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.

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