Undiagnosed eating disorders: another danger of our false assumptions about fit, fat, and food

Image description: This is a color photo of a round white dinner plate with one green pea in the very centre of it. There is a silver fork to the left of the plate and a silver knife to the right. The background is plain off-white.

If you’re like most people, when you think of eating disorders images of extremely thin, maybe even skeletal, young (and probably white) women come to mind. Recently there’s been more attention paid to other demographics that might not be as easy to spot. We’ve talked about eating disorders among older women and men.

But there is another group among whom eating disorders go unnoticed: people who are viewed as overweight or fat. This oversight is not only a result of our default mental images connected with eating disorders. More pernicious than that, it stems from our cultural preoccupation with thinness and the idea that it’s normal — even recommended — for “fat” people to be dieting.

According to Alexis Conason’s article, “The Hidden Faces of Eating Disorders: Why People at Higher Weights Go Undiagnosed,”

A recent study (Lipson & Sonneville, 2017) examined 9713 students from 12 different colleges and found that body weight was the most consistent predictor of eating disorder symptoms. Students with a BMI in the “overweight” or “obese” range were at the highest risk and students with a BMI in the “underweight” range were surprisingly at the lowest risk. A history of elevated body weight is common in patients seeking eating disorder treatment. A 2015 study by Lebow et al. examined patients seeking treatment for restrictive eating disorders, such as anorexia nervosa, and found that over 36 percent of patients had a history of BMI above the 85th percentile. And disturbingly, symptoms in these patients are often not diagnosed until later and more severe stages of the illness. A 2013 article by Sim et al. that I wrote about in an earlier post found that eating disorder symptoms in adolescents with a weight history in the “overweight” or “obese” range not only were under-diagnosed, but symptoms were actually encouraged by medical professionals who congratulated these patients for losing weight.

Even medical professionals don’t think of overweight people who are severely restricting their food intake as having an eating disorder. We are so culturally obsessed with the idea of thinness as a body ideal that food restriction and extreme dieting are considered praiseworthy, enviable skills to be mastered. People are not recognized to be in peril unless they are dangerously thin.

When people are rewarded and admired for not eating, particularly when they’re viewed as “needing to lose a few,” no one (themselves included) will think they’re suffering from an eating disorder. I was diagnosed with anorexia by two different professionals when I was a graduate student and I didn’t believe them because I didn’t think I was thin enough to “qualify.” If someone doesn’t recognize themselves as fitting the mold, then it’s difficult for them to take in messages about dangers and prevention.

Eating disorder prevention and intervention efforts are often targeted at people in the “underweight” range while people categorized as “overweight” or “obese” are targeted for weight loss interventions. Fat people are told to diet, even though dieting is one of the strongest predictors for both development of eating disorders and weight gain. Isn’t it time we stopped prescribing behaviors to people at higher weights that are diagnosed as eating disorder symptoms in people at lower weights? Food restriction, purging food (either through laxative use, self-induced vomiting, or exercising to compensate for calories consumed), viewing foods as “good” or “bad,” and defining our self-worth based on the numbers on the scale are unhealthy at any weight. We need to recognize these symptoms as what they are—signs of an eating disorder—even when the person who is engaging in them lives in a fat body.

So if you didn’t think there were enough ways in which our assumptions about food and fat and fitness can be harmful to people who are perceived to be carrying extra pounds, here’s another to add to the list. Fat-shaming and the idea that fat people are supposed to be doing things to lose eight, and that dieting is one of those things, is a harmful camouflage that allows disordered eating to go undetected.

9 thoughts on “Undiagnosed eating disorders: another danger of our false assumptions about fit, fat, and food

  1. Great article. I was an obese child and the pressure from medical professionals to lose weight definitely contributed my decade long struggle with anorexia/bulimia. I had a doctor say to me when I was eleven “you’re fat, your mom is fat, you’ll always be fat unless you do something about it”. I thought to myself “I’ll show her”.

    I’m now a healthy, fit woman in my 30’s with a child and a career in healthcare but still struggle with food/weight preoccupation. I always wonder what would have happened if I’d been treated with kindness as a child.

  2. And….no matter how your body changes with time your eating disorder doesn’t necessarily go away. I have been “thin” most of my life and starved myself there when I was younger. Genetics keep trying to make me go the other way and every time that weight creeps up on me (now that I’m “average size”) so too does that way of thinking. It can happen to any one of us at any size.

  3. I was thinking about this while listening to 13 Ways of Looking at a Fat Girl. One chapter of the memoir (there are 13 chapters, of course) tells the story of the main character eating only salads with dressing on the side for months at a time eating with a skinny co-worker whom she hates and calls, not to her face, Itsy Bitsy. Itsy Bitsy is painfully thin and gorges on pizza and no one would guess looking at Liz and Itsy Bitsy at lunch that it’s Liz who is starving herself and not eating enough to function.

  4. This is so sad, yet so true. No matter what shape or size everyone deserves the right to fuel their body without fear or scrutiny.

  5. Fat-shaming is a sad reality, but thankfully the mainstream body image is slowly but surely changing–particularly in the fashion industry with models like Ashley Graham.
    Great article, thank you for sharing!

  6. Thank you for this! As someone who’ve struggled with bulimia for 23 years, I can attest to the fact that I was able to “get away with it” without being noticed. As someone who is 1. black, 2. not super thin, 3. and with practice you can hide bulimia, I don’t fit the mold of someone with an ED. I was the one who had to break my silence to my doctors (PCP, ND, dentist) and eventually therapist.

    Aside from the classic, textbook ED, I have the “food fear”, body dysmorphia, orthorexia. I hope we can continue this conversation, especially on a fitness blog where I know I am not alone.

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  8. Thank you for this. It’s somewhat reassuring that it’s not just me.
    My last 5 visits to Drs for issues unrelated to being fat (massive chest infection and pap). In 3 of the appointments one of, if not the first thing to come up was my weight.
    I’ve found it incredibly harmful after each time, and disappointed with myself to say that it has triggered some ED behaviours. I have worked really hard to stop my negative thought patterns and being in situations where I’m open to these kind of comments.
    It hurts, that this kind of thing sets me back; especially considering on 2 occasions this was at an organisation that promotes itself as being inclusive and open.
    Thank you again for this. It’s a morale boost to know that it’s not me, it’s the system.

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