New Inquiries into Eating Disorders and Obesity

 

stethoscope1

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, GiardiaH. 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



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Mice Study Suggests Health Effects from Obesity May Extend to Next …

New research on mice suggests health problems linked to obesity, such as heart disease and diabetes, could skip an entire generation.

Investigators discovered the offspring of obese mothers may be spared health problems linked to obesity, while their own children then inherit them.

This finding is startling as health professionals and policymakers currently focus attention on obesity in the general population, including the emergence of obesity among children.

The University of Edinburgh study has shown that moderately obese mothers can make an impact on the birth weight and diabetes risk of grandchildren, in the apparent absence of effects in their own children.

Experts say that rates of obesity are at an all-time high. Among the associated health problems are breast and colon cancer and stroke. Moderate obesity is a Body Mass Index (BMI) between 30 and 34.9.

Scientists studied moderately obese female mice fed on a diet high in fat and sugar before and during pregnancy. The mice were found to pass on the risks of obesity to the second generation of offspring, while virtually no ill effects were seen in the first generation.

Reasons why the first generation is apparently protected are not fully understood. Researchers suggest that reasons could include differences in maternal weight gain during pregnancy or specific food eaten during pregnancy.

They add that studying effects of this kind – referred to as developmental programming – in humans could be challenging but possible.

Dr. Amanda Drake, Senior Clinical Research Fellow at the University of Edinburgh, said: “Given the worldwide increase in obesity, it is vital that we gain an understanding of how future generations may be affected.

“Future studies could look at these trends in humans but they would need to take into account genetics, environmental, social and cultural factors.”

Source: University of Edinburgh

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Kirstie Allie's yo-yo weight

kirstie alley before and after

Actress and TV host, Kirstie Alley, enjoyed her greatest television success in the 1980s and early 90s but she still hit the headlines for all the wrong reasons in the decades following her career.

In the early days, best remembered as Rebecca Howe in the hit series ‘Cheers’, she was almost a pin-up model. Her striking looks and slim figure were the focus of many viewers’ attention and she was much sought after because of it.

After the ‘Cheers’ days she enjoyed several years playing opposite John Travolta in the popular ‘Look Who’s Talking’ trilogy and further success with three years in ‘Veronica’s Closet’. But in the years following her pinnacle as a TV ‘hottie’ she slipped into an ongoing battle with her weight and the spotlight shifted from her charm and good looks to her increasing dress size.

After her active TV career ended, Alley ballooned and she was plagued by the paparazzi who were quick to publish very unflattering photos of her in the media (yes, just as we have).

 

Kirstie Alley has become like a pair of bellows.  Her weight loss and gain has been well covered by the press

At the time she weighed over 200 lbs (over 90kg) and was declared clinically obese. In 2004 she admitted to battling her severe weight issues by becoming the spokesperson for Jenny Craig, a weight loss and management company.

In 2006, after following the Jenny Craig program for two years, Alley appeared on Oprah Winfrey’s show in a bikini to show off her success and the American public lapped it up. Her achievement was celebrated in the United States and gave hope to a growing nation of obese couch potatoes who were searching for a cure to their own weight issues.

Although painful at the time, Kirstie says that one particularly hideous photo of her in a tabloid publication made her realize it was time to do something about her excessive weight and take better care of her health in the process.

The successful weight loss didn’t last though and after she walked away from the role of spokesperson for Jenny Craig piled on the weight once again.

Kirstie Alley as seen when she first appeared on Cheers

 

During an interview with Oprah she said: ”When you’re a spokesperson for a weight loss company … somebody weighs you every week. It’s pressure but it’s good pressure. I do better if I have some pressure on me,”

When I didn’t have that anymore … I just said, ‘I’m going to cut myself some slack.’ Big mistake.”

She stopped weighing herself and it was almost 18 months before she stepped up onto the plate again. The worst aspect was the guilt she felt, thinking that she let a lot of people down, people who looked up to her and admired her strength of will.

She admits that she has never really had control over her weight but says the best thing that came out of trying to lose weight and battling the bulge was quitting smoking.

Complications with Diabetes Contributed to Brittany Murphy's Death

Brittany Murphy at her healthiest looking

Former actress and drug abuser, Brittany Murphy, was found unresponsive in the shower by her mother who told paramedics that her ailing daughter suffered with Type 2 Diabetes.

Type 2 diabetes, or ‘diabetes mellitus type 2’, is the most common form of diabetes and occurs when the pancreas is unable to produce enough insulin, or when cells in the body ignore the insulin it produces.

Essentially, the body uses insulin to break down the sugar from food and transport it across through the blood system to cells. This conversion of sugar and starches makes glucose which is required for energy.

When the body’s cells do not obtain enough glucose due to a lack insulin production, or when the cells ignore the insulin, it can cause serious consequences. The body’s cells first begin to starve which leads to high levels of glucose in the blood. This can lead to organ damage with kidneys, liver and heart affected most commonly. It can also impair sight and can seriously damage nerves.

Brittany Murphy looking painfully thin. Eating disorders, drug overuse and diabetes contributed to her death.

Anyone suffering with diabetes, just as Brittany Murphy did, stand a much higher risk of suffering from heart attacks or dying as a result of cardiovascular disease.

Whether diabetes played a role in the death of the actress remains unknown for now but questions have been raised about the pressure on actresses to be ‘thin at all costs’ after Brittany’s anorexic struggles. It has been suggested that her eating disorder played a major part in her death.

Other factors mentioned as contributors were her minor heart condition.

Brittany Murphy in Clueless

Despite starring in films such as ‘8 Mile’, ‘Clueless’ and ‘Girl Interrupted’, Brittany Murphy’s substance abuse and eating disorders have been well documented. Clearly she was beset by mental health issues which ultimately led to her demise.

Upon their arrival at her house, paramedics tried to revive her but all attempts failed and she was pronounced dead on arrival at Cedars-Sinai Hospital.

Thandie Newton almost wasted away with bulimia

Thandie Newton

Zambian-born Hollywood star Thandie Newton has always been open about her bulimia. The eating disorder affected her life at the tender age of 14 when she was training to be a ballerina. Her struggle lasted a year and left her scarred both physically and mentally.

I had terrible bulimia for about a year … I ate nothing but cottage cheese. I’ve still got the scars on my knuckles from where I put my fingers down my throat.”

After that year she put it to rest and lived a moderately normal life but it reared its ugly head in her early 20s.

I’d been involved with this guy for a long time, he was much older than me and I felt a lot of shame about my sexual relationship with him.”

I would have these dinners with him and then go back to the flat and I’d throw up. Then I went out with someone who was emotionally abusive, criticizing me the whole time.”

Thandie Newton looking very thin

Thandie Newton looking very thin

After two abusive relationships she realized it was time to seek help; that living with an eating disorder would only lead her to more misery.

While working on a film shoot in Los Angeles she enlisted the help of a therapist.

I saw a therapist for the first time,” she said. “After that first session, I never threw up again. I had made the connection between shame and self abuse.”

This ‘Mission: Impossible II’ actress successfully recovered from bulimia through the initial therapy and then with support and determination. After working herself into super slim looks she fell into a healthy relationship and has developed a love of children.

I keep getting pregnant. So one day I’m slim and the next I have a bump. In the last two years my body has changed so much. I think the Hollywood size is a bad thing. I don’t stick to any diets. I eat when I’m hungry. Thankfully I have my mother’s frame and I’ve always been slim.”

Today, leading a wonderful and healthy life, Thandie is working hard on her films and motherhood and when asked about her self-perception she cheerfully replies: “I see a happy, defiant, loving friend.”

 

Susan Dey's family support helped her through anorexia

Susan Dey overcame anorexia

Susan Dey’s attractive, fresh-faced charm landed her a role in the hit television series ‘The Partridge Family’. With no prior acting experience she took on the role of Laurie, the eldest daughter of the fictional family but with little in the way of guidance at the time she began to develop her eating disorder.

At the height of her illness she weighed a mere 92 pounds and stopped menstruating. Her skin colour became orange because she was reportedly eating nothing but carrots.

Anorexia researchers say that this is a common trend observed in people suffering from eating disorders: they eat exclusively one type of food.

Mono-meals are actually quite a natural thing which harkens back to our foraging days when we would hang around in one place and consume whatever we found – that usually being one thing.

Susan reportedly realized she had a problem during a cast party at the beach when Danny Bonaduce saw her in a bikini and commented, “What’s wrong with you?! Your skin is orange! You look disgusting.”

Susan Dey in the Partridge Family

Susan Dey in the Partridge Family

20 years later, Susan gave an exclusive interview in which she admitted she was still not over her eating disorder.

I’m not in the clear yet – I’m still trying to overcome my anorexia, It’s something that has been plaguing my life.”

Beating a severe eating disorder is something you can not do alone,” she added.

Eventually she did overcome anorexia and now works as a member of the board at UCLA’s ‘Rape Treatment Center’ where she is giving something back to other women suffering personal traumas.

Her TV career earned her critical acclaim and after her four-year stint with ‘The Partridge Family’ she moved onto ‘LA Law’ where she played Grace van Owen, a role that won her a Golden Globe, three statues at the Emmy’s and many other nominations.

Stephanie Pratt flaunted bulimia in front of her mom

Stephanie Pratt in 'The Hills'

Stephanie shot to fame through her role in the hit TV series ‘The Hills’ but during that time she caved in to public opinion and that led to a period of her life struggling with a return of bulimia; an illness she suffered with as a child.

As a young girl her parents were very conservative and she flaunted her problems in front of them without them ever noticing, knowing that there would be little chance of them working things out.

My mom and dad were very hands-on parents. They were never on vacations or anything like that, and I did everything right under their noses — I did drugs, I threw up my food — in the same house as them. And for them to never see that, my mom was just like, ‘What did I do wrong?’ ”

The ‘Hills’ star wanted to share her problems as they are being mirrored in so many young women who live apparently ‘normal’ lives and who are not subject to the pressures of the media limelight.

If she had known the signs of what to look for, I could have been helped a lot earlier,” she said about her mother.

I’m so thankful I got professional help and I’m healthy now, but I just really wanted to do this to help all of those moms to see those signs in their daughters. [Bulimia is] such an ugly, ugly word. I wish I could have danced around it and said I had eating issues, but this isn’t an article for me to shine.”

Stephanie Pratt displaying weight loss

Stephanie Pratt displaying weight loss spared rumours of eating disorders

The rumour mill went into overdrive about her eating disorders after Stephanie, the sister of Spencer Pratt (who is married to Heidi Montag), joined the cast of a reality TV show.

Although not officially confirmed that she suffered a relapse of her bulimia she was quoted as saying at the time: “I can’t believe how huge I look walking over to Lauren.’”

There were indications that she was unhappy with her body and these clues fuelled the fires for plenty of publications to have a field day. She reportedly once said: “It’s embarrassing working with skinny girls.”

After some help from her friends and family she has come to terms with herself and is now living a much healthier lifestyle.

Sally Field became bulimic after joining the Hollywood crew

Sally Field is all smiles after overcoming bulimia

During the early years of her career critically acclaimed actress Sally Field was struggling to live with bulimia. She realises that the illness began in her early 20s and it continued to dog her for a further three years.

The pressure of being around so many slimmer actresses weighted heavy on her mind and that sowed the seeds of her disorder

Everybody then was Twiggy, except me.”

A young Sally Field before her brush with eating disorders

A young Sally Field before her brush with eating disorders

The actress who featured in popular TV show the ‘Flying Nun’ and in the ”Smokey and the Bandit’ films where she starred alongside Burt Reynolds used to binge on balloons and candy during the filming of the popular 1960s show.

She became concerned when she drastically lost weight and the eating disorder converted her healthy body into a fragile one.

I was losing so much bone density that I would have been in grave danger. And I mean grave danger. If I had let it go just a few more years I could have broken my hip or spine just picking up my granddaughter.”

Sally’s battled with bulimia and anorexia didn’t leave her body unharmed and in a candid interview with People magazine she told them: “I would lose 10 or 15 pounds in a week, eating nothing but cucumbers and working all day. My hands would shake all the time, and sometimes I’d pass out. But then I would go on these enormous binges. I lived alone and was very lonely.”

She eventually returned to a normal lifestyle and with it came the realisation that that no-one can judge your body and that to be swayed by the opinion of others is complete counterproductive to a healthy state of mind.

It took me a long time not to judge myself through someone else’s eyes.”

Though Sally, 63, now suffers from osteoporosis, she is on a normal and healthy diet so as to live a happy and fulfilling life.

Anorexic Portia De Rossi almost proud to weigh 82 lbs

Portia De Rossi opens up to Oprah Winfrey about anorexia battle

Portia De Rossi lived on 300 calories per day during the height of her anorexia, a fact she shared with another well documented eating disorder victim, Oprah WInfrey.

A tearful De Rossi admitted that it was almost a proud achievement to weigh in at just 82 lbs.

It wasn’t that I was proud of it,“ she told her host, “But it was certainly a recognition for my self control.“

As part of her purging ritual she would take up to 20 laxatives a day and her sense of personal perspective was seriously derailed by a ‘win or oblivion’ mentality

I would prefer to die than fail another diet.“ Became her clarion call.

De Rossi’s problems began when she left her native Australia for Hollywood and landed a role in US drama ‘Ally McBeal’, starring alongside Calista Flockhart, who was also battling anorexia at the time.

I’ve often wondered if I wasn’t on that show if it (anorexia) may not have happened. I didn’t really know at that point what it was like to be a celebrity, and the only people I knew at the time who had a similar experience were these women whom I worked with. They became my role models.”

Portia De Rossi almost hits her lowest weight of 82lbs

Portia De Rossi almost hits her lowest weight of 82lbs

De Rossi though was fortunate to have help on hand and were it not for the love of her wife, Ellen Degeneres, she fears she would have been consumed by the illness.

The couple were introduced at concert for ‘Rock The Vote’ in March 2001 and De Rossi admitted she was instantly smitten. In that year things had gone awry as she’d been diagnosed with oesteoporosis, cirrhosis of the liver, organ failure and the auto-immune disease lupus.

Ellen has taught me not to care about other people’s opinions,“

She saw a glimpse of my inner being from underneath the flesh and bone, reached in and pulled me out.“

In August 2008 De Rossi married Degeneres, who is 15 years her senior, in a private ceremony in their Beverly Hills home.

Now, with her life on track, she has written a memoir detailing her struggles with anorexia called ‘Unbearable Lightness: A Story of Loss and Gain.’

Paula Abdul battled bulimia for years

Paula Abdul

Famous American dancer, recording artist and American Idol judge, Paula Abdul, admits her life is a perfect learning example to anyone suffering from bulimia. Known for her great dance moves, figure hugging outfits and a string of 80s hits including, “What have you done for me lately?” she enojyed critical acclaim in the public eye but away from the glare, lurking in the shadows she quietly battled against bulimia.

She used to binge eat for short periods before purging however possible, a process which lasted for 17 long years.

Battling bulimia has been like war on my body. Me and my body have been on two separate sides. We’ve never, until recently, been on the same side.”

She says she always saw herself as a little too short and fat, and claims that her eating disorder was a punishment for her body. She was a constant source of disappointment to herself and when eventually speaking openly about it she said, “I learned at a very early age I didn’t fit in physically. I learned through years of rejections from auditions…. I would ask myself, “Why can’t I be tall and skinny like the other dancers?”

Paula Abdul had a torrid time with bulimia

Paula Abdul had a torrid time with bulimia

Years after overcoming bulimia, Paula reflected on those horrendous times: “It became a living hell for me. I wanted to get help. I want to be free from weighing myself on the scales”.

I used to be a fanatic. I used to exercise four or five times a day.

Now it’s different. I don’t exercise too much for the wrong reasons. Three times a week I’ll do some cardiovascular or aerobic activity.”

She sought treatment in 1994 opting to take psychiatric treatment to end the 17 years of ‘living hell’. She spent a solid month in treatment after which she began the slow process of healing.

Always her own harshest critic she reflects on her time in rehab where she had a series of epiphanies: “I thought `God I’m not perfect. I’m going to disappoint people. That’s what I thought.”

But nowadays looking in the mirror is no longer a traumatic affair and her issues about her height and weight are a thing of the past.

I have my moments when I look in the mirror and say, ‘I’m okay.’ I refuse to weigh myself. I don’t have scales in my house”.