Obesity and Eating Disorders

Today during my talk as part of the awesome Golda Poretsky’s HAES Masterclass Brittany asked about how we deal with eating disorders and weight.  Our culture has a disturbing tendency to forget that “obesity” is defined as a ratio of weight and height and that eating disorders are a complex combination of physical and mental symptoms.  I recently saw a study that compared brain circuits of obese women with brain circuits of women with anorexia.

This is essentially comparing apples to bowling balls, fat is not the opposite of anorexia nor is it the diagnosis of  an eating disorder. Our cultural tendency to conflate weight and health can be deadly when it comes to eating disorders.   Eating disorders happen to people at all sizes.  Unfortunately when a fat person develops an ED that includes food restriction and/or over-exercising they are often encouraged to continue and even step up the behaviors, even if they can get to the point that they are aware that they are sick and are actively asking for help.  Our society is so convinced that thin by any means  is better than fat, that sometimes I’m a little surprised they don’t just pass out cocaine to all the fat people.

Some eating disorder diagnoses require very specific criteria which includes weight and that has led to a group of diagnoses known as “EDNOS” or Eating Disorder Not Otherwise Specified.  This is important because a fat person who develops an under-eating disorder can die before becoming underweight and so if we assume that someone who is fat can’t suffer from an under-eating disorder then we make a very grave error.

Even professional are susceptible to this mistake.  I have taught dance and movement at a number of eating disorder treatment centers.  At one that worked almost exclusively with patients who were very thin and dealing with undereating disorders.  I happened to come in the day that they got a fat patient, one of the therapists said “I’m glad you’re here, [first name] really needs to exercise.”  I asked her how much exercise she had been doing previous to starting treatment and she responded that she assumed none. I insisted on a work-up.  It turns out that the girl had been overexercising for a long time and, based on her profile, had she not been fat they would have immediately recommended a period without exercise. I’ve also had a Binge Eating Disorder specialist tell me that, in her “vast experience” there was nobody who got to my size without suffering from BED.

We all know the adage that if all you have is a hammer then everything looks like a nail.  We also know that when a healthcare professional sees a problem repeatedly in their patients they can inappropriately extrapolate to everyone who looks like their patients (like when Dr. Oz says that every fat person he operates on has heart problems and tries to say that means that all fat people have heart problems.  Of course in reality one would hope that every person he operates on, fat or thin, has heart problems, otherwise what is he doing cracking their chest? Just like people come to him for heart problems, people come to a BED professional for BED treatment.) But I think this goes deeper.  I think that this is what happens when society tells people incessantly that you can and should make assumptions about what people eat and how much they exercise just by looking at them.

Eating disorders can be deadly so we have to get this right.  Eating disorders happen independent of weight.  There are fat people who have anorexia and bulimia, there are thin people who have binge eating disorder.  There are very fat people who do not have an over eating disorder.  There are very thin people who do not have an under eating disorder.  Calling someone “anorexic” is not a substitute for calling them very thin, and while we’re talking about this how about we just stop talking negatively about other people’s body sizes altogether?

I think that the best thing we can do when it comes to eating disorders, and healthcare in general, is take the focus off of weight and put it on treating people based on what is actually happening – their symptoms and situation. It sure beats a treatment plan based on just making guesses based on body size.

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15 thoughts on “Obesity and Eating Disorders

  1. “I’m a little surprised they don’t just pass out cocaine to all the fat people.”

    In Jr. High, a doctor gave one of my friends a prescription for what is essentially a low-dose version of speed to help her lose weight. Yes. A doctor gave a form of speed to a fourteen year old girl.

    1. This happened a lot when I was in junior high and high school. I guess I wasn’t actually heavy enough for the doctor to consider giving me a prescription for it because I would have gladly taken it. At that stage in my life I would buy diet pills off other people who had prescriptions, more because I wanted the buzz than anything else.

      1. Me too. Back in the 70’s they gave you a prescription drug called Fastin which contained phentermine. I was 16 when the doctor prescribed it for me. It made me very anxious and I hated it. But the doctor insisted that I stick to it so I could become a thin, pretty young girl.

        Finally, I was permitted to go off it when the doctor saw I wasn’t losing any weight. He was quite angry with me said it was my fault because I must be cheating on my diet and obviously didn’t care about myself. Just toxic. I wouldn’t permit that today. But I was only a kid.

    2. Phen-fen was half speed. “Phentermine, a contraction of “phenyl-tertiary-butylamine”, is a psychostimulant drug of the phenethylamine class, with pharmacology similar to amphetamine. It is used medically as an appetite suppressant.” (wikipedia).

      In her great memoir, Elna Baker loses 80 pounds and feels virtuous and happy and meets lots of young men and believes for a while that it’s God helping her…until she goes off the diet pills and then back on, at which point she learns the phentermine was causing both the lack of appetite (which she had attributed to God-given self control) and some of the euphoria.

  2. Wow. It blows my mind that someone who works at an eating disorder treatment facility would make that assumption (in regards to the fat girl that “could use the exercise.” I’m overweight and I am in recovery from a very severe eating disorder that I justified because I wasn’t thin. It is because of health care professionals that knew that eating disorders come in all shapes and sizes that I was able to finally accept that I had an ED and get help.

  3. I mostly eat normally these days. However, I was bulimic for a number of years. I have had periods of anorexic behavior where I ate little or nothing, usually when I was in a state of severe depression. I have also at times engaged in binge eating without purging afterwards. My relationship with food is healthier now (in great part thanks to size acceptance) but it is always a bit precarious.

  4. I have been in recovery from anorexia for a few years. It started because no one thought twice when a girl lost weight her freshman weight. Once I became underweight, people took notice. However, to my surprise, my doctor at the time didn’t take me seriously. She just thought I took dieting too far and she didn’t see a reason for me to get help! She thought that making sure I didn’t lose more weight was good enough.

    Last year I ended up in an eating disorder partial hospitalization after I insisted that, despite being overweight, I needed help. My new doctor didn’t understand, but luckily I convinced my therapist. I hate that I had to convince her though.

    The good part? My therapist there and the other girls in the program understood that behaviors and weight are separate. I don’t know how sick I would be if I hadn’t found a therapist that told me the behaviors and thoughts, not the weight, are what matters. She’s slowly getting my doctor to understand and she has gotten pretty far with my family. It’s too messed up that I had to go through 3 ED therapists before finding one that stood up for what I already knew.

  5. Unfortunately when a fat person develops an ED they are often encouraged to continue and even step up the behaviors…

    This. So much.

    I’ve never been diagnosed with an eating disorder, and body size has certainly been a prime factor in that.

    But I’ve definitely had disordered eating patterns — and I still have disordered food thoughts — and they’ve definitely been almost exclusively restrictive. (Well, and with some compulsive exercise thrown in.)

    Not only have most people — most health care professionals included — never so much as hinted that my restrictive eating could be self-harmful, most of them have verbally exclaimed that such habits were good for me and that I should keep doing them.

    And, you know, I kind of wonder — If some of the reasons these patterns of mind have been so hard to break is because they’ve been so long ingrained and so conscientiously enforced.

  6. “I think that the best thing we can do when it comes to eating disorders, and healthcare in general, is take the focus off of weight and put it on treating people based on what is actually happening – their symptoms and situation.”

    If only this were possible. Unfortunately, the vast majority of health care workers I’ve dealt with simply don’t believe their fat patients. If they believe that everything we say about our weight, eating habits and exercise is a shame based lie, then how can they treat based on reality? If they are generous, and don’t believe we are actively lying, then they believe we have very short memories and MUST be forgetting about 2/3 of the food we eat, or we are unable to judge portion size.

    When I tell doctors I’m hyperthyroid, they never believe me. They assume I’m mistaken, because one can’t be fat and hyper. Its not until they have some actual “proof” that they begin to believe me. And I’ve also had the occasional really stubborn doctor who keeps trying to treat me like I’m hypo even when I’m displaying obvious hyper symptoms. They see fat….and that’s all they see.

    I wish the docs office was like a confessional – where they can’t see us, they are forced to only listen, to actually hear why we are seeing them. What our symptoms are, and the answers to their follow-up questions before actually seeing us so that their assumptions are based foremost on our symptoms rather than their assumptions based on what we look like.

  7. This should be required reading for medical and mental health professionals. When I sought help for my ED I was told by the therapist I was seeing that there was no way I was eating as little as I said I was because I was simply too big for that to be possible. Nevermind the ridiculous amount of weight I lost because I wasn’t eating, but because I was still fat there was just no way I could be anorexic.

    This idea that the only ED a fat person can have is an overeating problem pisses me off so much it often makes me cry. Finding a fat friendly mental health professional sometimes seems like it’s harder than finding a fat friendly medical doctor. Nearly every therapist, psychologist, psychiatrist, and counselor I’ve seen has someone tried to make my mental health issues about my weight, sorry Doc, my weight has nothing to do with my mood disorder. And that post-partum depression, also has nothing to do with my weight, but thanks for ignoring everything I say.

  8. I was lucky enough to find an eating disorder therapist who took me seriously, regardless of my weight. More seriously, actually, than I took it myself. She recognized that my symptoms were incredibly dangerous, even though my weight, at the time, wasn’t.

    I often feel like I have to explain to people that I used to have a restrictive eating disorder in order for them to understand that I do, actually, still have one, even though my weight is normal, and has been overweight and obese. While still having a serious eating disorder. Only by explaining that my weight gain in recovery kicked off a binging weight-gain and then bulimia and restrictive weightloss do many professionals hear me at all. That pisses me off.

    I once had a doctor say to me, when I told her that I’d had eating disorders for 14 years and had been up and down the scale – I was, at that time, near my highest weight – “but you were never REALLY thin, right?” I was blown away. First of all, I’m unable to objective about my weight, and I would never say “yes” to that question. And second – she asked it in a way that implied “you’ve never REALLY been sick, right?” Meaning “this isn’t REALLY serious, right?” She made me feel horrible, because she didn’t take my – medically serious – symptoms and complications seriously, treating me as though I couldn’t possibly have an eating disorder, because, at the time, I was obese. I was also a serious full-blown bulimic.

    Personally, I was sickest, physically and mentally, when I was at my highest weights.

    That, for instance, someone would assume I didn’t exercise because I was overweight pisses me off. That “well, you’re not doing it right, then,” attitude.

    That “well, you’re overweight, so you should do what you can to lose.”

    But I am grateful to have met a few professionals who took me seriously, no matter my weight – based on my symptoms alone. We need more like them

  9. Oh – this made me laugh out loud. Thank you so much for it!

    “like when Dr. Oz says that every fat person he operates on has heart problems and tries to say that means that all fat people have heart problems. Of course in reality one would hope that every person he operates on, fat or thin, has heart problems, otherwise what is he doing cracking their chest? “

  10. “Unfortunately when a fat person develops an ED they are often encouraged to continue and even step up the behaviors”

    This has absolutely been my experience. This creates not only a stigma in the medical industry when it comes to treating people with EDs but also potentially within the person trying to recover.

  11. “Unfortunately when a fat person develops an ED they are often encouraged to continue and even step up the behaviors”

    I think you should clarify that the eating disorders you’re talking about are related to restriction because when I first read this (as someone with a compulsive eating/binge eating disorder) I thought, hu? Are we saying compulsive eating isn’t an eating disorder? It’s a nightmare eating disorder and while not all fat people have it (and not all thin people don’t – I for one had the very worst time with BED when I was at my very lowest weight – I COULD NOT STOP EATING). Overall, I applaud your post and it’s astute observations about hammers and nails and the sh*tty assumptions people make about you when you deviate from their conception of what a person who looks like you does with food or exercise, but I think it’s as harmful to act like anorexia and bulimia are the only eating disorders, as it is to make assumptions about who has them.

    1. Hi Beth,

      My apologies, I thought it would be clear since I covered BED and EDNOS and the fact that you can’t make assumptions about who has an eating disorder in the paragraphs following the one that you quote, but I see how it could be unclear and so I’ve changed the sentence for clarification. Thanks for sharing your thoughts.


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