalized Approach in Obesity Management” is an example of a long-term, family-based, multi-professional weight management program in Estonia. Real goals for the child’s lifestyle change were selected using the LINE chair Visual Analogue Scale (VAS—1–10 points) in a motivational interview method [82]. Only 14% of children and only 9% of parents felt that their children’s health was comparable to that of healthy children, as reported by the children themselves. The indicator of children’s physical and emotional health (90–92 percent of respondents) was found to be the most frequently disturbed. According to the EU Joint Action on Nutrition and Physical Activity (JANPA), the project’s results can be seen as an example of best practice in Estonia.
Few studies have examined the impact of bariatric surgery on the symptoms of disordered eating. When 19 obese adolescents underwent a reversible bariatric procedure, improvements in emotional and behavioral factors were observed [89]. Adolescents who underwent bariatric surgery had better weight loss and disordered eating symptoms one year later, according to a sub-study of the Teen-LABS Consortium [90], than those who only underwent lifestyle changes. Following Roux-en-Y gastric bypass surgery, adolescents in the Adolescent Morbid Obesity Surgery (AMOS) study had a median improvement in BE and uncontrolled eating after five years of follow-up [91]. It has been found that emotional eating decreased and cognitive restraint increased over the course of five years following surgery, as well. Higher scores for BE and emotional eating at Lang 2 years and 5 years, and for uncontrolled eating at 2 years after surgery, were also significantly associated with smaller percentage changes in BMI at 5 years relative to baseline.. Adolescents who have undergone bariatric surgery do not seem to benefit from it in terms of their eating habits, which suggests the necessity of a multidisciplinary team for long-term health support following the procedure [91].
As obesity and EDs continue to rise, there is a need to better understand and identify risk factors that increase vulnerability. Pediatricians are in a unique position to identify and disrupt the progression of disease at an early stage. Despite numerous studies showing a connection between obesity and poor mental health in children and adolescents, little attention is paid to the mental health consequences. Risk factors for both obesity and eating disorders should be identified as an important focus for an intervention designed to simultaneously address these two issues. Obesity and erectile dysfunction (ED) are serious health concerns for children and adolescents, and more research is needed to identify risk factors early and prevent the onset of these problems, better understand the underlying mechanisms, and, finally, provide effective treatment for those who need it. Efforts to reduce disparities in health and improve public health necessitate collaboration between different fields.