When Kristin was 12 years old, her primary care doctor took note of the fact that she was obese, and talked to her about healthy eating and exercise. Kristin tried several diets, which failed, and by the time she was 14, her weight shot up to more than 180 pounds.
She began restricting herself to 1,500 calories daily and ran 7 miles every day. In three years, Kristin lost more than 80 pounds, but also experienced dizziness and stopped getting her period. Her mother worried she had developed an eating disorder, and on several occasions, brought her daughter to her primary care doctor, who assured her Kristin's body mass index -- a measure of weight relative to height -- was "appropriate."
By the time Kristin had an eating disorder assessment, she had significant fear of weight gain, restrictive eating, binging, persistent back pain and had experienced multiple stress fractures.
Kristin's is one of two cases described in a new Pediatrics paper, published Monday, that says overweight and obese children and teens who lose weight are at significant risk for developing eating disorders, but their symptoms are often overlooked. It raises questions about the formal criteria used for diagnosing eating disorders, and suggests there may be a significant blind-spot among the doctors who treat children and teens.
"These case studies really represent a phenomenon we're seeing in our clinic more and more," study author Leslie Sim, an eating disorders expert with the Mayo Clinic Children's Center, told HuffPost. "Thirty-five percent of kids who are coming in with anorexia nervosa -- with restricted eating and significant weight loss -- started out in the 'obese' or 'overweight' weight range. And it takes them about a year longer to be identified."
Public health efforts have drawn national attention to the harms associated with childhood obesity, among them; overweight children are more likely to have high blood pressure and cholesterol; are at greater risk of Type 2 diabetes and asthma; and are more likely to be obese as adults. Recent Centers for Disease Control and Prevention estimates found that among preschool-age children, obesity rates are dropping, but in the United States, roughly one-third of children and teens are obese or overweight.
Pediatric eating disorders have not received the same level of public health focus, but they also affect a significant number of children -- at least 6 percent of youth have an eating disorder, according to figures cited in the study. Additionally, more than half of high school girls and 30 percent of high school boys have engaged in disordered eating behaviors, like fasting or taking diet pills, to lose weight.
"We know that if a child is obese, or large, or having any weight challenges that they may end up getting teased, picked on, discriminated against -- the list is long. They're vulnerable, by nature of that, and they may try and diet and possibly engage in unhealthy behaviors," said Lynn Grefe, president and CEO of the National Eating Disorders Association.
She said she was "not the least bit surprised" by the conclusions reached in the new study.
The second case in the study focused on Daniel, who was overweight growing up and who, at age 14, started limiting himself to no more than 600 calories per day while running cross country. Daniel had difficulty concentrating and was irritable; he withdrew socially and experienced physical symptoms that are hallmarks of anorexia, such as cold intolerance and fatigue.
Yet despite those red flags, and the fact that he had lost more than half his body weight, a medical evaluation concluded there was no evidence suggestive of an eating disorder. In the 13 medical encounters that took place while Daniel was losing weight, there was no documented discussion of how or why he shed the pounds.
"The question we have is, when should physicians get concerned? How much weight loss is too much? Where do you say 'stop?'" Sim said, arguing that some doctors rely too heavily on where children fall on healthy weight charts, when they should instead take a more comprehensive look at their weight history, asking them how or why they have shed pounds.
And parents also have a role to play in that, she said.
"If they're [losing weight] by eating 200 calories a day, or vomiting, or skipping meals, that weight loss is not healthy," she said. "We need to be asking 'What are you doing? How did you lose this weight?'"
Correction: An earlier version of this story misspelled Sim's last name.