At the intersection of obesity and EDs: Body weight, risk factors, and diagnosis
A study has been making the rounds and the headlines today with items like this:
Pretty significant stuff. And, based on my own experiences and stories from other people, not really all that surprising.
So I tracked down the study (Sim, Lebow, & Billings, 2013) to get the information from the source and found that the study didn’t exactly match up with the media reports.
It was a case study, which basically outlined two patients with eating disorders who started out with an obese BMI and then developed AN. It chronicled the start of their symptoms, their weight and behavior history, their diagnosis, and their treatment. Let me be clear: there were only TWO patients.
I do not believe, for a moment, that the problem of EDs in kids, teens, and adults with obesity are limited to these two patients. I don’t believe they’re the only ones with EDs, they’re the only ones with EDs that aren’t strictly binge eating, and that they’re the only ones who have problems with the medical establishment taking their illnesses seriously. Not for a moment.
But this was not a large study. Our ability to conclude much of anything from this type of research is rather limited. I do think it deserves coverage in both the popular and scientific literature, but, please, caution!
What the study actually found
So I’m not going to keep everyone in suspense. Let’s dive into what the study found and what we can interpret from there.
Scientists from the Mayo Clinic reviewed two cases (a 14-year-old boy and an 18-year-old girl) that had presented to their ED clinic. For those who prefer to avoid numbers, there will be some mention of these in this half of the blog post. If you would rather not read further, that’s totally fine. You can skip down to the next section header where I discuss the results, numbers free.
A summary of the boy’s case:
Daniel is a 14-year-old boy who presented to an ED evaluation with a 2-year history of signiﬁcant weight loss (39.5 kg) that developed in the context of a history of obesity…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 including difﬁculties concentrating, worsening mood and irritability, extreme social withdrawal, as well as cold intolerance, signiﬁcant fatigue, bloating, and constipation. Similar to many individuals with AN, Daniel had little insight into the seriousness of his problem. Daniel’s weight loss came to the attention of his medical providers in the context of a pediatric gastroenterology evaluation for concerns regarding constipation, bloating, and intermittent postprandial chest pain. Results of the gastroenterology evaluation, including screening for celiac sprue, Giardia, and Helicobacter pylori, a hydrogen breath test, thyroid testing, and a brain MRI, were unremarkable. However, Daniel exhibited marked sinus bradycardia, and laboratory results were consistent with signiﬁcant dehydration. 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 emphasis (my own) serves to point out the two more ironic statements in this poor kid’s history:
- That he was the only one with little insight into the seriousness of his condition. Sorry, don’t buy it. His doctors also had no insight into the seriousness of his condition.
- That physicians only wanted to discuss his excess weight or weight gain but were perfectly happy for him to starve himself to death as long as his BMI was “normal.” If you really were considered about his health, rather than his weight, you would also be concerned about severe, marked weight loss and the accompanying health problems.
That’s pretty much the clearest picture you can create of the difficulties in diagnosing and treating EDs in a culture completely obsessed with weight.
Oh, and if the above summary of one of the cases isn’t enough for you, here’s the image of the boy’s BMI percentile tracked over time. As they say, a picture is worth a thousand words:
The girl’s story is fairly similar: drastic, rapid weight loss; dragged to every medical expert imaginable; ED diagnosis tabled because the BMI is still “normal”; and so on. I won’t go into it in detail, but the full text of the study is online so you can read it yourself.
What does this mean?
Apart from seeing is as a harbinger of things to come, there’s not a whole lot you can extrapolate from a case series. The authors didn’t have anything to compare it to. In order to say for certain that obese adolescents suffer significant delays in ED diagnosis, you would have to compare the amount of time between onset of behaviors and diagnosis. I wouldn’t be surprised in the least if that was the case, but we can’t say for sure yet. This, however, didn’t stop a lot of the headline writers.
“Overweight but anorexic teens are often overlooked by doctors.” Often? We can’t really say that. “Have the potential to be overlooked?” That’s a little more like it. But it’s not snappy and short.
I’m not against this type of study being published and being covered by the media. It is seriously important. We need to be thinking about these things, especially since early detection and treatment are the best predictors of ED recovery. We’re letting our own prejudices about weight and health get in the way of proper diagnosis, and you don’t need to be a rocket science to show that this is very, very bad. Losing weight for any reason can trigger an ED, and we need to be much, much more cognizant of that, especially in light of the proliferation of obesity prevention programs. The potential risks have been neither highlighted nor studied. If nothing else, this most recent case study shows that these issues deserve much more attention than they’ve been getting.
Sim LA, Lebow J, & Billings M. (2013). Eating Disorders in Adolescents With a History of Obesity. Pediatrics. DOI: 10.1542/peds.2012-3940.