Fat and Eating Disorders

This painting was gift to me from my Best Friend, Kelrick.
It’s National Eating Disorder Awareness Week, and I wanted to talk a little bit about the ways that our culture screws up when it comes to the discussion of body size and eating disorders, because those screw-ups kill people.

The first is when we see “obesity” compared to “eating disorders” as if they are opposites. Our culture has a disturbing tendency to forget that “obesity” is defined as a ratio of weight and height – essentially just about body size – and that eating disorders are a complex combination of physical and mental symptoms.

I 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 diagnostic criteria for 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.  Parts of our culture are convinced that thin by any means  is better than fat, and that can lead to people dying.

Some eating disorder diagnoses require very specific criteria which includes weight and that has led to a group of diagnoses known as “FED-NEC” or Feeding or Eating Disorders Not Elsewhere Classified [edited thanks to Duckie’s comment below].  This is important because a fat person who develops an eating disorder can die before becoming “underweight” and so if we assume that someone who is fat can’t suffer from an eating disorder then we make a very grave error. Further, thin people can have trouble getting respect and treatment for Binge Eating Disorder, while people can incorrectly  assume that a fat body is – in and of itself- a diagnosis for BED.

Even professionals are susceptible to these mistakes.  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 eating 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.”  I pointed out that her experience of people my size involves them coming to her office for treatment for 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 bulimia and anorexia (or, rather, would, if the diagnosis didn’t include weight), there are thin people who have Binge Eating Disorder.  There are very fat people who do not have an eating disorder.  There are very thin people who do not have an  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 making judgments about other people’s body sizes altogether?

I recently wrote a piece for The Emily Project about how the normalization of fat hate can not only influence the development of eating disorders, but can also prevent any chance of a full recovery.  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, and encouraging people to see their bodies as amazing and worthy of care.


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16 thoughts on “Fat and Eating Disorders

  1. This post resonates with me on a very personal level. My mother is obese and she developed anorexia and bullemia. But because she was obese when she started dropping weight, everyone was telling her how great she looked and how much healthier she must feel.

    it wasn’t until I went to visit her one day and asked if she had been ill because she looked so grey and drawn, and had obviously lost a lot of weight at an unhealthy speed, that people closest to her began to look closer and question what was happening.

  2. I’ve read way too many accounts of thin young women developing eating disorders because they are afraid of getting fat, not because they actually are fat.

    While not an eating disorder per se, we’re also seeing a large percentage of young female smokers who took up cigarettes because they heard smoking helps prevent weight gain. (Yeah, that’s a real healthy alternative!)

    The implied message in our culture is, “Being thin is healthy, and it’s worth killing yourself to achieve!”

    1. In our society, where fat and fat people are so demonized, it’s no wonder people will go to such lengths to not be fat. Our society teaches people that, aside from being a murderer or something horrible like that, fat is about the worst thing you can be. I still remember that poll where most people taking it said they would rather lose an arm or a leg than be fat. …That makes me so sick that people would rather maim themselves to such a horrible extent than to be or become fat.

      As a fat person with a pretty awesome, happy life, that just blows my mind.

  3. fwiw, EDNOS is a DSM-IV diagnosis. DSM-IV is no longer used, It is now Feeding or Eating Disorders Not Elsewhere Classified (FED-NEC) in the DSM5. Also in the DSM5 diagnostic criteria, weight and size is downplayed a bit in the diagnosis of anorexia from what it was in the DSM-IV. Amenorrhea has been removed entirely as a diagnostic criteria….. Here’s a decent rundown: http://www.eatingdisorders.org.au/eating-disorders/what-is-an-eating-disorder/classifying-eating-disorders/dsm-5#anorexia … it’s getting better, but nowhere near perfect.

  4. I am small/average. I have spent years under eating, fixated on what I could and couldn’t eat, and excessively exercising.

    Forever encouraged by others as I looked very fit. People often remarked at how much restraint and willpower I had. I was dying inside. And this fed it.

    Eventually booze became my last resort. The anxiety and distress required for spend my life obsessing over my body and food was too much.

    Looking at me no one would have ever though eating disorder. But it was there.

  5. I recently ended up in the hospital for my ED – which is based in over-restriction and over-exercising. My heart nearly stopped from an electrolyte imbalance. I had lost 100 pounds. But I am still overweight – so none of the doctors (except the one female doctor!) caught on that this might be the possible problem. They all feel it is “mystifying” and looked for congestive heart disease (none) high cholesterol (none) and other issues that aren’t present. You know. Fat person problems that come from all the overeating I am not doing.
    My GP still wants me to lose weight, of course.

    1. That is just maddening. I’m in recovery – have been anorexic, bulimic and a binge-eater. For years I’ve been undereating and using laxatives – but I’ve been gaining weight. Last year started doing exercise classes three times a week. Sometimes my arms get weak (physio says probably a nerve pinch in my neck) and my GP told me several times she thinks it is deconditioning from lack of exercise. Docs just assume if you’re overweight, then you must be sedentary and binge eating. She instructs me to start walking everyday and to count calories and write down my eating.

  6. I’m working on working with people who have eating disorders, mental illness, or as a nutritionist. And I just.. I cannot thank you enough for writing this. When I was trying to explain this to other classmates in school they just weren’t getting it. So I just, I really appreciate seeing this and I hope more people continue to see it too.

  7. Such an important message! These ideas seems to be virtually unknown by the public (and the non-science-based facility mis-serving the girl you met). Science-based and progressive voices such as yours are badly needed.

    I am a member in recovery over at Gwyneth Olwyn’s Youreatopia, and one of the facts Gwyn shares again and again is that 2/3 of those suffering from a restrictive eating disorder will never have an “underweight” bmi; even in their starved states, they will have “normal” or above-“normal” weights.

    Another way Gwyn explains it is by example: For instance, if someone’s genetic set point is bmi 32, she will be just as emaciated at bmi 25 as another person who has a genetic set point of bmi 23 who has dieted down to bmi 17.

    Size isn’t what’s relevant, it’s the very creation of calorie deficits that steals from body, brain, spirit and life itself.

  8. Eating disorders are a mental health issue first and foremost – they often have physical symptoms, but we forget this and diagnose based on the physical presentation vs. what’s really going on in the mind and the behaviors.

    I’ve been 65 pounds heavier and 10 pounds lighter…and I’m broken at every weight. Food issues are like liquid in an opaque bottle – until you open it, you can’t tell if it’s vodka, root beer, or gasoline.

  9. I developed disordered eating at the age of twelve, when I started hating my developing body big time. I have starved myself, binged and purged, binged without purging, over-exercised, and yo-yo dieted.
    I still have an eating disorder. It is a fight every day not to let it win. Sometimes it does. Generally not for as long as it did in the past.

  10. I’ve been anorexic in the sense most people assume…..got very very thin. But now I’m obese from a number of issues, a slow creep over ten or so years. But the eating disorder mentality never left. Yet if I said I had an eating disorder today, most people would say “yeah, you eat too much”.

    Not at all.

    I’m scared to eat because I’m fighting a nasty disease that requires a lot of medications cycled in and out throughout weeks (and now years), and a lot of medications have the same side effect… weight gain. People don’t understand how I can be this size if I’m not eating much. I get tired of explaining and I just tell them illness doesn’t suddenly mean cheek bones. Just ask the guy next to me who keeps having to get pounds and pounds of fluid drained from his body because he has the same disease as I do.

    It’s exhausting.

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