the HAES files: part of the problem? or part of the solution?

by Health At Every Size® Blog

by Jon Robison PhD, MS

This old 60’s mantra was ringing in my ears a few weeks ago as I addressed the National Eating Disorder Summit put on by The Ben Franklin Institute in Las Vegas. My talk was entitled Binge Eating Disorder (BED) and the “War on Obesity.” Though I have taught about and counseled many people with compulsive/disordered eating over the years I do not treat BED, so I spent numerous hours poring over the literature and speaking to my colleagues, many of them ASDAH members and ED specialists to make sure I was understanding the often confusing information I was gleaning from the literature.

The proposed classification of BED as a separate disorder in the upcoming DSM V is good news for those who suffer from and treat this most common of all eating disorders. However issues surrounding etiology, identification and treatment remain to be clarified. Particularly difficult is the relationship between “obesity” and BED. Though greater than 92% of individuals classified as “obese” do not have BED, most people with BED come to treatment seeking to lose weight.

My review of the literature was truly eye-opening. Most researchers (and all the ED therapists) I spoke with agreed that deprivation is the major cause of binge eating. People who have been dieting almost always end up bingeing; often on the very foods they have been restricting. In addition, bingeing can occur as a result of the use of food for affect regulation. The young girl who grows up without a father and with a mother who is rarely available because she has to work to make ends meet may turn to food to help cope with her loneliness. Weight gain occurs (and is what gets noticed), underlying issues are never addressed and the girl is seen as “having a weight problem.”

This all made sense to me as I have worked with many people in the past that easily fit into these descriptions. But, I was not at all ready for the craziness that was about to follow. In the same articles identifying deprivation as the main cause of BED, the next paragraph or page would invariably go on to discuss how dieting and restriction might be a good treatment for BED! What? I had to go back a number of times to make sure I was reading this properly – and I was; everything from moderate dietary restriction to low fat, low density regimens to Very Low Calorie Diets were being recommended! No, you didn’t just warp back into the previous millennium – I said Very Low Calorie Diets (VLCDs).

The logic provided for these recommendations truly boggles the mind. Stated most succinctly, it goes something like this. We can treat people who have BED as a result of deprivation by depriving them! But even more amazing is how the results of the studies were reported. Take one of the VLCD studies for example. While people were on the VLCD – drinking 500 or so calories (can you say starvation?), they lost weight.  Hard to believe that! Furthermore, they didn’t binge. Immediately the researchers claimed success – weight loss and elimination of bingeing. Starvation leads to weight loss and it also does not increase bingeing – so it is probably a good treatment for people with BED!

I emailed another researcher who had recently presented her study (involving a low-energy density diet) at a National ED Conference and asked if I could see the slides and the research. She replied that the paper would be published in a few months and no, she was not comfortable sending me her slides. But she referred me to a study on which she said hers was based. This one-year treatment program targeted weight loss and binge eating in 97 “obese” females. Two groups followed different variations of a reduced energy diet. Each group met with a dietitian weekly for 6 months and then twice a month for another 6 months.  Both weight loss and binge eating decreased over the year and the authors claimed that:

“The two strategies for reducing energy density that were tested in this trial were both effective in reducing body weight and maintaining weight loss.”

Once again, I had to go back and re-read; 6 months of weekly meetings and 6 months of every-other-week meetings. So, I emailed the researcher who had referred me to this study and asked how  weight loss maintenance could be claimed after one-year when the program was a one-year program (in other words while the program was still going on). Her response was almost comical.

“You need to see how wt maintenance is defined.  It could mean a wt maintenance phase (e.g., monthly sessions for a period of time after an intensive wt loss program) or simply follow-up assessments after the wt loss intervention has ended.”

OYE! – I sent her back the NIH Guidelines which state that follow up needs to be 3-5 years after treatment ends. Surprisingly, I haven’t heard back since.

My research uncovered other troubling anomalies. One leading ED leader, in support of an online weight management center’s offer to have people referred by their friends responded in defense of the program that:

“People don’t choose to be overweight. Something deeper is going on and you need to reach out and say ‘I’m concerned.’…If you saw a loved one with a sore on their arm that could be a melanoma, you would ask, ‘Have you had that checked?’  If you think their health is at risk, it’s not a judgment, it’s a concern. If you saw someone with a gun to their head, you would try to take the gun away. If the person is at risk for diabetes, they could lose their sight, they could lose their legs. The person, in a way, has a gun to their head. They may not know what to do.”

And another ED organization had this on their website; with a link supplied so people could actually do the math:

“The healthiness of your weight can be measured using the Body Mass Index (BMI) calculator. The calculator uses a person’s body weight and in relation to their height to define normal, overweight and obesity.”

I don’t think I need to go into all the levels on which these kinds of recommendations are problematic. The more important point I believe is that there are some special issues related to BED that speak to how deeply-rooted the thinness and diet mentalities are in our culture. I believe it is difficult for many researchers and therapists to believe that fat people coming to therapy for BED (or for whatever reason) don’t need to be concerned about and “working on” their weight. And, in spite of all that we know about the probable consequences of this approach it is a truly formidable task to pull out of a socio-cultural paradigm that has been dominant for such a long time.

There is a tremendous amount of paradigm-busting work to be done in transitioning from a weight-centered to a health-centered paradigm. While BED offers many challenges for researchers, patients and health professionals alike, it also offers an opportunity to solidify the Health At Every Size® philosophy and approach to helping people with weight and eating related concerns. Let’s seize the moment and help all concerned to unqualifiedly understand the problem and definitively be part of the solution.

7 Comments to “the HAES files: part of the problem? or part of the solution?”

  1. Thanks for this post Jon. You touch on an important point–the ED field is as vulnerable as the rest of our culture to a thin ideal and blinded by “weight-centered mentality.”

  2. Thank you Jon, for bringing your fresh eyes to the situation in the ED field.
    I don’t believe we know every cause of BED and we do need to be cautious about this at a point where we need much more research. But it is really surprising to me as an eating disorders specialist that some clinicians’ experience of treating thinner people does not always translate when the same problems arise for fatter people. I have sometimes thought of this as being “blinded by BMI” – if you have the same binging, purging, or yes, restricting behaviors that we see in thin people but you are fat, many specialists (let alone the rest of the world) will frame the behaviors differently and change what they would normally do because the patient “needs to lose weight.” In fact, some clinicians will prescribe for fat people precisely the behaviors they diagnose as part of the eating disorder in thin people (tracking everything you eat, weighing every day, compensating the next day for what you did today, basing your sense of accomplishment of weight loss, etc).

    I keep thinking if the only way fatness is not blamed for every possible problem is that fat people could have absolutely no problems, then how are we going to snap out of the old paradigm?

  3. This is great Jon. One of the many things that alarmed me about this post is that researchers are defining terms like “weight maintenance” with their own definition, that is inconsistent with more established definitions. It takes time, a critical eye, and lots of questioning to get the entire story from a study. It’s unfortunate that studies like this are peer-reviewed and published

  4. I just recently saw the “melanoma” quote from a supposed ED expert used in an article that got national media distribution. I was SO disgusted! I responded in a comment that was published on the web site of the publication in which I read the article, but of course that’s just one of I don’t even know how many newspapers – and I don’t have any credentials, so most people won’t pay any attention to what I said, anyway. I’m a fat person, so even if I had credentials, my words would probably be dismissed.

  5. This seemed completely nonsensical until I realized that it has an exact counterpart on the other side: anorexia treatment in which the overwhelming focus is refeeding to “normal” weight – I’ve often read AN ED bloggers criticizing treatment programs that take that approach.

    Then it made… well, clearly, not sense, but followable pseudologic. What’s being “cured”, in either case, is the deviation from the socially-constructed “normal” body, not actual clinical psychological disorder.


  6. I am truly heartened by this post and any others that highlight the stupidity. This nicely explains the flimsy research that often exists in this area. I am currently doing my masters in nutrition & dietitics and so frustrated at the focus on weight and BMI in nearly every lecture. I can only imagine this will escalate the further I go in the course and in doing prac. At this moment I am ok with learning this information but certainly will be looking to do better studies that highlight these kinds of flaws

  7. Mr. Robison, are there any figures about what percentage of people seeking treatment for BED are obese, and what percentage are in other BMI groups (“overweight”, “healthy weight”, “underweight” and whatever granularities are generally used to categorize weight distribution across groups)?

    My own experience as a high-body-weight person with an ED related to restriction is that when I have been part of multidiagnosis ED groups that the people being treated for BED seemed to be generally similar in distribution across BMI categories to the general population. And yet, dieting and restriction seemed to be recommended even to the BED patients who were clear that they had been identified as “underweight” clinically. (The whole question of whether dieting or restriction should even be discussed in multidx ED groups is another can of worms, of course…)

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