Last week, there was some media coverage of a new study, published in Pediatrics (the journal of the American Academy of Pediatrics), that highlights the concurrence between obesity/overweight and eating disorders. The study sheds light on the fact that a significant number of young people who seek clinical treatment for eating disorders come from a history of overweight or obesity. At the Mayo Clinic Children’s Center, where Dr. Leslie Sim, one of the authors of the study, works, 45% of adolescents seen for ED treatment in the last year came from a history of obesity. The study makes a case for recognition of obesity as a common precedent to disordered behaviors. It also illuminates the very tendency of primary care providers to overlook symptoms of disordered eating in people with history of obesity. It highlights two case studies: a fourteen-year-old boy and an eighteen-year-old girl whose eating disorders were misdiagnosed in large part because they had previously been obese.
As I read this article, I felt an enormous sense of disappointment at the way both obesity and eating disorder treatment are failing young people in this country. Because our emphasis is on weight loss at all costs (rather than the fostering of healthy habits), obese adolescents often transition directly into anorexia, bulimia, binge-eating, and EDNOS. At least half of the men and women I know who have struggled with eating disorders were overweight or obese growing up, so it comes as no surprise that what I’ve observed is borne out in the 45% statistic. Still other individuals who have shared their stories with me say that the eating disorder began when they were advised to lose weight by a health care provider or school nurse. In their dutiful attempts to obey that mandate, they quickly turned to extreme forms of restrictive eating or exercise.
Sim, Lebow, and Billings’ study details the history of a fourteen-year-old boy who had lost over 87 pounds. Possessed of a significantly higher than average BMI through childhood, he’d begun dieting at the age of 12, first by eliminating sweets, fats, and carbohydrates, and ultimately resorting to eating 600 calories per day. He developed hallmark symptoms of an eating disorder: difficulty concentrating, low moods, bloating, constipation, social withdrawal, fatigue, and intolerance to cold. His health care providers tested him for a number of GI disorders (celiac sprue, Giardia, H. pylori), and thyroid abnormalities. In spite of the fact that he began to show heart irregularities and dehydration, eating disorders weren’t suggested.
The study states,
In spite of having lost over half of his body weight, the medical documentation associated with the evaluation stated, ‘there is no element to suggest that he has an eating disorder at this particular time.’ At the request of his mother, however, Daniel was referred for an ED evaluation. Of note, Daniel’s weight was a focus of discussion at all medical appointments throughout his childhood. However, during the 13 medical encounters that took place when he was losing weight, there was no discussion of concerns regarding weight loss.
Italics are mine.
The next case study is equally disturbing. An eighteen year old girl was sent to an ED evaluation because she was demonstrating extreme fear of weight gain, amenorrhea, intolerance to cold, stress fractures, excessive exercise, food restriction, and binge eating. She, too, came from a history of obesity. She had begun dieting at the age of fourteen, ultimately going from 97th percentile for weight to the 10th percentile in only three years. After the first year of her weight loss, she developed amenorrhea, but the suggested explanations were PCOS or her long distance running, and she was put on birth control pills. She was referred to a dietitian after her stress fractures developed. The dietitian didn’t suggest ED treatment or express concern over her severely low fat diet, even when the girl’s mother suggested that she might have an ED. According to the study, the girl’s physician noted, “‘given that her BMI is currently appropriate, it is reasonable to do a trial off the birth control pill and see if her menses resume.’”
Italics are mine again.
In our green recovery discussions, we have often touched on how flawed BMI is as a marker of health. The USA Today coverage of the new study discusses this problem. It notes that many of the people who need ED treatment aren’t immediately identified as being at risk because they aren’t underweight:
It’s a “new, high-risk population that is under-recognized,” says Hagman, medical director of the eating disorders program at Children’s Hospital Colorado, who was not involved in the new report.
The kids she sees in this condition “are just as ill in terms of how they are thinking” as they are in terms of physical ailments, she says. “They come in with the same fear of fat, drive for thinness, and excessive exercise drive as kids who would typically have met an anorexia nervosa diagnosis. But because they are at or a even a little bit above their normal body weight, no one thinks about that.”
These cases are no surprise, says Lynn Grefe, president of the National Eating Disorders Association. “Our field has been saying that the more we’re pushing the anti-obesity message, the more we’re pushing kids into eating disorders” by focusing on size or weight instead of health and wellness.
Medicine is not a perfect science. BMI can help physicians to quickly identify someone who is very overweight or underweight, but like any diagnostic tool, it has limitations. One way to circumvent these limitations is to use multiple diagnostic criteria when it comes to complex conditions like EDs. Weight may be telling, but it doesn’t tell the whole story. Listening to a patient’s symptoms, history, and habits is equally, if not more, crucial. It’s time for treatment providers to stop equating eating disorders with the state of being underweight. People who are not underweight by the books can have eating disorders, and–as one of my commenters noted–people who are underweight don’t necessarily have them.
What struck me most about this study was the bias it unearthed. It is the idea that there are two types of people– people who have been overweight, and people who are, or could become, restrictive– and that those two types of people are not and cannot be one in the same. This is the bias that leads a primary care physician to miss overwhelmingly evident ED symptoms in a kid who used to be obese. It is the bias that, left uncorrected, may allow countless adolescents and adults who are in need of care to go unnoticed.
US News and World Report interviewed Dr. David Katz as a part of its coverage. Katz is the Editor-in-Chief of the journal Childhood Obesity, President-Elect of the American College of Lifestyle Medicine, founder and President of the non-profit Turn the Tide Foundation, and the founding director of Yale University’s Prevention Research Center. He has devoted much of his career to combating childhood obesity through education about healthy eating and a comprehensive approach to patient care. He echoed the dangers of treating obesity and disordered eating as mutually exclusive phenomena, and underscored the fact that there is quite a bit of fluidity between them:
“First, obesity itself is a risk factor for eating disorders,” Katz said. “This link is well established for binge-eating disorder, where obesity is potentially both cause and effect…Second, while weight loss in the context of obesity may appear beneficial, there is a point at which the methods used — or the extremes reached — may indicate an eating disorder,” Katz said.
“Effective treatment of obesity cannot simply be about weight loss — it must be about the pursuit of health,” Katz said. “An emphasis on healthful behaviors is a tonic against both obesity and eating disorders. By placing an emphasis on diet and activity patterns for health and by focusing on strategies that are family based, we can address risk factors for both eating disorders and obesity.”
Just as weight restoration alone cannot remedy anorexia, neither is weight loss, in and of itself, an adequate treatment for obesity. In both cases, changes in weight should be accompanied by an emphasis on the importance of nourishing foods and an attempt to foster lasting, positive body image.
✵ ✵ ✵
Between the ages of eight and ten, right after my parents’ divorce and during a turbulent moment in my childhood, I gained some weight. My pediatrician remarked on it during an annual checkup when I was eleven–he wasn’t overly worried, he said, but a diet might help me get back to a more “appropriate” weight for my frame. He left it at that, and I took matters into my own hands. This was that summer that I discovered rules and restriction. It was the summer I realized that I could make my body “behave” itself. It was also the year that my weight took its first major plunge, and the roller coaster in and out of my ED began.
In bringing up my own story, I don’t mean to draw a direct or easy comparison between what I remember and what the two individuals profiled in the study experienced. Nor am I putting all of the blame on my physician, because he was acting in good faith, and there were many, many factors involved with my ED. But I couldn’t help but feel a sense of recognition as I read, an empathy that having comes from having once felt as if someone–someone who was supposed to be taking care of my health–had given me the message that I ought to reject my body. While I recognize the seriousness of childhood obesity, and support all healthful measures undertaken to treat and prevent it, I believe that the onus is upon health care practitioners to do so in a way that will encourage children to embrace their bodies, rather than renounce them. I’m hopeful that it can be done.
As always, I’d love to hear your thoughts on the study, which can be found here (Sim LA, Lebow J, Billings M. Eating disorders in adolescents with a history of obesity. Pediatrics. 2013 Sep 9. [Epub ahead of print]).
In the meantime, I wish you a happy Sunday, and a great start to the week ahead.
xo
October 11th, 2013 at 5:11 am
I am slightly confused on the denial part where you say “that this may be a real problem or may have serious consequences down the road.” Do you consider it denial if someone is overweight or obese (by the BMI chart), is weight-stable, has good health measures, exercises and eats a mostly healthful diet? Or are you specifically referring to someone a little higher on the Edmonton Obesity Scale by this? That would be more in line with my understanding of your general message, but it’s not clear to me here.
I guess I feel a little touchy on this one, because this smacks of the “Vague Future Health Threat” a lot of people get hit with by their doctors and pretty much all of society the instant they get above BMI 25.0. Any argument that says “really, I’m healthy,” is countered with the idea that we’re in denial.
October 11th, 2013 at 7:29 am
You hit the nail on the head every single time. This blog is full of win. Thank you!
October 11th, 2013 at 7:33 am
EC – if your weight is not really a problem then this is not a question of denial – after all there is nothing to deny. But, let us be honest, the vast majority of people with excess weight do have a problem – people who don’t, make up a rather small healthy minority of fat people. If this is where you belong, good for you.
October 11th, 2013 at 7:57 am
I’ve gotten a lot of response to a section in my book where I write about how going on a diet takes a person through stages of struggling with a sense of control.
You pick a day to start a new diet and make a plan. The planning gets you all motivated and excited.
At first, you stick to the plan very specifically and it makes you feel proud of yourself. You have a sense you’re “doing something” to solve a problem and you’re being good at it.
The diet plan imposes changes on your regular routine and lifestyle that are difficult to maintain so little by little, it starts to break down. The breakdown usually begins with a temptation to eat something off the diet plan so you bargain with yourself that you’ve “been good” up to this point so you deserve a treat and it’s OK.
The diet plan becomes more difficult to maintain over time so the bargaining gets bigger. You fall off the diet one day so you consider that day a total loss, you might as well eat whatever you want. You do it because you bargain with yourself to be back “on” the diet tomorrow.
Eventually you consider the diet a complete failure. You bargain with yourself to be “off” the diet and decide it’s over. You eat whatever you want in an “off” a diet manner until the day that you decide you will start your new diet. You feel OK about what you’re eating as long as you stick to the terms of the bargain you make with yourself.
You start the cycle over again.
People have written to me that they do this all the time and they realize they’ve used up months and years of their lives living like this. I know I did.
October 11th, 2013 at 7:58 am
I would like to share a little correction to your premise, based on my limited time as a lay chaplain. These are the Kubler-Ross stages of death. They are what people go through from diagnosis to final chapter of life as they confront their own mortality (and, as you rightly point out, the order is not set — though bargaining is usually listed before depression). The stages of death are frequently confused with stages of grief, and often misapplied, especially in early grief. The first stage of grief — when one learns that someone dear has died — is chaos. The grieving person may bounce back and forth from feeling numb to feeling profound sadness to feeling uncharacteristic emotions. Often friends see the numb stage or an uncharacteristic emotion and inform the poor griever that he or she is in denial and must move on. This is unhelpful. It makes the grieving person feel guilty for something that is natural.
October 11th, 2013 at 8:35 am
This is awesome Dr Sharma. Thank you for putting this together. As a Dietitian I see people battling with their weights all the time and some days I struggle to help them. I use the stages of change, but this is excellent. Thank you.
October 11th, 2013 at 8:39 am
I wrote this a couple of years ago and your article reminded me of it:
The Many Layered Cake of Obesity
1. The bottom layer is the pain that started it all. Whatever drove us to seek comfort, solace, numbness in food, over and over again. Most of this probably started very early in our lives and was not our fault.
2. The next layer contains the real physical effects of being obese: diabetes, cholesterol, heart disease, fatigue, joint deterioration, etc.
3. The next layer contains the self-loathing that we cannot control this thing that eats at us.
4. Another layer is all the unkind judgmental things that others have said to us, well intentioned or not.
5. …all the times and ways that others have tried to “help” or “fix” us by controlling us.
6. …all the misinformation and unhelpful advice that we have received directly or indirectly.
7. …the isolation we seek in order to avoid being hurt again.
8. …all our other needs, wishes and desires that cannot be fulfilled because of our obesity and/or others’ attitudes.
October 11th, 2013 at 8:42 am
I’m with EC. I am super healthy and fit but with a BMI over 30. So am I in denial? No, actually bargaining, most of the time and sometimes acceptance. But EC is right, there is a constant pushback to doctors that the BMI does not mean I have any illness which I am denying.
But I am curious about your comment about numbers, Dr. Sharma. What is the percentage of EOSS 0 or 1 in the population of people who have BMI’s over 30? Are we a tiny minority or are we sizable enough to warrant attention to what genetic factors drive our ability to be fit, strong and fat?
October 11th, 2013 at 8:55 am
Pierrette I live with these steps everyday.We have “been there,done that”.When we talk to others that are still in denial we no longer try to convince them.
Until they reach the other factors, we are talking for nothing.
I know of “no” people that are obese and exercise regularly and eat properly.
Those that say they do are full of it and are in real strong denial.
People that are obese simply eat all the time because they are always hungry.I know.I did also.
When I changed my lifestyle and realised that I can eat healthy foods and be totally satisfied, then and only then did I really join “my fight” to become healthy.
My wife is 62 and I am 61 and we are both in the best health of our lives…..Wow
Pierre Pierrette Trudel
October 11th, 2013 at 9:14 am
Melinda: The exact numbers based on NHANES III for population with BMI 30 to 35 is Stage 0 = 8%, Stage 1 = 19%. For BMI greater than 40, the numbers are Stage 0 = 5% Stage 1 = 14%
October 11th, 2013 at 9:15 am
Linda: The Layered-Cake of Obesity – interesting idea!
October 11th, 2013 at 9:20 am
DebraSY: You make an important point – all of these stages are “natural” and even “healthy” as part of the process. Thus, for e.g., although it sounds negative, “denial” is a very healthy initial response, so is “depression”. The problem is when people get stuck in one of the other stage or fail to eventually progress to acceptance. The notion of thinking of this as a staged process (not always linear) is for the professional to recognise where your patient is at and counsel appropriately. As I said, trying to talk someone, who is in the denial stage into addressing the problem will only create defensiveness.
October 11th, 2013 at 9:23 am
Dagny – you perfectly describe someone stuck in the bargaining stage. This person has not yet fully accepted that changes have to lifelong and that the expectations have to be realistic. I know hundreds of people (probably most people trying to lose weight), who are stuck in the bargaining stage and never make it to full acceptance.
October 11th, 2013 at 9:46 am
This is so much like a blog post I made on 11/13/12…great minds, you know
http://thesurvivalofthefattest.blogspot.com/2012/11/the-five-stages-of-accepting-myself-as_13.html
October 11th, 2013 at 9:49 am
As usual, I find myself offering a contrary voice. I believe from experience, that these stages are better understood as interwoven threads. Rather than experiencing them one at a time, a person who is gaining weight cycles through them often on a moment by moment basis. All the threads exist in the same time and space but the person is more focused on one or the other. This is not nearly as true for grief, but it is true for weight management. What this means for a qualified and caring CBT is that you are not required to wait for the client to transition into acceptance, you can help the client shift focus and change perspective. You can help the client find motivation, strength and purpose. We are complicated and powerful. Within each one of us, at every single moment,lives the potential to simply make another choice.
October 11th, 2013 at 10:22 am
Elina – you are bang on that these stages are interwoven (which is why I chose the image of the ribbon for the illustration). I also agree all all these stages can co-exist from minute to minute, from day to day. A skilled CBT counsellor will recognise this and provide the necessary support.
October 11th, 2013 at 10:25 am
Pierre: you no of NO ONE who is obese and exercising regularly and eating properly? All obese people are “full of it” and “in real strong denial”? Wow, that’s harsh. Is Diana Nyad in denial? What about 75% of the Kansas City Chiefs (my team) or, for that matter, 75% of other people’s football teams. What about Oprah (also proof positive that no amount of accountability and resources can assure permanent weight-loss maintenance). What about Janet Cook, the first person to swim the Berring Straight? There are also many non-famous obese people who quietly exercise and eat well with no fanfare. I knew quite a few when I belonged to the YMCA.
Please reconsider your judgments. Weight bias hurts people.
October 11th, 2013 at 10:47 am
I don’t deal with weight because of “pain that started it all.” I don’t allow people to treat me like I am some weak, broken emotional wreck or to label me in that way. Some of us can have bodies that manage energy very efficiently and brains that want to think about food and connect it to everything in our lives. Fighting that to manage your weight in an intensely obesogenic environment is VERY DIFFICULT. Even if you think certain situations triggered certain habits, the struggle with weight itself becomes the difficulty.
We have to get rid of this paradigm that says every fat person is a screwed up mess of emotional issues and “pain that started it all.”
Food is its own driver.
Weight is its own stressor.
Fighting to control your body and mind is immensely difficult and can feel endless
October 11th, 2013 at 11:41 am
Dagny, well said. Thank you!
October 11th, 2013 at 5:31 pm
Very wise words. So how can one move on to that stage of acceptance, or help a client or loved one to do so? I find myself cycling between denial, depression and bargaining–and would love to be able to move to acceptance, so I can fix my weight and my life.
October 11th, 2013 at 5:37 pm
Sharon – that’s a great question. I am not a counsellor but there are many who read this – they may wish to chip in with some advice.
October 11th, 2013 at 7:56 pm
This is at Sharon- You might just not be done cycling yet. Acceptance often comes when all the other possible versions of reality have been exhausted. When you get tired of running in circles and the reward of one more bite does not seem worth it. When the payoff from the denial and the depression and the bargaining no longer works for you. When that times comes, find a great CBT counselor, come in with a willing heart and and an open mind. Walk in to work, do not expect to be fixed, but rather to be empowered to fix yourself. When that day comes, your counselor will help you open the door and you will have found acceptance.
October 12th, 2013 at 7:49 am
Pierre’s comment is exactly why I brought up the “denial” issue, because this is the kind of thing I hear over and over. Thank you, Debra and Dagny, for pointing out the flaws in assuming that every fat person is an emotional wreck, or a lazy glutton, or “in denial” — an attitude I find frustrating and insulting.
While the numbers of obese in EOS 0 or 1 are small, it is still enough that it’s not a total anomaly. I would guess that for people in overweight BMI (where I am — high side of it), those numbers are a bit higher. It needs to be addressed instead of doctors having the knee-jerk reaction of prescribing intentional weight loss to everyone above BMI 25, even if those folks are healthy and weight-stable with good enough habits.
October 12th, 2013 at 8:38 am
You go Dagny!
If we aren’t being judged as being lazy and deceitful (Pierre), we are judged as being broken emotional wrecks with childhoods laden with abuse.
The reality is our bodies are hyper efficient and in some of our cases, due to external drivers to be thin, we engaged in behaviours, like yo-yo dieting, that made our bodies even more efficient.
However, thin friends of mine face some of the same labels – if you are skinny, you must be anorexic with an unaccepted history of abuse.
How about we agree that we can be healthy people whose genetics and body morphs are different from someone else’s.
If we are struggling with mental illness that impacts our physical health, then focus on that and not make stereotypical judgements.
October 12th, 2013 at 8:39 am
Dr. Sharma, I have bounced back and forth through all of these stages, spending lots of time in denial. It took a lot of work with an addictions counsellor to get me to the stage in which I was willing to go to any lengths to get healthy again. I am on the waitlist for surgery in BC and have been for 4 1/2 years. I don’t have a date yet but I have reason to believe I will have one soon. I appreciate that you recognize that it is sometime a battle to get what we need to get healthy. Thank you for all the work you do on our behalf.