Is ED recovery easier when your body is “normative or stereotypically desirable”? The anon asking the question implied that recovery could be more difficult because “an obese person … will never stop hearing hearing extremely triggering stuff about their body type.” Anon asked, “Have there been any studies on this?” Andrea tackled this question in her last post (it might be helpful to read it first if you haven’t yet); in this post, I will expand on my original answer.
Assuming anon meant, “Have there been anything studies assessing whether recovery is harder for individuals who do not fit the normative body type (because of fat phobia/fat shaming/diet culture)?” Then, my answer is: Not really, or at least I couldn’t find anything evaluating this question directly.
I was only able to find a few studies commenting on the history of overweight or obesity as a predictor of recovery/treatment outcome (but there are probably more):
- Hergenroeder et al. (2014) reported that, among 218 adolescents admitted to inpatient and outpatient services, “premorbid obesity was unrelated to outcome.”
- Ricca et al. (2010) reported on a 3 year follow-up study on the efficacy of CBT in 144 BED patients. They found that “overweight during childhood” was a predictor of treatment resistance (along with “full blown BED diagnosis” and “high emotional eating”).
- Wildes and Marcus (2012, open access) found that “history of overweight or obesity failed to demonstrate consistent associations with the study outcomes.” In their study, 23% (42/185) of the sample had a history of overweight and 9% (17/185) has a history of obesity.
These studies were all different. They studied different populations in different contexts, and so it is hard to really conclude much.
There are studies addressing this issue somewhat indirectly, that is, not necessarily looking at history of overweight or obesity as a predictor of treatment outcome but as a factor in seeking treatment, receiving a diagnosis, and engaging in treatment, among others. Many show that individuals who either do not fit the stereotype of an ED patient or who do not fit normative body ideals face more barriers. (In this post, I will focus on weight, but as has been blogged about before, not being a young, white female makes things harder too.)
BARRIERS TO SEEKING TREATMENT
As Andrea mentioned, individuals who feel that they don’t fit the “profile” of someone with an ED (e.g., their body weight is “too high”) are less likely to seek help because of stigma or fear of not being taken seriously (e.g., Becker et al., 2010).
BARRIERS TO RECEIVING AN ED DIAGNOSIS
Clinicians often do not realize their patient has an ED if the person doesn’t fit the typical “profile” of an ED sufferer.
Research has shown (see post here) that individuals who don’t fit the typical “profile” of an ED sufferer wait longer to receive a diagnosis and are more medically compromised when they are diagnosed.
Lebow and colleagues (2014):
Formerly obese or overweight adolescents represent a substantial proportion [36% in this study, but as many as 45% according to their 2013 paper] of treatment-seeking adolescents suffering from restrictive eating disorders (eating disorders characterized by dietary restriction and/or unhealthy weight loss). Despite similar severity of symptoms as their thinner counterparts, the findings of this study suggest that these adolescents are diagnosed at a later and more severe point in their disease.
In a 2013 paper by the same group (open access, go take a look!), Sim et al. wrote:
… The current diagnostic system’s inclusion of an absolute weight requirement has allowed many seriously ill patients to go undetected or to receive a diagnosis of eating disorder not otherwise specified, which might not convey the seriousness of the patient’s weight loss to other practitioners. This situation is particularly troubling given research that, compared with adolescents with AN, a sample of overweight teenagers who had lost >25% of their premorbid weight were more medically compromised.
Given that the shorter the duration of the ED, the more likely individuals are to make a full recovery(e.g., Reas et al., 2000; Le Grande et al., 2012; Hargenroeder et al., 2014), then this would also likely make recovery more challenging. Of course, having negative interactions with clinicians (especially if they invalidate one’s feelings or thoughts), does not engender trust and can also negatively affect recovery.
Clinicians often do not realize the seriousness of extreme dieting, weight loss, or exercise behaviours when the individuals engaging in these behaviours are overweight or obese. Indeed, many promote these behaviours.
Sim et al. (2013) reported on two case studies. This is an excerpt from one:
Daniel’s weight-loss efforts began with attempts to eat healthily and exercise but quickly developed into severe restriction: he reported eating no more than 600 kcal per day while running high school cross country. He eliminated sweets, fats, and carbohydrates from meals and would only eat “diet food.” Daniel also exhibited many physical and emotional sequelae of low weight
But guess what:
In spite of having lost over half of his body weight, the medical documentation associated with the evaluation stated, “there is no element to suggest that he has an eating disorder at this particular time.” At the request of his mother, however, Daniel was referred for an ED evaluation. Of note, 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.
The other case presented in the study is similarly horrifying. And these cases are not unique. In 2014, Whitelaw and colleagues (open access) reported similar findings,
It is noteworthy that some of the patients in the current study had been advised by a health professional that they should lose weight, but no advice or follow-up was provided. None of the patients were engaged with any medical or professional service at the time they lost weight.
BARRIERS TO GETTING CLINICIANS TO REALIZE THE SERIOUSNESS OF THE ED
Despite past or present ED symptoms, many primary care physicians (and perhaps family members and friends) continue to explicitly or implicitly endorse or promote unhealthy weight loss behaviours — or at least weight loss that, for that individual, may only result from unhealthy behaviours. This is from a different study (also open access):
Ms. Z, a 35-year-old African-American single woman with a body mass index (BMI) of 37.8 kg/m2 (height 5 feet, 5.5 inches, weight 238 lb.), presents for an evaluation for bulimia nervosa. She was referred to the eating disorders program by her primary care physician who knew about her eating disorder, but was primarily concerned about her weight and blood pressure.
BARRIERS DURING TREATMENT
Faster rate of weight gain experienced by individuals with a history of overweight or obesity may complicate recovery.
In 1977 (open access), Stordy et al. reported that patients who had been previously obese (8/15 of the sample! — this was when AN was defined as >25% weight loss vs. BMI of 17.5) gained weight more rapidly on the same food intake than those whose pre-illness weight had been in the “normal” weight range. This result has been repeated since.
The authors did not mention the effects of this rapid weight gain on the patients, but I doubt previously obese (however they defined this) patients recovering from AN were thrilled about this, particularly seeing their non-previously obese counterparts gain at a slower rate. Finding similar results, Shinder and Shephard (1993) aptly commented:
It is suggested that during the early stages of recovery from anorexia nervosa, energy utilization is more efficient in the heavier patients. However, it seems more difficult to sustain a high food intake in such patients, possibly because they fear a return to obesity.
Goals of weight loss can also complicate recovery.
We know that when patients fear weight gain, they are less likely to engage or accept interventions. For instance, McKisack and Waller (1996) found that women with BN were less likely to attend group therapy if their “immediate wishes (e.g., weight loss)” were not addressed. The individuals in the non-completers group had a higher average BMI than those in the completers group (24.4 vs 22.0, and although this was not statistically significant, it could have been very significant to the participants). The non-completers group also scored significantly higher on the “drive for thinness” and body dissatisfaction than the completers group.
The authors also wrote:
There was also a nonsignificant association with being overweight in childhood.
Of course, individuals of all weights express desire to lose weight, but those whose bodies fit the societally acceptable/normative body type are less likely to have their physicians (and/or friends and relatives) encourage or approve their goals, too. Many individuals in recovery (or thinking about recovery) also fear “becoming fat”. This is typically met with responses like, “Don’t worry, you won’t get fat,” sometimes implying that the person is being irrational. But what if the person will become (or stay) fat?
Weight suppression can also complicate recovery.
The fear of weight gain or becoming (or going back to) being overweight or obese brings us to another issue that may complicate recovery for individuals whose natural bodies do not fit the societal ideal: weight suppression. Weight suppression is the difference between one’s current weight and one’s highest weight. Jackie wrote two posts on the effects of weight suppression on eating disorder recovery in the past (see here and here), focusing on bulimia nervosa.
… Given that weight suppression has been associated with larger or more rapid weight gain during treatment, it is possible that individuals may be triggered to engage in compensatory behaviours or be psychologically and emotionally uncomfortable with the rate at which they are gaining … Lastly, the faster rate of weight gain may mean that patients would have a shorter amount of time to adjust to their new body, potentially increasing risk of treatment dropout and/or relapse.
… Since many individuals with BN were previously at a significantly higher weight, they may have an even greater fear of gaining weight. This would contribute to greater levels of dietary and compensatory behaviours.
Of course, weight suppression tells only part of the story, since two individuals could be equally weight suppressed but one’s highest weight could be in the low range of “normal” while the other’s in the overweight or obese range. So, Berner et al. (2014) stratified individuals with AN not only based on the extent of weight suppression but also on whether their starting weights were high or low:
Results suggest that when amount of weight gained in treatment is held constant, an individual’s weight history and current weight status interact to predict her psychological reaction to the weight gain. . . . High weight suppression was associated with greater psychopathology at baseline, and, among patients with higher BMIs, predicted high levels of symptomatology at discharge.
Patients with AN with relatively higher BMIs and high weight suppression are more likely to have a history of being closer to overweight than those with higher BMIs and low weight suppression. .. The prospect of weight regain may be more distressing for patients with a history of being near-overweight or overweight, as they may fear that weight regain will culminate in a return to their previous weight status. Thus, increased distress about gaining weight, even when amount of weight gained is held constant, may explain the higher discharge scores on measures of body dissatisfaction and concerns about weight and shape among individuals with high admission BMIs and high weight suppression.
However, to my knowledge, these hypotheses have not been evaluated directly.
BARRIERS AFTER TREATMENT
Achieving and maintaining recovery is probably harder when you are inundated with messages that promote and encourage weight loss.
Admittedly, I haven’t come across studies that have directly tested this hypothesis (which doesn’t mean these studies don’t exist), but I don’t think it is a stretch to imagine that this is probably the case. After all, fat stigma and fat shaming is prevalent in our society and I don’t see why individuals recovering from an ED would be somehow immune to these pervasive and damaging messages.
SUGGESTIONS FOR CLINICIANS
Bulik et al. (2014) wrote:
It is critical to establish clear communication with primary care providers to develop a comprehensive clinical picture that includes any weight-related morbidities and to ensure that recommendations made by the primary care provider related to weight regulation are consonant with the goals of treatment for BN (e.g., not recommending dieting for weight loss).
Similarly, Sim et al. (2013) concluded with the following suggestions:
It is essential that ED symptoms are on every practitioner’s radar, regardless of the patient’s weight. Disordered behaviors must be identified as early as possible, and patients referred for appropriate intervention. By maintaining awareness that EDs and obesity are, in fact, heavily overlapping, and not distinct, classes of disorders, health care professionals can improve overall patient health.
Changing society is hard. But I do think primary care physicians, nurses, psychiatrists, and anyone else who has a high likelihood of interacting with individuals with eating related problems, MUST be educated on these issues. Two main things here, I think:
- Serious eating disorders individuals across the weight spectrum. The severity of an eating disorder is not determined by weight. Individuals need not be objectively thin to be very ill and require treatment.
- Admittedly, I don’t know how clinicians should navigate weight/adiposity-related morbidities in patients with ED histories, but I think suggesting, promoting, or approving dieting or unhealthy exercise behaviours to patients with past or present histories of eating disorders is not okay.
Readers, what are you thoughts?
PS. I highly recommend reading a paper by Samantha Kwan titled “Navigating Public Spaces: Gender, Race, and Body Privilege in Everyday Life.” I shared it in my public Dropbox folder. I think it is particularly useful if you (like me) have body privilege and as a result might not be aware of the types of daily life experiences that individuals who do not have body privilege endure.
Berner, L.A., Shaw, J.A., Witt, A.A., & Lowe, M.R. (2013). The relation of weight suppression and body mass index to symptomatology and treatment response in anorexia nervosa. Journal of Abnormal Psychology, 122 (3), 694-708 PMID: 24016010
Bulik, C.M., Marcus, M.D., Zerwas, S., Levine, M.D., & La Via, M. (2012). The changing “weightscape” of bulimia nervosa. The American Journal of Psychiatry, 169 (10), 1031-6 PMID: 23032383
Prevalence+of+a+History+of+Overweight+and+Obesity+in+Adolescents+With+Restrictive+Eating+Disorders.&rft.issn=1054-139X&rft.date=2014&rft.volume=&rft.issue=&rft.spage=&rft.epage=&rft.artnum=&rft.au=Lebow%2C+J.&rft.au=Sim%2C+L.A.&rft.au=Kransdorf%2C+L.N.&rfe_dat=bpr3.included=1;bpr3.tags=Medicine%2CPsychology%2CHealth%2CPsychiatry%2C+Eating+Disorders%2C+Overweight%2C+Obesity%2C+Prevalence">Lebow, J., Sim, L.A., & Kransdorf, L.N. (2014). Prevalence of a History of Overweight and Obesity in Adolescents With Restrictive Eating Disorders. The Journal of Adolescent Health PMID: 25049202
McKisack, C., & Waller, G. (1997). Factors influencing the outcome of group psychotherapy for bulimia nervosa. The International Journal of Eating Disorders, 22 (1), 1-13 PMID: 9140730
Sim, L., Lebow, J., & Billings, M. (2013). Eating Disorders in Adolescents With a History of Obesity. Pediatrics, 132 (4) DOI: 10.1542/peds.2012-3940
Wildes, J.E., & Marcus, M.D. (2012). Weight suppression as a predictor of weight gain and response to intensive behavioral treatment in patients with anorexia nervosa. Behaviour Research and Therapy, 50 (4), 266-74 PMID: 22398152