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.

References:

Sim LA, Lebow J, & Billings M. (2013). Eating Disorders in Adolescents With a History of Obesity. PediatricsDOI: 10.1542/peds.2012-3940.

Twitter Digg Delicious Stumbleupon Technorati Facebook Email

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! http://sizedupedawareness.tumblr.com/post/62783998126/invisible-eating-disorders

  9. Thanks to his growing spurt, a teenager has boundless energy which needs to be
    channeled constructively. Older children ages 7 to 12 at this summer camp will work with a vocal coach,
    choreographer and director to improve their singing,
    dancing and acting skills. We also have advice for people with health savings accounts (HSA) and flexible spending accounts (FSA).
    The teens residential treatment options are dedicated to social change through free learning and community building.
    In Santa Monica, there’s the Aqua Surf School Surf Camp (310-902-7737) and
    Santa Monica Surf Camp (310-467-6898). My parents worked very hard to
    make our life better each and every day. There
    is less truth in that statement than one would believe. If you take all these factors into consideration,
    you will be able to have a generator that works more smoothly
    and efficiently. If you don’t, pickpocket the disarm codes
    off of Curtis. They may do recycling activities, such as constructing a bird-feeder out of
    used materials, and specific games designed to teach children ways to conserve energy and water.

    my blog Camps Kids Delray Beach

  10. The beginning of the end came the day Nia’s boyfriend didn’t
    take up her offer of caring for him when he was ill. It is important to
    always make sure that your hair is well maintained by ensuring that
    the hair is kept clean. Hair loss is of concern to most people at one point
    in their lives.

    My web-site: laser hair regrowth machines

  11. This is done in order build reserve fat before going on to the low calorie diet so
    that the body is able to cope up and adjust to
    the drastic changes. It is said that when there is a scarce of HCG in the body, it becomes difficult to manage the body weight.
    This is when you’ll see major weight changes – sometimes up
    to a pound a day.

    Here is my web page: drops of jupiter lyrics

  12. Low calorie and low crab diet is one of the
    safest rapid weight loss diet plan. Actually, this technique has been utilized for thousands of years so when looking at effectiveness, we can’t question them.
    You can have a look at them and then decide whether to choose one for you or not.

    Here is my homepage – hcg weight loss results

  13. The company offers low cost service and makes shipping process convenient.
    Individuals can check the availability of various companies on the web.

    Once the actual data for period five is collected and recorded into the table,
    the forecast for period six can be calculated.

    Feel free to visit my webpage: moving and storage containers canada

  14. You will probably recognise some or all of these as some as used more than others with very great
    success in carp baits:. The options within the area range from Myall Lakes houseboats, cottages, apartments,
    cabins and guests houses, lodges and hotels among many
    others. If you are getting ready to go deep-sea
    fishing, there are a few things you might want to know about sea fishing bait.

    Here is my homepage – marine dock box for sale

  15. Face lift involves procedures to smooth out wrinkles
    and lines by surgically tightening the skin of the face.
    This is the reason why studies and techniques have been created to deliver the best
    natural-looking results. By using a radio frequency face lift, many men and women can prolong the need for a full-fledged face lift later on in life.

    Stop by my blog post facial plastic surgery recovery time

  16. Comfort comes in the form of the beautifully upholstered
    reclinable deck seats and bow seats, and a drive.

    Nowadays, these super coolers are used for both commercial and domestic
    purpose. So, you will be guided accordingly and will learn better
    and faster.

    my page marine how to replace a refrigerator gasket

  17. Unlocks the Think Fast title and the League Grenade emblem.
    Maybe you may change your look, try a new sexy hairstyle or new hair color.
    Employers can post simple job listings or seek out full recruitment
    services to advertise to the 50,000 people who visit the
    site each month.

    my web blog … cheap moving companies in houston tx

  18. He became interested in HCG as a diet aid, and started developing the
    drug as a dietary regimen for losing weight. Pour into
    sterile fifty percent-pint jars, seal, and cool. “Never feeling hungry is not a sign of being healthy,” stated Dr.

    My weblog: hcg weight loss world

  19. Moving day can feel more like chaos than order, especially when there are
    half a dozen movers running around your home, packing up your belongings, and carrying out your
    furniture. 3G data card will allow to stay connected with the whole world
    while moving from one place to another. Again, the credibility and market reputation of Indianapolis movers ensure that everything, from packing to
    transportation, will be simple and easy.

    my blog olympia moving and storage company

  20. The hair follicles are not receiving the right balance of nutrients
    they need to grow. Electrolysis – Electrolysis is a
    solution which utilizes a needle to kill
    the hair at its root. However, pulling on a scab that was adherent to the skin usually dislodged the graft –
    often several days after pulling on a hair was safe.

    my website; Laser Light Therapy

  21. *If the IRS receives no response, you may receive notice
    for additional tax assessment or audit. We can see
    the importance of this concept by noticing companies
    today whose operations are strictly financial advising.
    Remember that this form of tax debt relief is the most
    beneficial, so it may be prudent to give yourself every possible chance at success.

    My weblog: charles brandon Fort Lauderdale CPA firms

  22. A person having little expertise meanwhile can handle
    these issues before a professional comes in frame.
    This is made of vitreous china, a ceramic fired at high temperature to form a non-porous
    body coated. The important thing is to a step closer to the kitchen you’ve always wanted.

    Here is my web page :: pompano daytona beach plumbers beach fl

  23. But now, with the prevalence of social media accounts,
    caretakers must now tackle the hurdle that is their loved one’s
    online presence. Promote multiple affiliate
    programs in your website but don’t promote every little
    thing the world has to offer. After so much spent or so many visits, offer a free product or percent off.

    Feel free to surf to my web page: beach body p90x

  24. Most people also purchasing their own host from one way or another.
    You should always keep yourself abreast with the latest
    happenings in the seo world. In all this, Press
    Release distribution service is great way to enhance your
    website’s visibility.

    Take a look at my web site: social media marketing survey

  25. Excellent web site you have here.. It’s difficult to find excellent writing like yours nowadays.
    I seriously appreciate individuals like you! Take care!!

  26. Hello, My business is definitely delighted Ive discovered this data. Presently bloggers release nearly chit chat along with web things and also this is really frustrating. A good web site along with useful information, this is exactly what We need. Thanks for making this site, and also Ill become traveling to yet again. Does one complete news letters through e-mail?

  27. Hi there Dear, are you really visiting this website on a regular basis, if so afterward you will absolutely get pleasant know-how.

Trackbacks/Pingbacks

  1. Obesity and ED follow up | Sweetly Striving - September 10, 2013

    […] There has been new information going around the web on the issue of ED and obesity. Here is a article here. […]