Department of Plant Biology, Ecology, and Evolution, Oklahoma State University, USA
Received Date: May 04, 2021; Accepted Date: July 28, 2021; Published Date: August 20, 2021
Citation: Benton KA, Fishbein MH (2021) When Worlds Collide: The Relationship of Feeding Disorders and Obesity in Children. J Child Obes. 2021, 6:8:74
Copyright: © 2021 Benton KA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Pediatric feeding disorders include a complex spectrum of eating and nutritional concerns frequently observed in children. Historically, pediatric feeding disorders have been broadly conceptualized and categorized, creating diagnostic confusion and a tendency to oversimplify contributing factors. Recently, Goday and colleagues proposed a comprehensive definition for pediatric feeding disorders as well as a framework for incorporation of psychosocial factors and medical/nutritional components.
Obesity; Metabolic syndrome; Nutrition; Weight gain
Pediatric feeding disorders are defined as “impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction . The inclusion of psychosocial factors is a positive step forward in recognizing the complex interplay of mental, behavioral, social, and environmental factors, even in cases of feeding disorders that are largely due to medical issues. These factors may influence the development of a formal feeding disorder as well as contribute to its continuation. While definitions of feeding disorders have varied over the years, there has been a strong consensus among experts that the “gold standard” approach for evaluation and treatment should be multidisciplinary. Individual facets of pediatric feeding disorders that must be considered include largely gastrointestinal medical conditions, nutritional compromise, and oral motor deficits that would typically be addressed by the gastroenterologist, dietitian, and speech language pathologist respectively . Many multidisciplinary programs also include occupational therapists to evaluate selffeeding and the presence of any sensory issues affecting feeding, and psychologists or other mental health providers for input on psychosocial factors. The new conceptualization for pediatric feeding disorders stipulates that eating disorders such as anorexia nervosa, pica, and rumination should be delineated as separate comorbid conditions. Pediatric obesity, however, is notably overlooked or dismissed as a possible comorbid condition of a pediatric feeding disorder. Revisiting the relationship between feeding disorders and obesity is recommended due to the recent redefinition of pediatric feeding disorders and its implications, and the alarming economic, health, and societal consequences of the obesity epidemic.
Obesity accounts for roughly 186,000 excess deaths per year . The cost in medical care of obesity in the U.S. is $147 billion per year . Annual obesity-related productivity costs are estimated to be between $3.3 billion and $6.38 billion . During the past couple of decades, the obesity rate has risen dramatically. In 1999-2000, 64% of U.S. adults were overweight, a sizable jump from 56% in earlier surveys for 1988-1994. Moreover, 42.4% of adults were obese in 2017-2018, compared to 23% in earlier surveys [6,7]. The prevalence of obesity has also increased in the pediatric population. In children aged 2 through 19 years, 28.8% were overweight during 1999-2000 while 35.1% were overweight in 2015-2016 . There is no single underlying cause or solution for obesity in America: evidence suggests that obesity arises from a combination of genetic and environmental variables . Similarly, there is no single solution to the obesity epidemic . Therefore, it is necessary to understand all possible factors contributing to childhood obesity, including those that may arise from pediatric feeding disorders. Currently, data are sparse regarding the prevalence of obesity in pediatric feeding disorders. Benton et al. reported a prevalence of 5.9 percent in their broadly defined outpatient feeding clinic referral population . None of these obese children possessed deficits in oral motor skills, such as chewing and swallowing difficulties that are typically represented in a feeding disorder population and predispose them to inadequate caloric intake and poor weight gain. Therefore, the remainder of this review will focus on children with picky eating and sensory-based feeding disorder who particularly may be at greatest risk for over nutrition and obesity. Picky eating, also known as neophobia, refers to children who exhibit very strong food preferences, accept only a narrow selection of foods, and show an unwillingness and/or extreme anxiety about trying any new foods. Interestingly, while overall food variety may vary between picky eaters and non-picky eaters, their food preferences do not. Picky eaters typically prefer fries, chicken nuggets, crackers, ice cream, and pizza, while children with typical eating habits prefer many of the same foods (fries, pizza, nuggets) as well as pasta and rice [11,12]. Therefore, it may be the quantity of intake of these foods (versus quality) as the major contributing factor to childhood obesity . The relationship between picky eating and obesity has been explored previously in several studies yet has not yielded robust findings. A recent longitudinal study compared the growth trajectories of children identified with different degrees of picky eating at 3 years of age 14 Children classified as somewhat picky and very picky were not found to be at any higher risk for obesity than the children who were not picky at ages 7 through 17 years. In fact, some of the children who were identified as “very picky” were found to be thin at multiple age points, more so than the non-picky children . Another large study out of Finland found that being a picky eater placed pre-adolescents at higher risk for being underweight but not overweight . These studies seem to negate the concern for picky eating leading to higher risk for obesity, but it is important to consider that many studies have used different definitions and criteria for classification and identification of picky eating. A systematic review of 41 studies conducted by Brown et al. noted large variations in how picky eating and food neophobia were defined . Aside from a trend towards being underweight in some studies, no clear association between obesity and picky eating was determined . While there is a lack of evidence for the association between picky eating and obesity, this is likely due to the variability of children’s characteristics and diagnoses as included in studies. It is possible that some children labelled as picky eaters may carry a higher risk of becoming obese. Based on our experience and available literature, possible at-risk subtypes include 1) those with contributory sensory profiles; 2) those exhibiting maladaptive eating behaviors and patterns; and 3) those with autism spectrum disorder. A combination of these subtypes would enhance obesity risk.
Sensory-based feeding aversions occur widely in pediatric feeding disorders. Sensory integration describes the interrelationship between the individual’s environment and his or her senses. Individuals of all ages rely upon sensory integration to perform routine daily activities including such basic tasks as bathing, dressing, and brushing one’s teeth. Individuals with impairment in sensory integration or sensory processing disorder may demonstrate features of over-responsiveness, under-responsiveness, sensory-seeking, and sensory-avoidant behavior. Expressions of over-responsiveness include distress from light touch and the feeling of agitation from clothing tags or seams. A common example of sensory under-responsiveness is having diminished recognition of touch or temperature change. A common example of sensory seeking is craving sensory input in the form of spinning or deep touch. Sensory avoidance may manifest in behaviors such as covering of ears for loud noises or refusing to walk barefoot on sand or grass. Children with sensory-based feeding aversion tend to eat foods with appealing sensory qualities and avoid foods based upon perceived unfavorable sensory qualities. For example, many children show sensitivities to specific food textures, smells, and tastes, and may even react to the temperatures of different foods . Tactile sensitivity, which includes oral tactile issues, has been found to be strongly associated with picky eating . Children with various sensory aversions may gag and vomit with new foods. They may prefer liquids over solids. Contrarily, children with under-responsiveness, possess less awareness of sensory input, and require more stimulation in order to respond . These children may prefer foods offering higher sensory input, such as crunchy foods, spicy foods, foods with strong odors, and foods that are served at hot or cold temperatures. Both sensory profiles, through distinct and separate mechanisms, may increase risk for obesity. In conjunction, heavy reliance on liquids may also be a pitfall for weight gain, particularly if consuming large quantities of unhealthy beverages . Children with oral sensory sensitivities also tend to avoid lower calorie foods such as fruits and vegetables due to their unfavorable sensation and taste . Lastly, both groups of children may be drawn to high-fat and high-sugar foods that have very pleasing sensory properties . Strong sensory preferences about foods may contribute or lead to maladaptive eating behaviors, particularly if left unheeded. Children with sensory regulation challenges may also develop maladaptive and obesogenic feeding behaviors. Sensory regulation refers to an individual’s ability to monitor and manage states of arousal, emotions, thoughts, and behaviors in ways that support adaptive responses. Self-regulation skills are needed so that one can maintain attention, control our bodies, manage our emotions, and respond to internal cues such as hunger, fatigue, and pain. When self-regulation skills are poor, impact on eating behaviors can include a tendency to eat foods too quickly, overstuffing while eating, and not recognizing cues for satiety . In a study of 7-12 year-olds conducted by Webber et al., children who exhibited appetitive tendencies such as eating for emotional reasons, eating very quickly, and having a high desire to drink liquids were more likely to be overweight or obese . These findings suggest a possible connection between eating behaviors and emotion regulation in children, although more research is needed to extrapolate on these findings. In a recent study conducted by Hebert, food intake and sensory sensitivity were examined in adult women . They found that women with high sensory sensitivity displayed higher rates of eating in response to both emotional and external food cues, suggesting that being highly reactive to sensory input may be related to a tendency to regulate emotions differently and/or to use different strategies to respond to emotions (e.g., over-eating). Similarly, in another study, adult women with high sensitivity ate more offered chocolate than their counterparts with low sensitivity . Thus, underlying appetite traits may increase the risk for over-eating, especially in individuals who have sensory issues, difficulties with self-regulation and/or picky eating habits. Children diagnosed with autism spectrum disorders demonstrate food neophobia and selectivity at high rates, and this population also has a high rate of obesity . Individuals with autism who are at highest risk for becoming overweight and obese are those with autism severity in the moderate to severe range [27,28]. Some of the contributory factors to the high percentage of obesity in children with autism include lifestyle variables such as tendency to spend more time in sedentary activities and less time doing physical activity, and the increased likelihood of being prescribed medications that cause weight gain [29-36]. Picky eating is also extremely common in children with autism. Many foods preferred by children with autism are pre-packaged, sugary and salty snack foods, and other highly processed foods [37-39]. These calorically-dense foods may hold appeal as their sensory properties are very consistent, and the packaging may be visually reassuring to children with autism who may not easily trust foods that are less familiar. An additional risk factor for children with autism is that they are described as having a strong appetite by their parents whereas many non-autistic children with picky eating display a poor appetite, making them less likely to become overweight [40,41] .
Lastly, it is important to consider the frequent use of food as a reward/incentive in certain treatment protocols for children with autism. Using food as a reward during therapies provides an iatrogenic pathway by which obesity risk becomes heightened for children who may already be predisposed. Applied behavioral analysis (ABA) therapy, has been heavily researched and found to be one of the most effective treatment strategies for children with autism. It involves use of immediate rewards to reinforce behaviors that approach a target skill. Children practice these skills repeatedly until they master them. Some children receive as many as 40 hours a week of ABA therapy. Food rewards are common, but caution should be used sparingly and paired with other non-food rewards in order to avoid over-reliance . Use of food rewards disrupts the normal process of recognizing hunger and satiety cues, and they encourage a child to eat at non-mealtimes. Additionally, many of the foods that serve as rewards are high-calorie, high-sugar and foods dense in carbohydrates . With repeated exposure to these types of foods, children will quickly develop a taste for them and begin to regard them as highly desirable. It has been demonstrated that children, when given the opportunity, will overeat foods that have been used as a reward in the past population [44,45].
In summary, research to date has not shown a strong and/ or consistent link between picky eating and pediatric obesity. However, studies have varied considerably in how they have defined and studied picky eating. For some children, picky eating appears to serve as a protective factor, making them less likely to become obese. However, there may be additional subsets of children and/or risk factors that may increase the likelihood that picky eating will lead to weight gain. Children who exhibit strong sensory preferences about food choices may be at higher risk (preferring crunchy foods, foods with high salt and sugar content, fried foods, and highly processed foods). There is also growing evidence that a desire to drink large amounts of liquids may also be a risk factor, depending on the caloric content of preferred drinks. Children who are picky and who also exhibit tendencies such as eating very rapidly, showing less awareness of satiety cues, and an increased tendency to eat for emotional reasons may also be high-risk. Lastly, picky eating in children with autism represents a very important subgroup of children who should be closely followed as they are likely to represent a “perfect storm” when it comes to their risk level for obesity. In addition to a tendency towards a strong appetite, preference for high-calorie foods, sedentary life-style, maladaptive behaviors and sensory processing challenges, many of these children are also exposed to therapies that use foods as a treatment strategy and medications that predispose to weight gain.