the HAES files: Why Obesity is NOT an Eating Disorder

by Health At Every Size® Blog

by Jon Robison, PhD, MS

From time to time I overhear or read about people discussing whether obesity should be considered an Eating Disorder (ED). I have even seen obesity listed along with anorexia and bulimia as if it were just common knowledge that it belonged there. This is just wrong on so many levels that it almost seems like it is not worth acknowledging the discussion. On the other hand, it is so often promulgated both in the lay media and in scientific circles that perhaps it is important to elucidate the ways in which the classification of obesity as an ED makes no sense.

To begin with, Eating Disorder Reviews defines EDs as:

Extreme expressions of a range of weight and food issues…serious emotional problems that can have life threatening consequences.

Obesity, on the other hand, is defined as a Body Mass Index (BMI) equal to or greater than 30. It is a measure of height and weight (kg/m2). Just as there are different eating disorders, there are other measures of height and weight; The Ponderal Index, The Body Mass Prime and The Body Volume Index to name a few. An ED is a serious emotional problem/illness and obesity is a measure of height and weight. So, on the most basic level comparing obesity and eating disorders is somewhat like comparing apples and oranges.

Actually, the comparison is really a good deal more obtuse than that because apples and oranges are at least both fruits. The comparison between obesity and eating disorders is really more akin to comparing an apple with a chair. You can’t sit in an apple and you can’t eat a chair!

Actually, on a somewhat lighter note, I have seen a chair shaped like an apple, but you still can’t eat it.

It is important to remember (as I discussed in a previous blog post) that this BMI measure (1) was never meant to be a measure of health and (2) is a population statistic not meant to be used on individuals. So, making connections between this measure of obesity and the serious emotional health issue of EDs is scientifically unjustified and inappropriate.

On the next most basic level, it is certainly true that body weight and eating disorders both have something to do with food. Yet, the evidence that people labeled as obese eat more than other people is inconclusive at best, with some recent research even suggesting that just the opposite may be the case.  So, the very common suggestion that you can know whether someone is eating the “proper amount” of food (or the “right kind” of food for that matter) by looking at them is not supported by the evidence and therefore, doing so can best be defined as prejudice (pre-judging).

Of course, the lack of supportive evidence for this conclusion does not stop people from continually making it. In fact, the word obesity itself comes from the Latin obesus, whose primary definition, “one who has become plump through eating,” confirms the misconception.  Instructively but perhaps not surprisingly, the secondary definition for obesity usually includes the words coarse and vulgar.

From a phenotypical perspective, the concept of obesity as an ED also makes no sense. Most patients with anorexia nervosa and bulimia nervosa have always been thin and “normal weight” people.  However, everyone knows that the vast majority of people in these weight categories do not have an ED. With the acknowledgement of Binge Eating Disorder (BED), many therapists are now seeing fat people who have an eating disorder. As is true with people of any size, of course, the vast majority of fat people also do not have BED. Research suggests that somewhere between 4% and 8% of people labeled as obese may suffer from BED which means that the overwhelming majority, 92% to 96%, do not!

In conclusion, here is what we can now say about the relationship between obesity and ED. They are about as related as the chair and the apple. Suggesting that someone has an ED simply by virtue of their BMI is prejudicial, unscientific and unethical. As fat activist and author of Fat!So? Marilyn Wann puts so eloquently:

The only thing anyone can diagnose by looking at a fat person is their own level of prejudice toward fat people.

 

20 Responses to “the HAES files: Why Obesity is NOT an Eating Disorder”

  1. Obesity is not an eating disorder just as underweightness is not an eating disorder. Anorexia, bulimia, and binge eating disorders are of course.

  2. and maybe most patients with bulimia and anorexia are normal weight because NO DOCTOR BELIEVES A FAT BULIMIC. i had an extremely hard time getting doctors to believe me or to treat me.

    • This is true and very sad. Bodies can react differently to different kinds of disordered behavior. (And any healthcare provider/doctor/nutritionist will know this.) Health insurance companies also need to take steps to help folks that aren’t severely underweight and covered in down/losing hair get the recovery treatment they need. Sadly, once you gain “enough weight” or weigh “the right amount” you are often no longer eligible for treatment under many HMOs. Gross. (Also, I hope you can find a better doctor.)

    • That is very disturbing to read, erylin, that doctors wouldn’t believe you :(
      I heard a pediatrician who specializes in EDs mention plus-size people who are anorexic. They’re not thin…yet, but if they are unable to stop the behaviors, they will be. What a tragedy that they might not be believed, either. As that doctor said, people of all sizes can have any of the EDs.

    • Umm, no. Anorexia does have a weight criteria. Those who don’t meet it, but exhibit other characteristics of anorexia are diagnosed with EDNOS.

      • Actually, Angela, there is debate among eating disorder specialists about whether the weight criterion in the DSM IV (and proposed in DSM V) is a hard or soft feature – some have argued that the clinician should make an educated guess about whether weight is significantly suppressed below that individual’s setpoint or healthy weight range, and if so, diagnose as AN regardless of how their weight compares to the population norms. I would argue for that position since weight falls on a bell curve and if you start at a higher weight, it is harmful to wait to diagnose AN until the person is more malnourished and more entrenched in the disease. If you lose a jet engine at 40,000, you shouldn’t wait to take every available action until you are at 10,000 feet. Many states have parity laws that allow patients and families more resources and clout when they can use the AN diagnosis than EDNOS, so this has practical and sometimes life-changing implications.

        If I ruled the world I would eliminate the weight criterion altogether, because I think weight change is a complication of the disease and not the disease itself. I would call the category “Disorders of the Pursuit of Weight Loss” and code them by the behaviors (restriction, purging (including over-exercising), binging) and the thought processes (obsessions, compulsions, altered perceptual reality, lack of ability to set shift) that unique person was struggling with. Then I would code the medical features (ie, weight loss) on Axis 3, the way you would any other diagnosis.

      • Regardless of what you — or I, for that matter — feel is correct, as it stands, the DSM-IV has a weight criteria for anorexia nervosa. To say that you can be “normal” or overweight and clinically diagnosed with anorexia is incorrect.

        Look, I’ve been there. As someone who has struggled with anorexia for years, I have been diagnosis with anorexia (restricting subtype) and after weight restoration, EDNOS. And I agree that it would be good if the DSM-V addressed these issues. But facts are facts, and we can’t change that.

      • Angela, I am not denying your experience. But you should know as a consumer that there are eating disorder specialists who give the AN diagnosis to folks at higher-than-85%-of-normal-population-weights and find justification for it in the following phrase in DSM-IV (ApA, 1994): “These [weight] cutoffs are provide only as suggested guidelines for the clinician, since it is unreasonable to specify a single standard for minimally normal weight that applies to all individuals of a given age and height. In determining a minimally normal weight, the clinician should consider not only such guidelines but also the individual’s body build and weight history.” (page 540). My colleagues and I in the Academy for Eating Disorders have regular lively discussions about what to use as evidence of being below weight (or weight-restored, for that matter), since BMI is a notoriously bad proxy for health. Some people do ultrasounds of pelvic organs, some do labs on estrogen, some look at biological relatives and the person’s history on the growth charts.

        The other issue your own experience raises is that you don’t have a different disease just because you are partially weight-restored. I would conceptualize your illness as AN throughout your recovery, and that you have AN, in partial remission. This is different from someone who should receive a EDNOS diagnosis because their complications never included being at a low enough weight – for them – to meet the weight criterion for AN.

        So it is true that AN requires a significant dip in the weight appropriate for you as an individual and that is something I would change, but it is not true (though probably the actual practice of most clinicians) that the diagnosis requires that the individual be at a weight that represents being underweight for a population norm. Does that make sense?

  3. You are right. There are dozens of different reasons why people are fat, and for how fat they are. Some of my friends who are fat also have an eating disorder (addicted to sugar or whatever). Most of them seem not to have disordered eating, any more than anyone else does. Many eat “normally” but feel guilty about it. To my mind, feeling guilty about your size or what you eat, is what is disordered. How fat people are treated by themselves and by society is what is disordered.

  4. Doesn’t help that EDs are often defined by BMI – ie. you may struggle to get into a specialist ED ward with a BMI above 18 even as an outpatient. I’m sure this is because of limited spaces etc. But I’ve had friends with AN struggle to get any support at all before they are already very sick.

  5. Thanks tons for quoting me, Jon! I love this post!!! Apples and chairs, indeed!

  6. If it is a Dx, it can get treatment [should you want it] paid for. It also comes under some protections, eg, employment protections. And generally a medical Dx is not counted as a moral fault. These may not be enough to make this a good thing, but they are factors to toss into the discussion. Not all fat people are sick, and fat itself is not, imho, a sickness. But allowing something like ‘obesiitis’, = obesity that causes distress or difficulty, to be included in diagnostic lists, might be a good idea.

  7. Yes obesity can be caused by medication or medical reasons. Obesity is the result. Overeating on the other hand is most certainly an eating disorder because an overeater relates to food in an abnormal manner.

  8. thank you so much for this post!! I work in the ED field and from a HAES perspective. I am also fat. My experiences have ranged from tiresome to downright oppressive sitting on committees, speaking on panels etc. having to over and over explain to colleagues that obesity is not an ED. It seems simple to me… Fat is a body type; ED’s describe behaviours, attitudes and emotional distress. There is only occassionally a relationship between these two things… at times body size may be an indicator of an ED but it isn’t with the vast majority of clients that we see. In the case of many of those that we work with who have BED… distress about their larger body type was a contributing factor to the BED – not the other way around. I really appreciate the clarity of this blog post – and am excited to share it!

  9. I am appalled by this article. As a women in recovery from my own eating disorder, I have seen first hand how obesity/binge eating disorder has detrimental effects on the body (physically and emotionally.) I struggled with anorexia for 7 years and have been in treatment, both inpatient and outpatient, off and on over those years. I suffered from anorexia nervosa, however, I was in treatment with some who had obesity. It’s hard to describe, but both disorders relate on many levels. Just as an individual who is obese feels the urge to eat to fill emotional pain, anorexics feel the urge to restrict or exercise.

    My uncle Kelly Brownell a professor at Yale and has written MANY books about eating disorders. He has even opened treatment centers for obese individuals. Further, he is a leading researcher in the eating disorder field and his research is evidence for this argument. We all know you can not argue with research that provides solid evidence.

    Read this book: Handbook of eating disorders: physiology, psychology, and treatment of obesity, anorexia, and bulimia, Volume 236

    Maybe you will change your mind. I don’t see how any PhD could be so closed minded. This article just shows that people in the medical field are completely ignorant when it comes to eating disorders. It makes me very sad, but motivates me to make a difference.

    • You can’t “have obesity.” You can “be obese.” Also, not every obese person eats to fill an emotional void. That is generalization. Some thin folks eat to fill an emotional void, as do some “in-betweenies.”
      And you are right, research that provides solid evidence is valuable. Would you care to cite some?
      I like how you call someone who has gotten a PhD in this field ignorant. What are your credentials besides having an uncle who is a professor and your own life experience of an ED?

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