Obesity & Eating Disorders

Obesity and eating disorders are serious challenges that are not discussed in relation to one another enough. This is especially true when one considers the high prevalence-rate of both in the United States. Approximately 11 million people in the world struggle with eating disorders and worldwide obesity rates tripling since 1975 [1].

Obesity and eating disorders are not always experienced in tandem, however, they do co-occur more often than many understand, making it necessary that the topic of obesity be part of eating disorder discussions and vice-versa.

Is Obesity an Eating Disorder?

The World Health Organization (WHO) defines obesity or being overweight as “abnormal or excessive fat accumulation that presents a risk to health [1].” The WHO also specifies that “A body mass index (BMI) over 25 is considered overweight, and over 30 is obese,” although, it is important to note that BMI is incredibly limited as it only considers an individual’s weight and height without taking into consideration any unique individual lifestyle or health factors [1].

Technically speaking, obesity is not considered an eating disorder as it is not in the Feeding and Eating Disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which classifies criteria for mental health diagnoses. Even so, obesity can be an experience or symptom of someone struggling with an eating disorder.

Anorexia vs. Obesity

It is important to be clear that anorexia nervosa and experiences of obesity are not mutually exclusive. Too often, people believe that, because anorexia nervosa involves severe restriction of nutritional intake, an individual cannot struggle with it and experience obesity. This inaccurate belief was likely maintained due to a prior version of the DSM (the DSM 4), requiring that an individual be less than the 85th percentile in body weight for their height and age [2]. Once updated, the DSM 5 changed this criteria to take into consideration other factors that impact weight, specifying that the restriction results in “a significant low body weight in the context of the age, sex, developmental trajectory, and physical health [2].”

It is also important to note that Anorexia Nervosa has two subtypes – Restricting Type and Binge Eating/Purging Type. These subtype specifications allow for more nuance in the behaviors one engages in, as some that engage in restrictive behaviors also engage in binging and compensatory behaviors as well.

There is also a diagnosis of Atypical Anorexia Nervosa which is characterized by the same symptoms as Anorexia Nervosa yet “the single exception is that the weight of the patient with the atypical variant is within or above the normal range, despite significant weight loss [3].”

Can you be Overweight and Have an Eating Disorder?

One can absolutely be overweight and/or experience obesity and have an eating disorder. Studies have long-found that individuals at higher weights are at an increased risk for disordered eating behaviors.

One study notedly found that “overweight adolescents are more likely than their non-overweight peers to engage in unhealthy weight control behaviors, such as diet pill use, vomiting and laxative use [4].”

These links are likely related to the societal stigma that to have fat is “unacceptable” and, therefore, people feel they must lose weight to be viewed as “acceptable.” What is viewed as “harmless” dieting is much more dangerous than it appears and can quickly become disordered. In fact, “research suggests that dieting behavior may be causally linked to both obesity and eating disorders [4].”

Eating disorders and experiences of obesity may co-occur due to shared risk factors such as “dieting, media use, body image and weight-related teasing [4].”

Overweight with Anorexia

It is becoming more common for individuals to experience anorexia nervosa symptoms and being overweight or obese.

A recent study from the University of California San Francisco (UCSF) found that a large portion of those seeking treatment are those engaging in anorexia nervosa behaviors while also at normal weight or above [3]. It also determined that what is more characteristic of individuals in treatment is not whether they are over/underweight but how their weight loss is experienced. The study states, “patients with large, rapid or long duration of weight loss are more severely ill, regardless of their current weight [3].”

Additionally, health consequences of anorexia nervosa are not limited to those considered underweight, as “female atypical patients were just as likely as their underweight counterparts to stop menstruating, a hallmark of hormone suppression due to poor nutrition that impacts fertility and bone density” and that “both typical and atypical patients were susceptible to electrolyte imbalances from inadequate sodium, potassium, calcium and chloride intake, which can impact the brain, muscles and heart functioning [3].”

A final result from the UCSF study was that those individuals with Atypical ANorexia Nervosa scored higher on eating disorder pathology such as “avoidance of food and eating, preoccupation with calories and eating in secret, feelings of fatness and discomfort seeing one’s body, dissatisfaction with weight and reaction to being weighed [3].” Study creators determined that “some of the patients had been overweight and may have suffered stigma or teasing that made them feel worse about their size…or, if they were genetically predisposed to be on the heavier side, they may have had to employ more severe behaviors or have more severely disordered thoughts in order to fight their biology [3].”

Bulimia and Obesity

Bulimia Nervosa is an eating disorder characterized by engaging in episodes of binge eating followed by compensatory behaviors to “get rid” of the food consumed. While some may view binging as a risk-factor for becoming overweight or obses, and it is, however, the compensatory behaviors used in bulimia nervosa should be considered.

One article noted that those with bulimia nervosa tend to “be more preoccupied with their weight and a pursuit for thinness and tend to have severe restrictive dieting, interspersed with binge/purge episodes [5].” As such, “few patients with BN present with obesity; most tend to have normal weight or overweight [5].”

Binge Eating Disorder and Obesity

Binge Eating Disorder (BED) is characterized by “periods of eating where the patient eats more than their normal intake, eats more rapidly, even when not hungry, feels a loss of control over eating and feels guilt over the episodes [5].”

Individuals with BED often engage in binge episodes to cope with other mental health symptoms or experiences. They might also binge as a result of restriction via self-starvation or dieting.

BED is the most prevalent eating disorder as well as the one most commonly understood to involve diverse body weights, shapes, and appearances. While the research noted above shows that BED is not the only eating disorder with diverse bodies, it is the eating disorder most closely associated with obesity.

One study notes that “approximately 10–15% of people who are mildly obese and who try to lose weight on their own or through commercial weight-loss programs have BED” and that “the disorder is even more common in people who are severely obese [5].” Further, 30% of those that seek treatment for BED experience obesity [5].”

The study also noted that “obese patients with BED show a greater degree of psychiatric comorbidity and lower self esteem compared with obese patients who do not binge [5].”

How to Get Help for an Eating Disorder

Hopefully, reading this article has provided some research-supported evidence that one’s body type in no way indicates the presence or severity of an eating disorder. Anyone can struggle with disordered eating behaviors and you cannot determine one’s experience by their appearance.

If you are struggling with an eating disorder, it is important for you to advocate for the help and support that you need. Sadly, those living in larger bodies are often misdiagnosed or not diagnosed for their eating disorder at all purely due to their weight. There absolutely needs to be better eating disorder education in the medical field. However, in the meantime, it may be incumbent upon you to let your medical or mental health provider know of your struggle and that you need help. These individuals might have referrals for you or you can find reputable eating disorder treatment information and programs through directories on websites such as NEDA or Eating Disorder Hope.

The key is to seek help if you are struggling and do not stop fighting for your well-being until someone hears your struggle and gives you the support you need.

Resources

[1] Unknown (2021). Obesity and overweight. World Health Organization. Retrieved from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.

[2] Unknown (2016). DSM-5 changes: implications for child serious emotional disturbance. National Library of Medicine.

[3] Leigh, S. (2019). Anorexia nervosa comes in all sizes, including plus size. University of Southern California, Retrieved from https://www.ucsf.edu/news/2019/11/415871/anorexia-nervosa-comes-all-sizes-including-plus-size.

[4] Haines, J., Neumark Sztainer, D. (2006). Prevention of obesity and eating disorders: a consideration of shared risk factors. Health Education Research, 21:6.

[5] Vaidya, V., Malik, A. (2008). Eating disorders related to obesity. Future Medicine, 5:1.

Author: Margot Rittenhouse, MS, LPC, NCC

Reviewed & Approved by Jacquelyn Ekern, MS, LPC 8.1.22