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:

Eating Disorders Often Go Undiagnosed in Patients Who Have a History of Obesity

Could Obese Teens be at a Higher Risk for Anorexia, Bulimia?

Overweight But Anorexic Teens Are Often Overlooked By Doctors (STUDY)

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:

  1. 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.
  2. 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:

BMI history

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. PediatricsDOI: 10.1542/peds.2012-3940.

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30 Responses to “At the intersection of obesity and EDs: Body weight, risk factors, and diagnosis”

  1. Carrie, thank you SO much for covering this. Different news sources kept spitting out their rendition of the study and it was driving me nuts. Partly because it’s not really news since in order to lose weight some measure of increased restraint is required, and then also because of the extremely small sample size. But yea, I hope this type of coverage pushes doctors and other healthcare providers to think a bit outside of the normal box as to what might be going on. Really frustrating and such a complicated issue that I think we’re going to be seeing more of in the future.

  2. But… “In total, 45%
    of the patients seen in our ED clinic in
    the past year were adolescents with
    a history of obesity.”

    • This is true. But we can’t say whether physicians often missed their diagnosis without a formal comparison.

      That obese individuals can develop EDs (even AN) isn’t new. We’ve known that for quite a while. This isn’t what the news stories are hyping. Take the second story on my list. In the beginning it says this study “suggests that obese teenagers who lose weight could be at a higher risk for anorexia nervosa, bulimia and other eating disorders.” I’ve read the study and it says nothing of the sort. Saying obese teens are at risk for EDs, yes. But it doesn’t compare that risk.

      That’s the bit I’m annoyed at. We don’t know these things yet. I wouldn’t be surprised if they were true, but we don’t know that.

  3. Very interesting,my daughter has choking phobia and selective eating disorder and last year after she choked she lost alot of weight.Now even though she does not have AN there were alot of the same symptoms,moodiness,fat talk,extreme anxiety ect.I believe the rapid weight loss triggered that,she is now weight restored and pretty much back to normal.In my opinion in some kids weight loss can trigger an ED,maybe not AN but something and doctors need to watch for that.

    • Frankly, I think the diagnosis of AN is way too focused on weight and should instead look at behaviors and cognitions rather than the myopic focus on weight. Yes, I know the diagnostic criteria does include other things, but the way AN is actually diagnosed generally hinges on weight. That’s a big mistake in my book (can’t decide whether I meant that pun or not…).

      I think we would do much better to address specific symptoms and behaviors rather than a diagnosis. But that’s me.

  4. I agree ,AN or any other eating disorder is about the behaviors not weight,I was stick thin as a child,a size 0 and that size was unheard of back then,thank God my grandmother was a seamstress!But I was a happy kid,ate everything.If you didn’t know me you would swear I had an ED.It is the behaviors that make the difference.My daughter has two really small friends,1 of them I suspect has the beginnings of an ED,while they are both small I can see the difference in the 2 by their behaviors around food and just by knowing them.State not weight,a good rule to go by.

  5. I was overweight when I developed anorexia. It was triggered by deciding to lose weight and “get healthy”. For months people complimented me on how great I looked and said how proud they were of me. It wasn’t until my weight didn’t stop at a “normal” BMI that anyone looked closely enough to notice that something wasn’t right.

    I agree that this case study doesn’t address too much but I hope other people will continue to study this. It’s important for people unfamiliar with EDs to know that all EDs do not look like the stock photos we see with the articles about them.

  6. Thank you so much for this post. In a way, I have experienced the similar thing as this teen although I am over 40. My weight was going down and I lost my menstrual cycle. It has been 3 years since then. As I have been working on my recovery, I have gained back (not to the point of a healthy weight range for my height yet…). My doctor has never said anything, but “you are fine”. He said, “you just need to eat. You don’t need to worry about sugar or etc. You can eat Ice Cream, Cakes or whatever.” When I asked him if I should seek help from dietitian or therapists, he said,”well, you can if you want and that makes you feel better.” It was extremely discouraging. I didn’t seek help until recently.

  7. This was illustrated at a maudsley parents conference I attended from one of the lead pediatricians as how undiagnosed ED have deleterious results. And it rang such a bell for me. I think it is a failure on a profound level of pediatricians to know and understand growth and development of their own clients. And a failure of their responsibility to act when a patient falls off a growth curve, or in turn monitor it more closely. My D shot over her growth curve up to the 95% at her annual physical age 9. She decided to eat healthier. (unbeknownst to me by pitching all lunches and snacks). Four months later another covering ped said *nothing* about her falling off her growth curve when she had lost 18 pounds when we went in for a cold. Nada. And so it went. 2 more months and another 15 gone age 9……….No alarm bells went off, no suggestions of call backs or monitoring, or educating. And when relatives said “you look great honey you have lost weight!” little did they or I know it would be a nose dive off the cliff that was unstoppable. There should be sufficient data in the US to support a study. They weigh kids at every ped visit. For everything……Some how the AAP has to participate in this..

  8. Great post!

    I definitely think that through diagnosing eating disorders based on weight/BMI, as opposed to eating behaviours, stigma and misconceptions can be established and perpetuated! This practice can often act as a barrier to sufferers accessing treatment, since individuals with disordered eating behaviours, who may have a ‘healthy’ BMI’ may be overlooked or dismissed but medical professionals. Take a look at our blog about this study!

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