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

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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.

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