New Inquiries into Eating Disorders and Obesity


Last week, there was some media coverage of a new study, published in Pediatrics (the journal of the American Academy of Pediatrics), that highlights the concurrence between obesity/overweight and eating disorders. The study sheds light on the fact that a significant number of young people who seek clinical treatment for eating disorders come from a history of overweight or obesity. At the Mayo Clinic Children’s Center, where Dr. Leslie Sim, one of the authors of the study, works, 45% of adolescents seen for ED treatment in the last year came from a history of obesity. The study makes a case for recognition of obesity as a common precedent to disordered behaviors. It also illuminates the very tendency of primary care providers to overlook symptoms of disordered eating in people with history of obesity. It highlights two case studies: a fourteen-year-old boy and an eighteen-year-old girl whose eating disorders were misdiagnosed in large part because they had previously been obese.

As I read this article, I felt an enormous sense of disappointment at the way both obesity and eating disorder treatment are failing young people in this country. Because our emphasis is on weight loss at all costs (rather than the fostering of healthy habits), obese adolescents often transition directly into anorexia, bulimia, binge-eating, and EDNOS. At least half of the men and women I know who have struggled with eating disorders were overweight or obese growing up, so it comes as no surprise that what I’ve observed is borne out in the 45% statistic. Still other individuals who have shared their stories with me say that the eating disorder began when they were advised to lose weight by a health care provider or school nurse. In their dutiful attempts to obey that mandate, they quickly turned to extreme forms of restrictive eating or exercise.

Sim, Lebow, and Billings’ study details the history of a fourteen-year-old boy who had lost over 87 pounds. Possessed of a significantly higher than average BMI through childhood, he’d begun dieting at the age of 12, first by eliminating sweets, fats, and carbohydrates, and ultimately resorting to eating 600 calories per day. He developed hallmark symptoms of an eating disorder: difficulty concentrating, low moods, bloating, constipation, social withdrawal, fatigue, and intolerance to cold. His health care providers tested him for a number of GI disorders (celiac sprue, GiardiaH. pylori), and thyroid abnormalities. In spite of the fact that he began to show heart irregularities and dehydration, eating disorders weren’t suggested.

The study states,

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.

Italics are mine.

The next case study is equally disturbing. An eighteen year old girl was sent to an ED evaluation because she was demonstrating extreme fear of weight gain, amenorrhea, intolerance to cold, stress fractures, excessive exercise, food restriction, and binge eating. She, too, came from a history of obesity. She had begun dieting at the age of fourteen, ultimately going from 97th percentile for weight to the 10th percentile in only three years. After the first year of her weight loss, she developed amenorrhea, but the suggested explanations were PCOS or her long distance running, and she was put on birth control pills. She was referred to a dietitian after her stress fractures developed. The dietitian didn’t suggest ED treatment or express concern over her severely low fat diet, even when the girl’s mother suggested that she might have an ED. According to the study, the girl’s physician noted, “‘given that her BMI is currently appropriate, it is reasonable to do a trial off the birth control pill and see if her menses resume.’”

Italics are mine again.

In our green recovery discussions, we have often touched on how flawed BMI is as a marker of health. The USA Today coverage of the new study discusses this problem. It notes that many of the people who need ED treatment aren’t immediately identified as being at risk because they aren’t underweight:

It’s a “new, high-risk population that is under-recognized,” says Hagman, medical director of the eating disorders program at Children’s Hospital Colorado, who was not involved in the new report.

The kids she sees in this condition “are just as ill in terms of how they are thinking” as they are in terms of physical ailments, she says. “They come in with the same fear of fat, drive for thinness, and excessive exercise drive as kids who would typically have met an anorexia nervosa diagnosis. But because they are at or a even a little bit above their normal body weight, no one thinks about that.”

These cases are no surprise, says Lynn Grefe, president of the National Eating Disorders Association. “Our field has been saying that the more we’re pushing the anti-obesity message, the more we’re pushing kids into eating disorders” by focusing on size or weight instead of health and wellness.

Medicine is not a perfect science. BMI can help physicians to quickly identify someone who is very overweight or underweight, but like any diagnostic tool, it has limitations. One way to circumvent these limitations is to use multiple diagnostic criteria when it comes to complex conditions like EDs. Weight may be telling, but it doesn’t tell the whole story. Listening to a patient’s symptoms, history, and habits is equally, if not more, crucial. It’s time for treatment providers to stop equating eating disorders with the state of being underweight. People who are not underweight by the books can have eating disorders, and–as one of my commenters noted–people who are underweight don’t necessarily have them.

What struck me most about this study was the bias it unearthed. It is the idea that there are two types of people– people who have been overweight, and people who are, or could become, restrictive– and that those two types of people are not and cannot be one in the same. This is the bias that leads a primary care physician to miss overwhelmingly evident ED symptoms in a kid who used to be obese. It is the bias that, left uncorrected, may allow countless adolescents and adults who are in need of care to go unnoticed.

US News and World Report interviewed Dr. David Katz as a part of its coverage. Katz is the Editor-in-Chief of the journal Childhood Obesity, President-Elect of the American College of Lifestyle Medicine, founder and President of the non-profit Turn the Tide Foundation, and the founding director of Yale University’s Prevention Research Center. He has devoted much of his career to combating childhood obesity through education about healthy eating and a comprehensive approach to patient care. He echoed the dangers of treating obesity and disordered eating as mutually exclusive phenomena, and underscored the fact that there is quite a bit of fluidity between them:

“First, obesity itself is a risk factor for eating disorders,” Katz said. “This link is well established for binge-eating disorder, where obesity is potentially both cause and effect…Second, while weight loss in the context of obesity may appear beneficial, there is a point at which the methods used — or the extremes reached — may indicate an eating disorder,” Katz said.

“Effective treatment of obesity cannot simply be about weight loss — it must be about the pursuit of health,” Katz said. “An emphasis on healthful behaviors is a tonic against both obesity and eating disorders. By placing an emphasis on diet and activity patterns for health and by focusing on strategies that are family based, we can address risk factors for both eating disorders and obesity.”

Just as weight restoration alone cannot remedy anorexia, neither is weight loss, in and of itself, an adequate treatment for obesity. In both cases, changes in weight should be accompanied by an emphasis on the importance of nourishing foods and an attempt to foster lasting, positive body image.

✵          ✵          ✵

Between the ages of eight and ten, right after my parents’ divorce and during a turbulent moment in my childhood, I gained some weight. My pediatrician remarked on it during an annual checkup when I was eleven–he wasn’t overly worried, he said, but a diet might help me get back to a more “appropriate” weight for my frame. He left it at that, and I took matters into my own hands. This was that summer that I discovered rules and restriction. It was the summer I realized that I could make my body “behave” itself. It was also the year that my weight took its first major plunge, and the roller coaster in and out of my ED began.

In bringing up my own story, I don’t mean to draw a direct or easy comparison between what I remember and what the two individuals profiled in the study experienced. Nor am I putting all of the blame on my physician, because he was acting in good faith, and there were many, many factors involved with my ED. But I couldn’t help but feel a sense of recognition as I read, an empathy that having comes from having once felt as if someone–someone who was supposed to be taking care of my health–had given me the message that I ought to reject my body. While I recognize the seriousness of childhood obesity, and support all healthful measures undertaken to treat and prevent it, I believe that the onus is upon health care practitioners to do so in a way that will encourage children to embrace their bodies, rather than renounce them. I’m hopeful that it can be done.

As always, I’d love to hear your thoughts on the study, which can be found here (Sim LA, Lebow J, Billings M. Eating disorders in adolescents with a history of obesity. Pediatrics. 2013 Sep 9. [Epub ahead of print]).

In the meantime, I wish you a happy Sunday, and a great start to the week ahead.


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  1. Hi 🙂
    i’m a massive fan of your blog and this article particularly moved me. I thought i’d share my story with you because it deeply suggests the flaws of the whole BMI and eating disorder system. I’m an 18 year old girl from Sydney, Australia and am currently in recovery from anorexia and disordered eating. I was not/ nor have i ever been overweight but due to a lot of psychological issues and the use of an eating disorder as a coping mechanism i have struggle on and off for three years.
    What i find most riveting about your article is the fact that the study suggest that BMI contribute to a lot of the diagnosis.It is due to my BMI that i truely suffered. For me, i started this year with a lot of negative things happen leading to me developing Anorexia again. I was seeing a councilor at the time it started and kept telling her of my eating issues. She weighed me once and i had already dropped 7 kilos from my initial weight. She did not weigh me for 8 more weeks until my health team decided it would be a good idea to put me on anti-depressants. The psychologist who was called in was concerned about putting me on medication when i had mentioned how i restricted and purged occasionally. Eight weeks since my first weighing i had lost 10 kilos from my initial weight (which i might add was a healthy weight) and the psychologist suggested concern at the fact that my BMI was sliding underweight. She told me that once i got down to a BMI of 16 i could experience specific side effects.
    However, despite the fact that i was now “underweight” my health should have been fixed but my councilor did not take me seriously. I was told that due to my BMI, i was not yet classified “anorexic” so there wasnt really anything to worry about because i wasnt there yet.
    Now my councilor fully knew of my constantly evolving restriction yet every time i mentioned how much i was struggling i was given little help due to the assurance that i wasnt “sick” yet. My councilor threatened me by saying that if i didnt gain weight (which by this time i was petrified of- a clear sign of my eating disorder) that my parents would have to control my intake- yet due to her negligence i continued to get worse.
    I stopped seeing her and my weight continued to decline. I might add that i am in my final year of high school and am currently sitting major exams and i got worse with the eating disorder. I was fatigued, anemic, suicidal, low iron and low blood pressure, lacked concentration, was afraid to eat in front of others and started overexcercising. It was due to the fact that i was told my BMI wasnt proving i was sick that i didnt take my eating disorder seriously, thinking that i was too fat and obviously not sick when i was facing fainting feelings on the daily.
    My parents finally got me proper help and i’m finally making recovery. I’ve started eating more healthy then i did before, exercising and exploring how i can become the best person i can become. I feel like eating the foods i do (mainly superfoods, organic and mostly vegan) has helped me connect with the greater world and helped me in establishing a sense of self love and acceptance. Everydays a struggle but i love cooking and your website has been so beautiful and inspiring and i cant wait to try it all. Youre an incredible person and i’m so glad i’ve stumbled across your website!
    I completely think the BMI program can be flawed as despite the fact that i was indeed underweight i was neglected for several months. I am taking my recovery into my own hands and just that was more awareness about eating disorders as they are so destructive.
    wow this turned into an essay! Thank you so much for sharing your story and for everything xxxx

    • Hi Jamie,

      There is so much here, but I guess I’ll keep it simple and say THANK YOU so much for sharing your story. I’m glad that you’re feeling better, and I wish you so much luck on the road to a continued recovery.


  2. Thanks so much for writing this, Gena. So many people–children, teenagers, adults–suffer from eating disorders and are suffering so much inside but are never confronted about it in a helpful or concerned way because they are not “underweight.” I was overweight as a child which led to my eating disorder as a teenager, and I remember my primary care doctor complimenting me when she saw me–in my most darkest place, consumed by my ED–40 lbs lighter than the last time she saw me. She even made a joke about my chest being smaller, the only “downside” to dieting (as a female). Doctors need to be more aware of their patients in this way because what she said only fueled my ED at a time when, if noticed, could have prevented some major issues.

  3. Thank you for sharing this with us Gena. This makes me pretty sad… I’ve struggled with disordered eating in the past, but wasn’t overweight to begin with. People really are hyper-focusing on weight loss these days and it is so unfortunate that some feel the need to take it to extremes to lose weight. I feel like we are very centred on numbers instead of trying to promote health and wellbeing and happiness. Hopefully this will change.

  4. This is an excellent post Gena! As someone who works in this area, we definitely see overweight/obesity as a very common precursor to eating difficulties, and in adolescents in particular, we often seen what would be anorexia nervosa except that the person started with an above average body weight and so their weight is not low enough (despite significant weight loss and huge associated problems) to meet strict criteria. Fortunately, the latest DSM goes some what to addressing this by allocating ‘atypical’ anorexia nervosa as a diagnosis of those cases, which will hopefully help a bit with recognition and treatment. Overweight/obesity is a recognised risk factor for bulimia nervosa and there are some great initiatives to combine prevention/intervention approaches to suit overweight and eating disorders, it is just unfortunate that they don’t always trickle through to primary care settings and the people who need them.

  5. I just think this is fantastic. Thank you for sharing and providing your wonderful, as always, insight.

    I would love it if the world– medical and beyond– could just let go of “body talk” and instead favor health, both physical and mental. Extreme over- and under-weightedness can be equally harmful and should be approached in a similar manner. No doctor would treat anorexia or bulimia without acknowledging their patient’s mental state along with advising working towards a healthier body. Similarly, no physician should regard obesity as something that doesn’t have a psychological component. A healthy mind is the first step in the direction of a healthy body.

  6. Something that I think is overlooked is the fact that many who are obese or overweight actually have ED symptoms for full-blown EDs. When their weight drops, they just have changed EDs. I’ve had three EDs in my life — first I was overweight, then I developed anorexia as my first ED. Then I was an exercise bulimic. Then, when I started to have a binge/restrict ED, everyone thought I was recovered because my weight was more “normal.” But when I was overweight I had many symptoms of ED, notably binge eating, which returned during my binge/restrict phase. Perhaps if my disordered eating had been corrected in high school, it never would’ve been a full-blown ED.

  7. its so sad esp to see young kids go through this – ED is just not food related, I have noted that it is multi factorial and therefore it is important for different healthcare personnel to address the issue rather than focusing on just weight. Thanks for bringing up such an important topic.

  8. Its an incredibly sad scenario our youth is facing, I actually just posted a story on my Facebook about the general theme I’m receiving from emails all around the nation of VERY young kids (who shouldn’t even have email accounts) asking advice about strict eating, meal plans, weight loss, and eating disorders. This is such a multifaceted issue that has to be addressed socially, mentally, emotionally, physically, and spiritually. Media coverage of both sides of the story (obese/eating disorders) only perpetuates these negative thought patterns for individuals suffering from this- not to mention social media outlets such as Instagram which allow the hashtags anorexia (!!) which baffles me and it creates a DIY for children to maintain a destroying disorder. It breaks my heart and at the same time brings hope that situations like this can be treated with respect from passional health care professionals.

    • That’s so disturbing about social media, McKel. While I like to think that the internet can help a lot of people who are suffering to find community, there’s definitely a dark side, too. Thanks for sharing.

  9. I still fail to understand how modern medicine simply discards cases of ED just because the patient has a normal BMI!!! It’s not rocket science! BMI is not even that of an important factor! Body fat percentage can give you much more valuable information.
    A staggering example is that of amenorrhea. You don’t need to go below healthy BMI to stop menstruating, but only to show extreme,fast and abrupt weight loss/gain, usually when fasting, that disorients the body’s hormone secretion and balance OR very low body fat % (while possibly having healthy BMI), a problem that many athletes face OR stress.
    Disordered eating has first and foremost a psychological background and complication. It’s a way of thinking about food that manifests itself as a bodily illness. However, it’s an illness of the mind.
    Unfortunately, proper education about healthy,nutritious eating habbits is lacking in adolescents and even adults and that’s what government and medical institutes/departments that deal with ED/food administration should have as their #1 priority. “They’re pushing the anti-obesity message” while suggesting the SAD diet, one of the worst in the world, not a healthier alternative such as the Mediterranean diet! It’s all wrong!!! No wonder more and more obese youngsters desperately turn towards disordered eating!
    Gena, my story is very similar to yours and that continues to amaze me day after day. I, too, was encouraged to simply lose 5-8 pounds from a pediatrician at the age of 12. She left it at that too. No advice, no “how-to”. What she didn’t know was that I secretly wanted to lose weight and achieve a “perfect” phisique (I happen to be somewhat of a perfectionist and it was the only thing that I was lacking). Her comment reinforced my desire and ~3 years later “I took the matter into my own hands”.
    As a pediatrician, how on earth do you leave a child to take such a sensitive matter as weight loss into its own hands? A child that nowadays can be easily influenced by TV, the Internet, whatever happens to come to its attention regarding weight loss/popular fad diets? Thats the first mistake those doctors make, right there. They should NEVER advise weight loss without simultaniously providing guidelines and educational information on nutrition.
    I hope the next generation of doctors, which is by far more influenced and knowledgable regarding EDs, will bring forth the underlying and more serious issues of EDs and inovate the way EDs are diagnosed and treated.
    But we should never forget; The most significant principle of medicine is prevention. And it should apply to EVERY ailment, including ED. First prevent, then treat. And this is achieved by inspiring healthy eating habbits to children in school and home, educating about nutrition through adds/official guidelines, the medical community and every pediatrician raising awareness and giving integrated advice, not generalities and bunkum! Yes, the above definitely need political reforms and the independence of the government from private companies, but they can also be spread individually by teachers and doctors, who care, throughout the Educational and Medical Fields.
    Thank you Gena for being so inspirational and Medicine is lucky to have you!
    ~from a fellow med student

  10. This study (and your personal story) rings fully true for me as well. I gain a little weight in grade eight, and set out to lose it in the summer between grade 8 and 9. Instead of looking at the issues that had made me turn to food in the first place, I was helped by the adults in my life in my dieting pursuits. I was even congratulated on my weight loss achievements and “self control” for much of the beginning phases of my eating disorder. It is so sad to know that there is this middle ground between obesity and eating disorders. I believe it is because of the pure focus on weight, instead of looking at mental patterns, behaviour patterns, and all the other signs of disease.

    In a sense, these children may just be replacing one eating disorder for another. So much more focus needs to be paid to the mental/emotional needs of children in general. There is just too much focus on food and weight, and not enough on the heart.

  11. I really appreciate you writing this article and including the Green Series on your website. I’m 16, and last year, I struggled with an ED. I lost a lot of weight, but, fortunately, I have now gained it all back, plus a bit more. I still struggle with is and with accepting my body, but I always feed my body, and I am so thankful that I’ve found an embraced recovery and connected with other individuals in the same boat. I’m actually living now, and my every thought isn’t distracted by the ED. I’m finally moving past the awful times, and I’m loving and caring for my body now. 🙂 Our society is so cruel these days, and the pressure to look a certain way is terrible, and it is affecting people starting at young ages, which is especially detrimental because we’re growing and need a LOT of nourishment. I hope that all those who are struggling fin help soon, and that doctors, friends, family, and all people watch what they say and consider the effect it might have on others. Thanks again!

    • Lis,

      I’m so glad–and also super impressed–that you have managed to come to such a mature appreciation and understanding of the recovery process at your age. I know it’s very hard, but keep on. The more you right for recovery now, the more time you’ll have to go through the process and find health. I know you can do it, and in the meantime, please take support from the green recovery community!


  12. I understand that for EDs, the treatment often involves weight restoration without any attention paid at first to the mental issues with EDs. I understand why this has to be for emergent cases, but I wish both the body and mind could be addressed; I know I would have benefitted from it in my recovery.

    As for “EDs” that aren’t “classifiable”, I think this is wrong. The DSM is so narrow in it’s requirements; who is to say that someone isn’t suffering from disordered eating based on solely their weight and a few hallmark symptoms? This issue irks me to no end…

  13. This isn’t surprising to me, but it certainly is sad. I would actually say there are many blogs in the ‘healthy living’ and ‘weight loss motivation’ categories in which the authors have lost a significant amount of weight, but appear to have developed disordered eating patterns in the process. Difficult to tell online, of course, but it does make sense. And many bloggers have spoken up about their own experiences with this as well. I am glad that there are people looking at these sorts of issues because I think the stigma of obesity is going to increasingly affect mental health, as social norms dictate that it’s better to be obsessed with ‘health’ than to carry extra weight.

    My own experience is a bit reversed from yours. In order to convince my parents to “leave me alone” when they finally realised I had anorexia, I gained a significant amount of weight in a rather short period of time. Through binging, which I now know is a rather common behaviour to adopt in treatment, but then I thought I was a freak and a failure. Do you know what my mother did, rather than getting me help? Asked if I wanted to go to weight watchers with her! Her chronic dieting was a major influence on me, and here I was, less than a year out from restoring my weight after anorexia, with an offer to join weight watchers. It set me back enormously in my recovery. Plus I wasn’t even in the overweight category, so it certainly warped my perspective on what constituted a healthy weight even further.

    Back to the article: I would like to have a better understanding of just how disproportionately this population is represented, and I couldn’t quite tell from the article. It mentions 17% of children meet the criteria for paediatric obesity. But surely many more fall into the overweight category. The number at the Mayo Clinic you give is 45%…if that’s the same population that meets the paediatric obesity criteria (and doesn’t include those that fall into the overweight category?), then their representation in the population is wildly disproportionate and much worse than I would have imagined!

    • That’s a great question, Sarah. I’m honestly not sure, but it does say that 45% comes from obesity (not overweight), which would mean that the overlap between these two populations is quite remarkable.

      Thank you so much for sharing details of your story with us.

  14. Gena,

    Great post and interesting article! As a dietitian, I couldn’t agree more with your thoughts on the matter. I see a lot of obesity and some eating disorders in my practice. So many health care practitioners are not well trained on how to approach obesity in a sensitive way or how to identify eating disorders.

    As you point out, dependence on weight and BMI is so flawed. BMI was originally developed to assess populations, not individuals. So many factors influence what a healthy weight is for an individual (frame size, muscle mass, genetics, etc). It sounds like common sense (should be common sense) but so few providers take this into account.

    Your comment “the emphasis is on weight loss at all costs (rather than fostering healthy habits)” really resonates with me. I see this attitude from physicians and other healthcare providers all the time. In my experience, many doctors do not even ask thin or normal weight patients about their diet- almost implying that the quality of their diet or how restrictive they are doesn’t matter as long as their BMI is within the normal range. On the flip side, when an overweight patient comes in, the assumption is that they eat fast food or junk all day. Of course this is not always the case. Eating healthful, nourishing food is important regardless of size. Unfortunately you don’t hear this from most doctors.

    The most disturbing trend at my institution (and other institutions as well) is the push for bariatric surgery in obese, young adolescents. I have seen surgery performed on teenage patients who have had minimal nutrition or psychological counseling. Unfortunately, there are many complications (both medical and psychological) to this surgery and it does not solve the underlying problems. I’ve seen eating disorders develop after this surgery.

    I really hope the research you highlight catches up with clinical practice soon. The way we treat obesity and eating disorders in this country needs a dramatic overhaul! Thanks for this timely post!

    • I couldn’t agree more with all of this, Lauren. I also hope that a change is on the way for our treatment of obesity/overweight in young people (and everyone!). Thanks for sharing your insight.

  15. Gena,
    This is a really great post. Thanks for bringing it to light. It also shows how important that sincere, well and diversely read people enter into the medical field. I look forward to the day that you don the white coat and begin helping people.

    Unfortunately, it is not all that surprising that our medical system continues to fail those suffering from ED. The entire community suffers from a reductionist thinking- that same reductionist thinking that looks solely at single nutrients – until we recognize the complexity behind proper nutrition and food behavior our medical system will continue to fail us.

    • Ant,

      Great point about the tendency to look at particular nutrients and other specifics. It’s another symptom of the failure to envision patient care as a comprehensive process/approach.

      As for me and doctoring, I hope so, too 🙂


  16. This is interesting information, Gena. I have never really thought or heard about the correlation between being previously obese and then developing an eating disorder. In my own eating disorder experience, I know that having an overweight mother compelled me to behave in ways that would ensure I would never have a body like hers because I had this intrinsic fear of becoming fat. Unfortunately, this created an awful rift in our relationship that is only now slowly improving. I have since learned that what you look like does not determine your inner beauty and that it’s important to look at the whole picture of health because there’s always more to the story than what meets the eye.

    • Elisabeth, I so totally empathise. Having got ill as a teenager (I’m 23 now), I am terrified that my body’s natural predisposition is to be like my mum and grandma who are both overweight, even though I was never overweight as a child. They are, however, both unhealthy – on various medications for blood pressure and cholesterol so, unfortunately, how they look is indeed a part of the picture of their health.

    • Elisabeth,

      That sounds like a really difficult and painful experience. Interestingly, I have heard similar stories from young women whose parents struggled with weight. I hope that you and she continue to heal whatever rift developed through this experience.


  17. Gena, I’ve been a long-time lurker and have loved reading your posts about veganism and recovery. I’ve considered submitting something for your Green Recovery series because I feel so strongly about the positive impacts veganism has had on my own journey towards recovery! I went vegetarian and then vegan in the midst of my ED, and although the so-called “restrictive” aspects of these diets certainly fit in with my established ED mentality at the time, I truly was motivated from a deeper place of concern for the larger issues of the animal industry. In fact, one of the reasons I transitioned into a genuine recovery effort was because I couldn’t stand the cognitive dissonance I experienced when I would at times use my veganism, a deeply held ethical belief against causing harm, as a cover for my harmful disordered eating. I knew that so many vegans falsely experience eating disorder accusations and I hated to think that I was contributing to that.

    Anyway, this post really hit home for me because I experienced most of what was described in the excerpts you shared from the article. I grew up in a chaotic family with a disconnected food culture where we rarely ate meals together or participated in physical activity together. During puberty, I suddenly gained 30-40 pounds in a year resulting from stress-related binge eating, poor overall eating habits and low physical activity. During my four years of high school, I steadily gained an additional 10-15 pounds a year, receiving endless criticism (mostly from family and doctors) especially once I reached the “obese” category.

    During a period of stress as a college sophomore, I inadvertently lost about 15 pounds, which triggered waves of well-intentioned validation from friends and family. The rest of the story isn’t particularly unique. I lost about 60 pounds in nine months before beginning a few years of yo-yoing back and forth within the 25 pound range that separates me from a healthy maintenance weight and an extremely unhealthy (but “normal” BMI) low weight. The change from disordered eating to eating disorder kicked in after only 4 or 5 months of so-called “healthy lifestyle changes” after being technically obese for several years.

    Throughout the years of weight loss and fluctuation, the overwhelming majority of comments about my appearance were positive, particularly from those who had known me as an overweight teen. Only a few friends and professors had the finely tuned radar to sense that something was wrong. I became something of a poster-child for healthy weight loss on my campus, which unfortunately kept me from considering the reality of my disorder. When I saw a doctor after having lost my period for 9 months, no one ever considered EDs based on my history of obesity. PCOS was suggested and I was given brief hormone treatments to restore it temporarily. At a plastic surgery consult only a few months later, neither the surgeon nor his assistants ever asked about EDs. Though I was only 20 and in the lower half of the normal BMI range, the plastic surgeon recommended liposuction in addition to the surgeries I was already considering. Unfortunately, my surgeries dramatically worsened my body dysmorphia and encouraged further obsession. During a later relapse, my therapist feared for my health and required that I see a PCP if I wanted to continue treatment with her. The physician spent the majority of the appointment praising me for having lost so much weight. On my therapist’s insistence, I mentioned that I was under a lot of stress at home and at school, and that this was an “unusually low weight for my body.” Even then, she never asked about EDs, though she did order some blood tests which fortunately (and surprisingly) came out fairly normal. These stories are only a few of the many opportunities where a physician could have helped identify my ED, but failed to do so based on my history of obesity and current “healthy” weight.

    The fear, shame, and hatred towards heavier bodies and reverence or awe for those who have achieved the thin ideal is incredibly disturbing and damaging. Anyone who has experienced weight loss and/or exhibits signs and symptoms related to eating disorders should be evaluated for EDs, including those with a history of overweight or obesity. Thanks again for all you do, Gena!

    • J, you certainly seem to be able to offer an unfortunately substantial contribution to the GR series. This is heartbreaking.

      • Thank you for the support, Amanda. On a more uplifting note, I should mention that I celebrated my first year of recovery in May and am slowly but surely moving on to a healthier and happier future 🙂

    • J,

      To echo what Amanda said, yes, you would have much to contribute to Green Recovery. I am so, so sorry that you have had this experience. While it’s wonderful that you are now celebrating recovery (!), I understand that the emotional scars left by this sort of ordeal go deep, and linger. I wish you much continued healing. And I share your tremendous disappointment and concern about the glee with which people celebrate weight loss.

      Green recovery is always here for you — when you are ready, if you are ready.


      • Thanks for your thoughtful and kind reply, Gena. I really didn’t intend to write such a long comment, but I’m glad for a safe space to share part of my story since apparently I needed the catharsis! The scars do linger, but I’ve gradually come to believe that healing is possible.

        The work you’ve done here has substantially informed my conceptions of recovery from an ED, as Choosing Raw was one of the first blogs I started reading when I began that healing process. Your posts and the stories shared by the Green Recovery contributors absolutely played an important role in my journey. I truly appreciate the honesty and sensitivity with which you discuss such difficult subjects, so thank you again for your hard work!

        Hopefully I’ll be brave enough to contribute to Green Recovery some day soon 🙂

  18. This is the biggest thing that bothers me about the popular concepts around weight-loss. I (guiltily) watch all the major weight-loss shows, like Biggest Loser, and I’ve been disturbed by the amount of contestants who develop eating disorders. The trainers sometimes will casually address it, mostly by yelling at the contestants that they need to eat their minimum calories. No one seems to recognize these as giant red flags; that the contestant needs to receive help from a qualified mental health practitioner.

    It all feeds back to America’s obsession with thinness and anorexia as ideals. Being “fat” is shameful, being “thin” is something to be proud of but NOT if you’re naturally thin, then people hate you. I wish we could all just be compassionate and get over it. A focus on health, with intense education for everybody about how food and chemicals affect our bodies, combined with compassion and empathy is what we so desperately need. There is no worse feeling on earth than being dismissed by someone who should care about your health because you’re not thin enough to warrant concern, or because you used to be heavier.

    • I really love what you’ve said about compassion. I think that this area is one where compassion is really needed. People judge those who are overweight/obese without knowing anything about their experiences, people judge those who are underweight, again without knowing anything about their experiences, and finally people even judge those who fit the ideal of society, once again without knowing anything about that person.

      Our outward appearance does not automatically tell the world our health, history, or worth and it shouldn’t be seen as such by the media, people we interact with, and especially not by health professionals. By working to be compassionate, hopefully we all can be better to those around us and get to know the whole person and not just focus on a number on the scale.

      • I am always shocked by the ways in which aversion to obesity/overweight is socially acceptable and commonplace. I couldn’t agree more, Helen.

  19. For me, the pressure to lose a few pounds at around age 12 was internally driven. I had been thin, athletic, able to eat anything and praised for such as a child. Though I was of average weight for a preteen, as I lost my skinniness, began developing curves, I perceived myself as losing my sense of distinctiveness (to piggyback on our many discussions on this thread.) So, that along w/normal preteen/teenage transition woes, precipitated my own first experiment with dieting – as means of gaining control of my body/life/identity.
    In my case too, my pediatrician was the first to recognize my weight loss and alerted my parents. So, I was lucky in that regard. ( If you can believe it, in those days, the term anorexia was not commonly known as it had just become “discovered” a few years earlier. In fact, on the way home from the physician’s office, I remember us stopping by the local library to pick up the only mainstream publication on the illness, by pioneer researcher Hilde Bruch.)

    But, back to your point: I wholeheartedly agree that the recognition of ED related behavior in adolescents must be a team effort, and even the most innocent comments – such as body praising or condemning – to those with predispositions or sensitivities can lead to lifelong patterns of disordered eating and body image wars.

    • This is all very interesting, Karen.

      As I mention in another response, I don’t mean to make it sound as though my physician’s comment was the sole origin of the ED. He was a good doctor, and I know he meant to help. My ED was driven by a constellation of factors, both external and internal, and had he not remarked, I’m fairly certain that I might still have headed down that path. But even if I was starting to feel uncomfortable in my body, hearing a comment from a health professional, whether well intentioned or not, did leave a big impact.

      It makes so much sense to me that the transition into womanhood — the advent of curves, as you say — made you feel as though that sense of being special was taken from you. All so relevant to the conversations we often have here, as you’ve noted. Me, I was the opposite, a very shy, bookish, and not-at-all athletic kid who developed that sense of being “special” only after my initial weight loss/ED bout. But I can empathize so much, nonetheless.

      Thank you for sharing details of your story with us.

  20. “Just as weight restoration alone cannot remedy anorexia, neither is weight loss, in and of itself, an adequate treatment for obesity.”


    After having been overweight since the age of 8, my ED behaviors began after my freshman year of college. A professor remarked neutrally on my weight loss over the summer, adding, “I hope you haven’t been ill.” Which is, of course, exactly what I’d become. But I wouldn’t realize that for a long time, largely because of the bias you highlight here from the study–not from medical professionals in my case, but friends and family confirming my assertion that going from fat to thin was a healthy thing I’d done. And almost no one even asked if I was still trying to lose when there was no need to keep losing. The weight loss completed is always the focus of conversation and, frequently, praise.

    This being defined by our excess weight or former excess weight, these are powerful, often unwelcome, identities that can provide fierce fuel for ED behavior. (I know you’ve written before about identity and EDs in your Rebuilding a Sense of Distinctiveness post way back when. I think it’s valuable, and I’m glad I read it, but it was hard, and I probably should’ve known better. I still have days where I deeply believe the only thing I’ve ever been good at was not eating. Again, these ideas are powerful stuff). I’d love to see the medical community lead the way to a better general-population understanding of EDNOS in particular, and I find very interesting the study’s closing suggestion that any weight loss in patients warrants ED screening.

    • Thanks for this terrific comment, Amanda. I’m sorry that the rebuilding a sense of distinctiveness business was hard. You’re not alone, though. It was hard as hell for me to write, and it’s still hard. We’re all stronger when we share this stuff with each other. <3

  21. Gena,

    IMHO, you’re too polite on people, especially doctors who use BMI at the individual level 🙂 BMI, at the individual level, is useless. Worse than useless, as its use can lead to problematic and incorrect conclusions. Any person, especially a doctor, who uses BMI, at the individual level, to give health advice, do perform diagnosis, should be laughed at, ridiculed.

    An individual with BMI at slightly above or below the “healthy” threshold isn’t necessarily unhealthy (eg athletes), similarly, an individual within the “healthy” thresholds isn’t necessarily healthy either, not even if you restrict health to just cardiometabolic health, eg certain ethnic populations, specifically South Asian, but also possibly East Asian, appear, for whatever reason, appear to be predisposed to store body fat as visceral fat (which has negative effects on cardiometabolic health, compared to if fat is stored peripherally).

    Furthermore, age is also a factor, ie, whereas young(er) women tend to store bodyfat peripherally, as women age, post menopause, bodyfat distribution becomes more visceral and central, more similar to males.

    And of course, as you point out, it is entirely possible for someone to have an eating disorder, even if BMI is within the “healthy” range. Indeed, this is especially the case with EDNOS, especially the case with young athletes, both women and men. The physician for the girl you mentioned should have been stripped of his licence, and forced to go back to school. Even looking at only the physiological markers, ie amenorrhea + intolerance to cold + stress fractures, should have told the guy that she has a very serious problem. A healthy young woman athlete should NOT have these problems. Even the stress fractures alone should have been a big warning sign. Healthy young athletes, men or women, eating properly, training properly, should NOT have a history of stress fractures, given that physical activity itself results in greater bone strength and density. If a young athlete has a history of stress fractures, or low bone density, especially compared to non-athletes, that is huge red flag that something is wrong.

  22. Interesting article – am also wondering if perhaps childhood and teenagehood eating disorders morf in to adult yo-yo dieting. Again, it’s the same obsession of losing weight, though not to the anorexic and obese extremes – just a thought.

  23. Thanks for sharing this piece, Gena. It seems fitting that I read this today, one day after seeing an account on Twitter of a woman who weighs around 270, but wants to get down to 135. I read tweet after tweet of her My Fitness Pal updates that were limiting her to 400 calories and mentioning purging if she binged up to 1000 calories in a day. Made me uncomfortable especially when I read the incongruous statement that her account wasn’t pro-ED, but in the context of this article and study, I feel that I have some perspective.

    • Ooof. That’s troubling, Melissa.

      I recently saw a People magazine article praising teens or young people who had lost around 100 lbs each. Granted, each of the individuals profiled had been obese, by the books, before the weight loss, and their weight losses had clearly remedied many things that had impacted their quality of life (shortness of breath, fatigue, knee or back pain, etc). And yet, when the magazine showed some “day in the life” snippets of what these individuals were eating to maintain that weight loss, I was stunned by how restrictive it seemed. I appreciated the inspiring message–which was that people who will benefit from weight loss can do it–but I had deeply mixed feelings about the kind of maintenance measures the magazine was highlighting

      • These sorts of excessively restrictive regimes are all over mainstream media and the Internet. Our “quick fix” weight loss culture is so pervasive and deeply trouble me to the point that I just avoid reading re. them altogether. I do know that If I were to follow such a low calorie diet, I’d be especially prone to lapse back into my ED. (I think in this way, EDs can often become addicts; once you’ve suffered from a serious, prolonged bout esp. during your formative years, you become physically and psychologically “allergic” to dieting in the same way a recovering alcoholic is forever “allergic” to drinking.)

      • This is troubling, too, Gena. In our society, it’s become a lot more acceptable for people to be between an average size and underweight than for someone to be either slightly overweight or obese. Plus, when all that matters is a size or a number on the scale and when most doctors have only the bare minimum knowledge of nutrition, it’s easy to see how these things can get out of hand.

      • This reminds me a little of the article by the New York Times health author (Tara Parker-Pope?) describing her own weight struggles and her frustration at not being able to eat more. I don’t want to believe that having been overweight or obese consigns one to a life of restricted eating, but it has been my observation. Friends and family members who have been overweight seem caught, like Parker Pope, in a doublebind: restrict intake or regain weight. I am not surprised to learn that eating disorders are rife in this population.

        So yes, we want to encourage healthy lifestyles and not restrictive dieting, but we also need to take seriously the risks inherent in obesity, one of which is (or seems to be) a life long struggle with weight. And so, while I do not condone your pediatrician’s triggering remarks, I *do* feel that it is appropriate for parents and for medical professionals, if they can prevent a child from becoming overweight, to do something. I say this cautiously – my own long battle anorexia was triggered by a remark from my running coach – I don’t pretend to have the answer.

        Do you remember the Vogue piece about the upper East side mother who put her daughter on a diet – very publicly – and promised her a whole new wardrobe if she lost the weight. She took so much criticism, and I remember thinking at the time that the woman herself didn’t have the healthiest relationship with food. The question is, did she set her daugher up for a life of eating disorders, or, perhaps, save her from one?

        Restrictive eating has clear physiological consequences – there is no question the metabolism is suppressed in both the overweight and the underweight. What still needs to be sorted out is how metabolic repair happens in different populations of dieters. I know (from my own experience) it is possible post anorexia. Even after 10+ years. Indeed, there is some evidence anorectics become “hypermetabolic” during and even post recovery, which is what makes weight gain such an ordeal. Among the obese, I know it can happen, and a raw food diet seems to help here – but there is mounting evidence that metabolism among the formerly obese remains suppressed. This is what Parker Pope was getting at in her article, and it is quite frightening.

        So, even though I consider myself an advocate for health at any size, I don’t, in principle, have a problem with doctors and parents stopping obesity in its tracks. What they are doing is not wrong, in my opinion. The real question seems to be 1) how to identify those children who are really at risk, and 2) how to encourage healthier relationships with food without triggering an eating disorder.

        Finally, it does seem that weigth gain (when there aren’t socioeconomic and other factors predicting it) in children can be a signal something else is going on. I remember one boy, the brother of a friend of mine, who became severely obese beginning in middle school. It was sad and perplexing … only 30 years later did I learn he was a victim of clergy sexual abuse.

        • Elizabeth,

          All great points, and I do see the value in setting children up for a life in which they will not have to struggle with weight. This is a delicate boundary to navigate. I remember your great comments when I mentioned the Pope article on my blog, and I agree that we have to find ways to help set kids up for a lifetime in which they won’t risk tumbling into the restriction that can injure metabolism (and all that follows).

          I also didn’t mean to foist the “blame” for my ED onto my physician’s shoulders. I have a strong feeling that, had his comment not been a catalyst, something else would have been, ultimately. There were so many factors that led into it, many of which were totally internal, not external. And I don’t believe that health care providers should hold their tongue about weight gain. In the case of pre-pubescent girls and boys, I wonder if more leniency should be granted for minor weight gain, since it’s common enough for kids that age to put on some weight that naturally resolves itself through growth spurts, puberty, and the advent of middle school athletics. But perhaps that’s my own wistfulness talking, my wish that an essentially “safe” amount of weight gain in my case had been given the chance to come off organically. And of course, a great argument could be made that, had my physician not mentioned it, peer teasing would have soon ensued, leading to the same consequences. In speaking up, physicians can prevent that sort of thing from happening, which is precisely your point.

          In any case, I think that what was problematic was the directive to go on a “diet” without any subsequent education — no pointing out which foods are healthful and nutritious, or information about how to make it happen without overdoing it. Tell an eleven-year-old girl to diet, and she will surely turn to her peers and/or the media for direction — and that can be very problematic, indeed. So while I do think that doctors should be conscious of their patients’ fluctuations in weight, and address them, I feel strongly that a sensitive, comprehensive, and education-oriented approach is key.


      • I too have really mixed feelings about the methods of weight loss that are encouraged in the media and even by health professionals. I’ve seen other examples similar to how you’ve described that magazine article and they always seems to praise really restrictive behavior to achieve weight loss which I think can really easy transition from a potentially beneficial weight loss tool to one that is maladaptive. I have found this to especially be the case when rapid weight loss is showcased.

        On a related note I took an online nutrition class this summer where for an assignment we had to track and measure all the food we were eating for a handful of days to compare our intakes to the recommendations by various organizations. One of my classmates shared how this was a very serious trigger for her as she has a history with ED and how the assignment was very hard for her to complete. It seems as though these methods, which I know can be helpful for some, are not even considered as potentially problematic when they are recommended.

  24. Though I’ve experienced several kinds of disordered eating, my weight never would have been an indicator, so sometimes I felt that I wasn’t taken seriously when I sought help. During the most severe restricting phase of my eating disorder, I was never underweight even though I lost 40 lbs in around three even though I felt stuffed 24/7 and felt like I couldn’t be near food without eating even though I knew I didn’t want to eat.
    It’s important to remember that eating disorders and mental disorders, and that no single physical symptom can be a reliable indicator. I agree with you wholeheartedly here. Thanks for posting this!

  25. This was a fantastic piece Gena, like all your other eating disorder or recovery pieces they are great reads especially since I can relate to them

  26. This study definitely appears to highlight an issue that is far too often overlooked – my own history is that of being overweight and then being unable to ‘switch off’ the losing weight mindset and only allowing it to become more extreme which led to some very disordered behaviours. I have never been an underweight BMI, but I have suffered with HA, even though I am actually now considered to be overweight by BMI standards my periods are yet to resume. I hope that this study helps some professionals to become more aware of the links between these seemingly opposite and separate issues, when the reality is that they are really just two sides of the same coin.

  27. Thank you so much for these posts about ED. You are living up to your vocation to spread compassion and understanding. Your vegan activism grows from compassion for animals and is helping to shape my own vegan journey. When you write about ED you inspire those in the midst of the battle, and teach those, like myself, who are ignorant of ED. Thank you for teaching me to be more compassionate. To all those who struggle with ED: You are in my thoughts and prayers every day. I pray for your continued recovery and journey to health.

  28. I hadn’t seen this study but have heard of numerous cases of overweight individuals setting out to lose weight and spiraling into eating disorders. I think Katz says it exactly right that we need to promote health not weight loss and realize that obesity usually has causes just as complex as anorexia which need to be addressed rather than simply telling the sufferer to lose or gain weight.
    My own anorexia wasn’t picked up on for a long time given that I’ve always had an officially underweight BMI. Another reminder that weight is certainly not the only factor to consider in the assessment of eating disorders.
    Thanks for another thoughtful and thought-provoking post Gena.

  29. I find the point that people who aren’t underweight but “are just as ill in terms of how they are thinking” an extremely important one… As someone who has suffered from an ED, I see it as a mental illness that manifests itself in physical signs. Even if those effects are not obvious yet it does not mean it does not exist or is less serious, as you have pointed out very eloquently in previous posts.
    I have never been overweight, but I do remember looking at an obese woman when I was in the midst of my ED and suddenly realizing that we were not so different. We had both lost touch with our bodies, the messages they send us and the balanced relationship that can exist between our minds and bodies. This post definitely reinforced my belief that so many people need help healing their relationship with food and that that should be the focus, rather than having people match up with the “right weight” at any cost.

  30. This is me, exactly, as you know from my story. It’s hitting a little too close to home to post more at the moment, but thanks for your attention to this topic!

  31. This sounds like a fascinating study. With the emphasis society has placed on obesity being a disease and the prevalence of childhood obesity, the idea that simple weight loss will fix the problem is an attractive notion. It’s unsurprising to me that a large percentage of adolescents would develop EDs out of that experience. I’m curious–does the study only make recommendations for changes in patient care, or does it call for broader societal change on dealing with the obesity “epidemic”? I think the conversation is starting to change away from dieting and more towards total health, but I think we still have a long way to go, societally. In terms of patient care, I think that BMI can be a good starting point, but it’s so important for doctors to look at patients as total people, not just numbers on a chart. According to the charts my pediatrician has when I was a kid, because I was only five feet tall (still am), I should have weighed less than a hundred pounds. But if she had taken a minute to look at my bone structure, she would have realized that the only way I was going to be at that weight was to develop an ED–it was not the right weight for my body type, regardless of my height.

  32. I think what you said about physicians neglecting to diagnose an eating disorder because the patient’s weight is not necessarily low enough is important but it can go the other way as well – just because someone is underweight does not mean that they have an eating disorder (and unnecessary or unneeded treatment is both a waste of resources and psychologically damaging to the patient).

  33. i feel like statistically speaking this kind of makes sense because childhood obesity has become pretty prevalent, so if a typical cross-section of the population were to develop EDs, a large number of them would be obese. still, i think this speaks to the fact that there’s not like a standard class to take or a healthy way that doctors tell you to lose weight besides “diet and exercise.” as a teen, i was at times significantly overweight and i was really frustrated by the lack of information on how to lose that weight without annoying diet tips from my family (and my mom has a history of eating disorders, so i feel like that may have not been quite so helpful). i ended up starting at weight watchers in my early twenties where i am still a member today. i feel like the only way this can be solved is by educating kids and their parents (starting very early) on what it actually means to live a healthful lifestyle.

    • Thank you so much for sharing your thoughts, anon.e.mouse. I agree that the numbers make sense statistically, but I do think it’s interesting to explore cases where obesity was a direct risk factor for the ED later on.

  34. Hi Gena,

    I’m so glad you pointed out the important points of this study. I read the article myself and was quiet disappointed about how child obesity was handled in the matter. I gained weight as a child after being sexually abused. It was my way of hiding behind my body that led to a 20 year follow up with disordered healing and a three year recovery recently.
    Though I’ll always consider myself a cautionary recovery survivor, I have a real problem with how overweight children are handled today. They aren’t being told that it isn’t there fault and or taught the wonderful effects of eating healthy and being physically active. Instead, most are fed junk food, and many live indoors and become inactive, while simultaneously being told they should be embarrassed of how they look.
    I understand all children are different, but I do know that I was never taught how to eat healthy as a child, and junk food was at my disposal to sink my emotions into, which I did.
    I don’t know if there will ever be a solution to this problem, but I’m glad someone else recognizes this too. Great post!:)

    • Really poignant commentary, Heather. I so appreciate your sharing your story with me, and with all of us. Thank you.

    • This is such a good point, Heather, thank you for bringing it up. There’s nothing worse than shaming someone about something they have zero control over, if from nothing more than a lack of knowledge.

      I’ve struggled terribly over the last several years with gradual weight gain that I couldn’t take off – come to find out from research on my own it’s due to significant hormone imbalance, which I am now working to correct. My physicians would bring up the weight gain, sometimes in a mean, cold way (former anorexic here, so this was doubly painful) but then would turn away from me when I tried to tell them about my bone-deep fatigue, insomnia, constant hunger, etc. Like I was supposed to magically get thin on my own without help from anybody, and be ashamed of myself until I was. If they had just listened to my symptoms, some simple, cheap tests would’ve revealed the problem and I could’ve healed from this years ago, instead of spending every day feeling disgusting and defeated.

      It’s a terrible precedent we set for our kids.

      • Hi Nichole,

        I found it interesting to read about your experience, as I, too, have struggled with the symptoms you listed: extra weight, extreme fatigue yet inability to sleep, unrelenting hunger, and, in my case, intolerance to cold. I no longer carry the extra weight, but I still suffer from the other symptoms from time to time, and some almost constantly. Sorry to hear your medical provider was not more helpful earlier on!

      • I am so very sorry that you’ve had this recent experience with your health. I hope that your hormone balance will be restored soon. Even in the wake of an ED, this is possible. I send you healing thoughts, Nichole!