Three researchers from the Mayo Clinic have published an article on a little-discussed issue this month, in the journal Pediatrics; they're looking at the seeming fact that obese kids (or even just formerly obese kids) with eating disorders are often overlooked and undertreated. The article describes the experiences of two once-fat kids who took dieting to extremes and who did not receive intervention for eating disorders in spite of their obvious symptoms, and their stories are simultaneously enraging and sad.
The first case they discuss is that of Daniel. At 12, Daniel was first found to be medically obese, and what began as a “normal” weight-loss diet quickly turned into severe restriction in which he reportedly ate 600 calories or less per day while also running with his school’s cross country team.
Although Daniel presented some worrying symptoms, and at one point underwent extensive testing to find a cause, nobody involved seemed to think that his having lost more than half his body weight might be a factor, with the end result of his workup stating definitively that there was no reason to believe he had an eating disorder.
Daniel was only sent for an ED evaluation later, when his mother asked for one (yay for proactive parents). This story is terrible enough, but one of the points that stood out to me was this:
Daniel’s weight was a focus of discussion at all medical appointments throughout his childhood. However, during the 13 medical encounters that took place when he was losing weight, there was no discussion of concerns regarding weight loss.
Weight was a “focus of discussion” at all medical appointments throughout my childhood as well; from the time I was 7 or 8 years old, every single encounter with my pediatrician, whether I had a sprained ankle or the flu, ended with a conversation about what “we” were going to do about my slightly-above-average weight. It’s little wonder that a kid could internalize this pressure as evidence that weight loss ought to be a primary goal, and that this goal is worth striving for by any means necessary.
The second case described is that of 18-year-old Kristen, who was likewise first alerted to her obese status by a doctor at age 12. After a couple years of failed dieting, Kristen embarked on a pattern of severe restriction and daily running, which brought her down to a “normal” BMI. She also stopped menstruating and began suffering from problems with dizziness and balance.
As the years went by, and her weight loss continued, and her mysterious symptoms persisted, Kristen’s mother suspected that her daughter might have an eating disorder, and said as much to her daughter's doctor, who ignored (or "overlooked," in the language of the article) these concerns. Instead, Kristen was put on hormonal birth control to address her lack of periods.
Kristen eventually incurred stress fractures from running, and a sports medicine physician who treated her raised concerns about her eating habits and other symptoms. Kristen was then referred to a dietician, who nevertheless “expressed no concerns regarding her minimal dietary fat intake or significant weight loss and instead recommended that she maintain her current weight and eating pattern.” That's right, the dietician told the girl with the eating disorder to KEEP HAVING THE EATING DISORDER because she was doing just fine keeping her weight down.
Of course, part of the problem of diagnosing young women like Kristen with anorexia is that in spite of her meeting so many of the signs of this disorder, she lacks one central criteria for an anorexia finding: her BMI is not technically abnormal. As defined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV), individuals with anorexia must maintain a body weight that is less than 85% of the expected normal range for their height and age. Criticism of this requirement has been increasing in recent years, especially when applied to children and adolescents, whose continuing physical growth complicates matters somewhat.
The end result is that young women like Kristen, in spite of having demonstrated nearly all the signs of long-term anorexia, are relegated to the heading of EDNOS -- the awkward “eating disorder not otherwise specified,” a category that is much less aggressively treated, being a catch-all for eating-disorders-that-we-don’t-know-what-they-are. EDNOS is also the most common eating disorder diagnosis made, which suggests to me that there is a major problem with how we define and understand EDs.
For example, imagine how this limited thinking affects who is thought to be at risk:
Somewhat counterintuitively, patients with a weight history in the overweight or obese range represent a substantial portion of patients presenting for ED treatment. Symptoms in these patients are not limited to binge eating or bulimic behaviors. In 1 study in >100 patients with anorexia nervosa (AN), the majority had a history of obesity. Another study revealed that nearly half of patients presenting for adolescent ED treatment had a history of obesity and that it took signiﬁcantly longer for these patients to be identiﬁed as compared with patients without this weight history.
I appreciate that the article in question is attempting to confront these issues and ask medical practitioners to be aware of them. But the fact that this is presented as “counterintuitive” is bizarre to me -- to be honest, I expect the number of fat people with restriction-based eating disorders is markedly higher than the current data would suggest.
I’ll admit that my take is probably affected by the fact that I am coming at this from the perspective of an ACTUAL FAT PERSON, and not a medical professional. But as a person who started dieting before her age hit double digits, it doesn’t surprise me in the least that both currently and formerly overweight and obese kids would be at increased risk for eating disorders. According to Leslie Sim, one of the study's authors and clinical director of the eating disorders program at the Mayo Clinic: "The No. 1 risk factor for developing an eating disorder is dieting, says Sim. 'I've never seen an eating disorder that didn't begin with a conscientious effort to diet.'"
And fat people as a group are the people who are most likely to be familiar with dietary restriction as a concept. It’s a rare long-term fat person who has never felt compelled to diet or exercise their way to social acceptance (or at least to a standard of "health" based not on actually healthy behaviors but on seemingly arbitrary appearances). Few fat people have not subsequently failed in their weight-loss efforts at least once, and tried again with renewed intensity, such that making the shift from a non-extreme diet to more dangerous behaviors with significant health consequences is a reasonable possibility.
As troubling as these findings with regard to eating disorders are, specifically diagnosed EDs only affect about 6% of children and adolescents. Far more worrying is the 55% of girls and 30% of boys of high school age who exhibit symptoms of vaguely drawn “disordered eating” patterns, like occasional fasting or purging, or the abuse of laxatives, albeit not with the life-consuming focus of full-fledged EDs. These behaviors can be a gateway an eating disorder, but more often, and more troublingly, they just quietly continue, a little-discussed but common means of maintaining or losing weight.
It took me years to unlearn my own screwed-up eating issues, and I'm still not done. While I now know how to eat mindfully, without guilt or self-flagellation, I still continue to hoard food I have no plans of eating, and to react with rage anytime my poor husband tries to take food off my plate without asking. Recovery even from mild disordered eating patterns is a lengthy process.
In an adolescent culture of body loathing and weight obsession, disordered eating is often normative behavior. This was certainly true when I was a kid and teenager, and given the ever-increasing obesity panic, I doubt things have gotten better since then. By the 6th grade, it was common for many of my friends to exercise for hours to make up for having eaten half a cookie, or to skip breakfast and lunch frequently in the hopes of losing weight, trusting that dinner with their families was enough to create the impression that everything was fine. I did this as well, to fit in, sometimes.
Did we all have eating disorders? Probably not. Was something terribly wrong nonetheless? Yes.
One of my biggest concerns with encouraging weight loss in young people is that for a kid, the difference between a weight-loss diet and disordered eating is not always very clear.
Depending on the kid’s stage of development, they may not be able to understand that dieting HARDER and MORE is not necessarily better, or that extreme restriction and exercise regimens come with risks to their health. And to some degree this shortsighted perspective makes sense. Culturally we’re led to believe that it is acceptable for fat people to lose weight by any means necessary -- even by an extreme low-calorie diet, or by surgical intervention, the long-term consequences of which may be untested and unclear. It is not surprising that kids would come to think of their weight as a thing that must be firmly controlled, no matter the ramifications.
Indeed, even among adults, on a social level it often seems that the main difference between an extreme weight-loss diet and an eating disorder is the size of the individual in question -- a perception underscored by the DSM-IV definition. Fat people literally CANNOT HAVE an eating disorder, even when they do. For a fat person, skipping meals and/or exercising excessively is totally acceptable and encouraged, even if the same behavior would cause significant concern in a thinner person, in spite of the fact that starvation and overexertion are bad for humans of all sizes.
Is this because on a cultural level, fat bodies are considered less valuable and less worthy of care than thinner ones? Probably.
I read Daniel's and Kristen's case studies, and halfway through I felt the massive tension I was collecting in my clenched jaw, my balled fists, and my slumping posture. I know the situations described are things that happen; I know that every day there are untold numbers of kids trying to starve themselves into looking a certain way, who are hurting themselves in the pursuit of social acceptance (or health, but very often the pressure to be healthy is social as well), and being cheered on in the attempt, no matter how destructive. And still it makes me incredibly angry that we are putting our kids through this wringer, and fat kids in particular.
The message we are transmitting to many of our children and teenagers is that weight loss is never bad or dangerous when it happens to someone who is fat, or who once was fat. This message is being delivered even by their doctors, the experts that parents rely on to help keep their kids well -- and some kids are hearing it and absorbing it to mean that their bodies are to be abused into compliance at any cost, a mindset they may well carry through to adulthood.
Are we really happy to trade childhood-obesity panic for a growing number of invisible eating disorders we can conveniently ignore, and perhaps eventually a generation of adults, half of whom are quietly engaging in disordered eating behaviors on a daily basis because they have forgotten -- or never really learned -- how to feed themselves with competence? I'm sincerely asking. When will we step back and recognize the damage we've done?