The first is when we see “obesity” compared to “eating disorders” as if they are opposites. Our culture has a disturbing tendency to forget that “obesity” is defined as a ratio of weight and height – essentially just about body size – and that eating disorders are a complex combination of physical and mental symptoms.
I saw a study that compared brain circuits of obese women with brain circuits of women with anorexia. This is essentially comparing apples to bowling balls, fat is not the opposite of anorexia nor is it the diagnostic criteria for an eating disorder. Our cultural tendency to conflate weight and health can be deadly when it comes to eating disorders. Eating disorders happen to people at all sizes. Unfortunately when a fat person develops an ED that includes food restriction and/or over-exercising they are often encouraged to continue and even step up the behaviors, even if they can get to the point that they are aware that they are sick and are actively asking for help. Parts of our culture are convinced that thin by any means is better than fat, and that can lead to people dying.
Some eating disorder diagnoses require very specific criteria which includes weight and that has led to a group of diagnoses known as “FED-NEC” or Feeding or Eating Disorders Not Elsewhere Classified [edited thanks to Duckie’s comment below]. This is important because a fat person who develops an eating disorder can die before becoming “underweight” and so if we assume that someone who is fat can’t suffer from an eating disorder then we make a very grave error. Further, thin people can have trouble getting respect and treatment for Binge Eating Disorder, while people can incorrectly assume that a fat body is – in and of itself- a diagnosis for BED.
Even professionals are susceptible to these mistakes. I have taught dance and movement at a number of eating disorder treatment centers. At one that worked almost exclusively with patients who were very thin and dealing with eating disorders, I happened to come in the day that they got a fat patient, one of the therapists said “I’m glad you’re here, [first name] really needs to exercise.” I asked her how much exercise she had been doing previous to starting treatment and she responded that she assumed none. I insisted on a work-up. It turns out that the girl had been overexercising for a long time and, based on her profile, had she not been fat they would have immediately recommended a period without exercise. I’ve also had a Binge Eating Disorder specialist tell me that, in her “vast experience” there was “nobody who got to my size without suffering from BED.” I pointed out that her experience of people my size involves them coming to her office for treatment for BED.
We all know the adage that if all you have is a hammer then everything looks like a nail. We also know that when a healthcare professional sees a problem repeatedly in their patients they can inappropriately extrapolate to everyone who looks like their patients (like when Dr. Oz says that every fat person he operates on has heart problems and tries to say that means that all fat people have heart problems.) Of course in reality one would hope that every person he operates on, fat or thin, has heart problems, otherwise what is he doing cracking their chest? Just like people come to him for heart problems, people come to a BED professional for BED treatment.) But I think this goes deeper. I think that this is what happens when society tells people incessantly that you can and should make assumptions about what people eat and how much they exercise just by looking at them.
Eating disorders can be deadly so we have to get this right. Eating disorders happen independent of weight. There are fat people who have bulimia and anorexia (or, rather, would, if the diagnosis didn’t include weight), there are thin people who have Binge Eating Disorder. There are very fat people who do not have an eating disorder. There are very thin people who do not have an eating disorder. Calling someone “anorexic” is not a substitute for calling them very thin, and while we’re talking about this how about we just stop making judgments about other people’s body sizes altogether?
I recently wrote a piece for The Emily Project about how the normalization of fat hate can not only influence the development of eating disorders, but can also prevent any chance of a full recovery. I think that the best thing we can do when it comes to eating disorders, and healthcare in general, is take the focus off of weight and put it on treating people based on what is actually happening – their symptoms and situation, and encouraging people to see their bodies as amazing and worthy of care.
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