The Hidden Faces of Eating Disorders

What is the face of an eating disorder? Often, we envision a young thin white woman. However, research indicates that people at higher weights—fat people—are at increased risk for eating disorders. And their symptoms typically go unnoticed.

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.

Why are people at higher weights at increased risk of eating disorder symptoms? For one, we live in a culture that villainizes fat. Inhabiting a fat body is seen as a moral failing, evidence of being a sub-par human being. Fat people face the scorn of society and are open targets for discrimination and bigotry. It’s no wonder that so many will try anything possible to lose weight, even if that means engaging in eating disorder behaviors that compromise their health. This is not to say that eating disorder symptoms are the first line of action for people trying to lose weight. More commonly, weight loss efforts start with dieting or “healthy eating,” which gives way to disordered eating.

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.

^{Alexis Conason is a clinical psychologist in private practice in New York City specializing in body image and overeating disorders. To learn more about her practice and mindful eating, visit drconason.com, like her on Facebook, or follow her on Twitter.}