January 2019 #obsm chat blog: Disordered Eating
by Alexis Conason
When we think about eating disorders, we tend to think about a specific group of people--typically thin, young, white, cisgendered women. However, research indicates that people at higher weights are at increased risk for eating disorders, and concerningly, their symptoms typically go undiagnosed or worse, may even be encouraged by friends, family, and medical professionals. This is especially true when the disordered eating behaviors are accompanied by weight loss. Eating disorders in higher weight individuals are often not diagnosed until the disorder is more severe, resulting in poorer treatment outcomes.
When we do talk about eating disorders and disordered eating in higher weight individuals, we tend to focus on behaviors that are associated with weight gain, such as binge eating, loss of control eating, and grazing (especially following bariatric surgery). Less attention is paid to eating disorders and disordered eating behaviors that are associated with weight loss, such as atypical anorexia, purging disorders, restrictive eating, and compulsive exercise. Perhaps this is because the latter are often perceived to be “healthy” since they are associated with weight loss.
Despite the stereotypes of what someone with an eating disorder looks like, there is growing recognition that eating disorders and disordered eating impact people across the weight spectrum. In fact, most people affected by eating disorders do not have a BMI in the “underweight” category, and higher BMIs are actually associated with an increased risk of eating disorders and disordered eating. It is likely that weight stigma plays a large role in this association. The widespread discrimination and stigmatization of people living in larger bodies leads to a pressure to lose weight (and maintain that weight loss) at any cost, even if that means engaging in disordered eating behaviors. Weight bias in the medical system leads to underdiagnoses and perpetuation of eating disordered behaviors when weight loss is universally praised without inquiry into what behaviors a patient is engaging in to obtain that weight loss. Praise for weight loss from friends, family, and even virtual strangers as well as alleviation of discrimination (i.e. being able to fit into public spaces, being able to shop at “straight sized” clothing stores, generally being treated with more respect, etc.) are more ways that weight bias may encourage eating disordered behaviors.
Eating pathology in higher weight individuals includes binge eating disorder, binge-purge disorders (including bulimia nervosa), restrictive eating disorders (including atypical anorexia nervosa), and other types of disordered eating such as chronic patterns of dieting/restrictive eating and overeating, chewing and spitting, grazing, loss of control eating, problematic emotional eating, and/or preoccupation with weight and shape. Atypical anorexia is one of the most overlooked eating disorders in higher weight individuals. Anorexia nervosa (AN) is characterized by restriction of food intake leading to weight loss or a failure to gain weight resulting in a "significantly low body weight;” a fear of becoming fat or of gaining weight; and a distorted view of themselves and of their condition. Atypical anorexia applies when all of these criteria have been met with the exception of “a significantly low body weight.”
A 2017 study by Gianini et al observed that people who have lost at least 30 lbs and maintained the weight loss for at least 1 year exhibit strikingly similar eating behaviors as people diagnosed with chronic anorexia nervosa. In a 2015 study by Lebow et al, 36% of patients seeking treatment for a restrictive eating disorder, such as anorexia nervosa, had a history of a BMI above the 85th percentile. Research suggests that individuals with atypical AN may experience more severe symptoms than those with typical AN. A study by Sawyer et al. (2016) found that, when compared with those with typical AN, adolescents diagnosed with atypical AN experienced more severe eating disorder symptoms and lower self-esteem. They also presented for treatment having lost more weight over a longer period of time than those with typical AN. Medical and psychological complications of atypical AN are similar to typical AN, except atypical AN is associated with more severe distress related to eating and body image.
The focus of this #OBSM Twitter chat will be on the full spectrum of eating disorders and disordered eating in higher weight individuals, including the role of weight bias in the onset, maintenance, and treatment of eating disorders and disordered eating in this population. We will consider the following questions:
1. What are some strategies to identify eating disorders and disordered eating in higher weight individuals?
2. What role does weight stigma play in perpetuating and encouraging a disordered relationship with food?
3. How does weight bias inhibit the ability to identify disordered eating or eating disorders in people at higher weights?
4. How can providers create a safe environment for people of all sizes when treating eating disorders and disordered eating?
5. What are some ways that patients at higher weights who are struggling with an eating disorder or disordered eating can advocate for themselves in medical settings when faced with weight bias?
6. How can providers and patients best support individuals at higher weights who are struggling with eating disorders or disordered eating behaviors?