Understanding Obesity and Body Dysmorphic Disorder in Childhood and Adolescence

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1 Understanding Obesity and Body Dysmorphic Disorder in Childhood and Adolescence Dr Wendy Duncan MBBCh(Wits) FCPsych(SA) Cert Child Psych(SA) Senior Specialist Child Psychiatrist Child, Adolescent & Family Unit CharloCe Maxeke Johannesburg Academic Hospital

2 OUTLINE Childhood Obesity Defining overweight and obesity Epidemiology AeQological Factors Psychosocial and Psychiatric Aspects PrevenQon and Treatment

3 DEFINING OVERWEIGHT AND OBESITY Obesity implies a state of excess body fat Commonly assessed using Body Mass Index (BMI); raqo of weight (kg) to height (m 2 ) In children BMI is ploced on growth charts; relaqve to healthy reference populaqon OVERWEIGHT - Between 85 th and 94 th age and gender specific BMI percenqle OBESE - 95 th age and gender specific BMI percenqle; BMI >3 (Barlow & the Expert CommiCee, American Medical AssociaQon, 2007)

4 CDC Growth Charts

5 EPIDEMIOLOGY In 1997 the WHO declared obesity to be a global epidemic Despite this the obesity prevalence in youth has conqnued to rise exponenqally in both industrialized and developing countries Child and adolescent obesity is a strong predictor for adult obesity EsQmated that if secular trends conqnue at current pace; OBESITY PREVALENCE in adults will reach 50% by 2025 (Spruijt- Metz, J Res Adolesc, 2011)

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8 Physical growth and development are sensiqve indicators of the quality of psychosocial, economic and poliqcal environment Obesity is a truly complex disorder Neuro- endocrine disorder arising out of obesogenic environmental factors and a polygenic predisposiqon which act in concert

9 AETIOLOGICAL FACTORS GeneQc factors Environmental factors Psychological and Behavioural Factors Medical concerns

10 GENETIC FACTORS Parental obesity is by far the strongest risk factor for childhood obesity Related to degree of parental obesity and whether both parents are obese This is believe to be strongly geneqcally influenced Influence of intrauterine environment on birth weight is strong Twin studies NB Heritability of BMI is maximal during late childhood and adolescence (Hebebrand, Lewis s Child & Adolesc Psych, 2007)

11 GENETIC FACTORS Both direct and indirect geneqc effects require consideraqon Gene x Gene and Gene x environment interacqon (30%) Macronutrient intake and levels of acqvity are geneqcally determined the geneqc background loads the gun but the environment pulls the trigger (Bray, Physiol & Behav, 2004)

12 GENETIC FACTORS MutaQons in genes LepQn LepQn receptor Prohormone convertase 1 (PC1) ProopiomelanocorQn (POMC) Shown to lead to autosomal recessive forms of obesity MutaQons/polymorphisms in the melanocorqn- 4 receptor gene (MC4R); codominantly inherited form of obesity

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14 ENVIRONMENTAL FACTORS Current environment encourages consumpqon of energy dense, highly palatable food in large porqons Discourages energy expenditure; increased sedentary behaviours The Built Environment Poverty Stress Diathesis

15 ENVIRONMENTAL FACTORS High rates of sedentary acqvity; poor gross motor development Computer use Video- gaming Other small screen recreaqon RelaQonship with TV viewing; five Qmes é in obesity rates for > 5 hours /day TV vs 2 hours Intra- uterine milieu including maternal smoking

16 PSYCHOLOGICAL and BEHAVIOURAL FACTORS Depressive symptoms Anxiety and other emoqonal problems Dietary restraint, radical weight control behaviours EaQng disorder features Perceived parental obesity Parental over- control children s feeding behaviour Inadequate sleep and short sleep cycles

17 MEDICAL CONCERNS MedicaQons Atypical anqpsychoqcs Lithium Valproate Syndromes Prader- Willi Metabolic and Endocrine Hypothyroidism

18 PSYCHIATRIC and PSYCHOSOCIAL ASPECTS Reduced quality of life SQgmaQzaQon Low self- esteem Higher rates of anxiety and mood disorders (in clinical populaqons) Substance Use Disorders Somatoform Disorders

19 PSYCHIATRIC and PSYCHOSOCIAL ASPECTS EaQng Disorders Risk for Bulimia Nervosa Associated with binge eaqng Psychiatric screening for obese children seeking intervenqon is highly perqnent

20 TREATMENT Lifestyle intervenqons Pharmacological intervenqons Surgical IntervenQons

21 PREVENTION Early idenqficaqon Annual calculaqon of BMI Encourage and support breasneeding Promote healthy eaqng pacerns Promote physical acqvity Limit screen Qme Recognise and monitor changes in obesity associated risk factors Advocacy (CommiCee on NutriQon, American Academy of Pediatrics, Pediatrics, 2003)

22 OUTLINE Body Dysmorphic Disorder in Childhood and Adolescence DefiniQon Epidemiology Clinical manifestaqons Management

23 BODY DYSMORPHIC DISORDER A. PreoccupaQon with an imagined defect in appearance. If a slight physical anomaly is present, the person s concern is markedly excessive. B. The preoccupaqon causes clinically significant distress or impairment in social, occupaqonal, or other important areas of funcqoning. C. The preoccupaqon is not becer accounted for by another mental disorder (e.g., dissaqsfacqon with body shape and size in Anorexia Nervosa)

24 BODY DYSMORPHIC DISORDER EPIDEMIOLOGY Limited literature, primarily case reports 10% of recent large cohort were 18 years or younger SubstanQally more females involved (±80%) No significant variaqon in body area preoccupaqon by gender

25 BODY DYSMORPHIC DISORDER Body image is an important aspect of psychological and interpersonal development in adolescents For both genders a number of normaqve challenges influence body image Pubertal development Emerging sexuality IdenQty formaqon The relaqonship between these processes and BDD is unknown

26 CLINICAL MANIFESTATIONS DisQnguished from normal developmental preoccupaqons by the level of clinical distress and funcqonal impact SomeQmes cause self- injury in an acempt to fix perceived flaw Interferes with normal adolescent development

27 CLINICAL MANIFESTATIONS Skin Scars, facial acne Hair Excessive body hair, balding/thinning Stomach Weight Teeth Engage in repeqqve camoflaging behaviour (Phillips et al, Psychiatry Res, 2006)

28 CLINICAL MANIFESTATIONS Poorer insight; complete convicqon Underdeveloped metacogniqve skills (one s awareness regarding the interpretaqon and modificaqon of thinking itself) are hypothesized to mediate this Higher rate of suicide acempts; not necessarily explained by higher rates of depression May be a more severe subset (Phillips et al, Psychiatry Res, 2006)

29 MANAGEMENT Gesng the Diagnosis right EssenQal ground work for treatment CogniQve Behavioural Therapy Pharmacological IntervenQons SSRIs (Phillips & Hollander, Body Image, 2008)