Who Among the Obese has an Eating Disorder?

The last post was a call for the community of eating disorder clinicians to recognize that all people with eating disorders, irrespective of weight, deserve adequate treatment. One specific point to help circumvent the bias was to create a clear interview process to distinguish between obesity and eating disorders. When the data says that up to 60% of Americans are overweight, obesity becomes a public health problem more than a disease. And so it's critical to know who among the overweight do and don't have eating disorders in order to provide the best treatment plan for each person.

Weight is an important marker in eating disorder treatment, but it also has clear limitations. For Anorexia Nervosa, following a patient's weight helps track progress during refeeding and helps prevent relapse. Similarly, someone who is overweight with Binge Eating Disorder needs weight followed to manage meal planning and possible medical consequences. However, there are just as many complicated cases in which weight is less useful. A patient with chronic food restriction over many years who attempts to eat may gain more weight than expected due to drastically slowed metabolism. Longstanding malnutrition or laxative abuse can impair the body's ability to manage fluid and result in 10-20 pounds of swelling just from retained water. Some people with Bulimia Nervosa always maintain normal weight yet remain severely ill for many years. Weight may be useful but only in conjunction with the person's full life story.
What lures young people into eating disorder symptoms and what captures the attention of the media are the dramatic cases. Photos of extremely emaciated girls and lurid stories of self-destructive eating episodes with rapid, large weight fluctuations draw a wide audience and simultaneously reinforce the notion that eating disorders are first and foremost based on weight. And society at large truly believes that if someone is at a normal weight, they must not have an eating disorder. The public has completely misunderstood what these illnesses are about.
Once the genetic predisposition, personality structure and life experiences have started an eating disorder, the outward manifestation of distorted eating behaviors and weight changes reveal only the surface of the illness beneath. What truly separates disordered eating from an eating disorder is the psychological torment. The obsession with food and meals combined with constant assessment of body shape and weight are relentless, yet even part of this reaction is a physiological response to chronic starvation that is cured by normalizing eating. For the person with an eating disorder, the failure to eat according to strict rules and to maintain the body shape demanded by the illness trumps all else. The thought process goes as follows: by failing to do exactly what the eating disorder laws dictate, you are a horrible person who deserves nothing and whose life is worthless. This personal philosophy feels immutable, like an unquestionable truth, and is not ameliorated by normal eating. By taking even a moment to imagine life under this edict, one can hardly compare the emotional pain of such internal punishment to the number on a scale.
Differentiating obesity from an eating disorder is conceptually clearer when weight is only a physical manifestation rather than the central component of the problem. Many people who are overweight or obese struggle psychologically with weight but don't have any semblance of the internal torture of an eating disorder. These people represent the majority of people who comprise the core of the growing public health problem of obesity, but they don't have eating disorders.
By understanding that the central experience of an eating disorder is psychological, a clinician can tailor the interview process accordingly. The goal isn't solely to assess food and weight because then the majority of the population would be sick. Instead, uncovering the punitive thought process will reveal the difference between obesity and an eating disorder and help ensure that those who need eating disorder treatment can get it.
Psychiatry, from a public health perspective, is likely to have a role in curbing the obesity epidemic. Without any direction, it's not clear how society will curtail the problem. Food is a powerful mediator of emotions, and with so much food at our fingertips, the pull to eat for emotional calming is often too strong to withstand. Sometimes it feels like society is even writing off the current generation of the overweight to fix the problem only in the future. The next post will address the role of psychiatry in the public health realm of obesity.


The Anti-Obesity Prejudice of the Eating Disorder World

The anti-obesity bias in the first world is undeniable and unchallenged. The obese have to weather ridicule and discrimination both in the workplace and in their personal life without any recourse to fight back. The causes of the obesity epidemic, when viewed objectively, are not personal: an excessive amount of available, processed food and a sedentary lifestyle combined with the genetic predisposition to facile energy storage. Still, the default world view of the overweight is that they are lazy and slothful.

Due to the overwhelming bias against the obese, people prefer to believe that being overweight is a choice. Much to the layperson's dismay, eating disorders are diseases of physiology as much as psychology. The emotional and psychological ways to use food to numb feelings and to cope with seemingly unmanageable problems in life are well-documented. But in order to become ill, these people also need to have certain physiological adaptations to hunger and fullness. Without the genetic ability to adapt to chronic starvation or chronic overeating, two sides of the same coin, all the exposure to food obsession and thin models won't trigger an eating disorder. The grand experiment combining the world of plenty with the desire for thinness created the epidemic in the first place. After forty years, we're now living with the results: a population that tries to starve while surrounded by limitless, delectable food will develop chronic food problems, and those at risk will develop eating disorders, including obesity.
To believe that we all have sound judgment about food and weight is no longer a given. The desperate longing to be thin led to an alternate sensibility which rewards any method used to successfully attain a desirable weight, and that includes eating disorders. It even includes ranking these illnesses in a hierarchy of preference. Anorexia Nervosa remains atop the heap. Despite the gruesome photos and sad stories of this lethal illness, the media and culture can't help but glorify Anorexia as the grand solution to our collective focus on weight. For a person to live on only a few hundred calories per day mystifies the masses bent on finding the magic diet. In fact, the primary medical intervention for the overweight is to create a similar state of starvation, either through a crash diet or Bariatric surgery, with no long term proven success. In reality, Anorexia is a mental and physical prison, but the world continues to believe otherwise. Bulimia Nervosa is a notch down in the ranking but remains more socially acceptable, especially if it is a successful means to lose weight. Any binging disorder, especially one that leads to significant weight gain, is regarded by society as a lack of willpower, not an illness. And the obese don't even make it on the list. The general consensus is that they just need to stop eating.
A bigger disappointment is that the eating disorder community has largely followed suit. Even though some clinicians are starting to treat overweight people with eating disorders more equitably, the prejudice remains strong. The mental prison in which a patient with Anorexia or Bulimia lives is no less evident in the obese person with Binge Eating Disorder, Compulsive Overeating or Bulimia Nervosa. However, the clinical community continues to focus on underweight people with eating disorders. A quick search for residential treatment programs or day treatment programs makes the bias obvious. Obese people will get into a treatment program but they're not truly wanted. Even the current diagnostic classification system leaves the catch-all diagnosis of Eating Disorder Not-Otherwise-Specified as the only option for the obese. As of now, there is no available treatment for the overweight.
It's time for the clinical community to recognize that societal prejudice has altered the direction of diagnosis and treatment. Just as with underweight patients, the overweight with eating disorders struggle with psychological and emotional symptoms and endure a wide range of medical effects from their disease. Moreover, these patients have the same genetic predisposition to an eating disorder, experience the same type of triggering external circumstances, benefit from the same kind of therapy and work through the same stages of recovery. The difference of weight is exclusively based on the person's innate physiology. This means the clinical community excludes a population of sick patients from treatment based solely on their body's response to an illness. Clearly, this is unacceptable. 
The eating disorder community can take a few simple steps to change this pattern. First, expand the available diagnoses to eliminate the weight bias. Second, create a clear clinical interview process to identify eating disorders in the overweight, one that enables clinicians to bypass their internal bias. Last, expose this discrimination to the community by emphasizing the behavioral and psychological symptoms of eating disorders over the focus on weight. A few small steps will open the door to treat all people with eating disorders.