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.