Weight Stigma Viewed Through the Eating Disorders Lens: Wendy Oliver-Pyatt, MD, FAED, CEDS

BEDA promotes cultural acceptance of, and respect for, the natural diversity of sizes, as well as promoting a goal of improved health, which may or may not include weight change.  The views expressed by our featured bloggers are their own.

Wendy Olivery-Pyatt

Wendy Oliver-Pyatt, MD, FAED, CEDS is co-founder and Executive Director of the Oliver-Pyatt Centers and serves on the Board of Directors for Binge Eating Disorder Association (BEDA).   She thanks BEDA for the opportunity to contribute to the Weight Stigma Awareness Week on this important subject, and for promoting awareness of Binge Eating Disorder and the impact of weight stigmatization. She enthusiastically encourages participation in this year’s Weight Stigma Awareness Week (WSAW), September 23-27, 2013.

Let’s Define the Conflict We are Faced With…

Our culture places significant importance on our appearance, and we experience pressure to be unnaturally thin.  Low body fat is equated with “fit” which is somehow then tied in with “better” or maybe “more worthy” or more “in control”.  Society tells us that dieting (defined as restricting our calorie intake, and ignoring inner cues) is the way to be thinner, fitter and healthier.   In fact, in our culture, hunger is viewed negatively; we pay money for drugs to suppress our appetite! We are bombarded with food and we don’t know what to do about it.  The grocery store line says it all.  On the right, there are the Cokes, Sprite, M and Ms, and other candies, and on the left the airbrushed models with fake bodies and smiles that stare at us,  leaving those who are vulnerable with a feeling of inadequacy and shame.  The thinking is, “Somehow I will be better, do more, and be more lovable if I am thin”.  So we diet and restrict.  And our intentions are good.

The “war” on obesity is one of those situations where the concept, ‘the road to hell is paved with good intentions’, comes to mind.

Binge Eating Disorder (BED) patients live in a culture which shames them on a daily basis (if they are among the 70% of BED patients who are labeled as a larger size, overweight or obese).  And the attack on the larger size person in our society places enormous pressure on those who happen to be bigger, to diet and to restrict their caloric intake.  A quote a patient once told me she heard from a doctor was “You are fat every day, so you should eat less every day and exercise more every day”.  This statement, (which sadly rings true of what the medical community and society tells heavier people each day), may be well-intentioned, by I would argue does not pass the test of “First do no harm”.  It’s time to talk about it!

Let’s start with some facts.  According to the DSM-V, Binge Eating Disorder is characterized by several behavioral and emotional signs:

  • Recurrent episodes of binge eating occurring at least twice a week for six months
  • Eating a larger amount of food than normal during a short time frame (any two-hour period)
  • Lack of control over eating during the binge episode (e.g., feeling you can’t stop eating or control what or how much you are eating) 

Binge eating episodes are associated with three or more of the following:

  • Eating until feeling uncomfortably full
  • Eating large amounts of food when not physically hungry
  • Eating much more rapidly than normal
  • Eating alone because you are embarrassed by how much you’re eating
  • Feeling disgusted, depressed, or guilty after overeating 

In addition:

  • Marked distress regarding binge eating is also present
  • Binge eating is not associated with the regular use of inappropriate compensatory behavior (such as purging, excessive exercise, etc.) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa

BED is a psychiatric disorder and is a red flag for both medical and co-occurring psychological conditions, including but not limited to Major Depression, Post-Traumatic Stress Disorder, Attention Deficit Disorder and other serious mental illnesses.  Because it is a serious mental illness, the typical “prescription” to diet to lose weight (a simplistic behavioral recommendation) sets up the BED patient to utter failure since dieting not only sets the person up to rebound, overeat and weight cycle (we will get to that shortly), but also misses the boat as far as helping the person cope with the serious underlying illness with which the person is faced. This is an illness which requires intensive multi-disciplinary treatment, including but not limited t,o a thorough medical and psychological evaluation, psychotherapy, and nutrition management.

One of the most challenging aspects of treatment lies in the pressure the BED patient faces from healthcare providers and society at large to lose weight, because this is at odds with the need to address an underlying restrictive and shame based mindset which sets the patient up to binge.  We have discovered that our BED patients are highly restrictive in their thinking about what is allowable with food, similar to the restrictive thinking about food in Anorexia and Bulimia.  Accordingly, the BED patient may be as fearful as the anorexic about eating carbohydrates or fats when we serve her breakfast in our center.  Because they are restrictive in their thinking, the BED patient eventually will binge to compensate for the restriction, and in the binges he or she (BED Is an equal opportunity disorder; 40% of those with BED are men) will consume large amounts of calories without compensating in some way.  This is how and why the patient with BED may gain weight over the time of their illness.  What then happens is when they are told they should lose weight? They go back to restriction, and the cycle of restriction, bingeing and weight gain continues!

In order to help the patient with BED, we must address the underlying shame around eating (which is reinforced by society who tells them that fat is bad and unhealthy).  This shame around eating is intensified beyond what most of us can probably imagine when the person is of a larger size.   I often tell my patients that every binge does not start with the binge; binges start with shame and the underlying restriction.  So we must help reduce the shame, teach acceptance of the need to eat, (which is akin to teaching the importance of managing our needs), and the skill of mindful eating to our BED patients, just like we teach to our other, possibly smaller framed patients.  We have to carefully address the underlying restriction, knowing full well that the pressure to lose weight is something the patient is facing throughout each and every day of their life if they have gained weight due to their illness (again, not every BED patient is of a larger size).

In addition, another common piece of mis-information, which drives the BED patient to binge, is the common belief in our culture that people who are heavier are eating more than the rest of us, and they are eating too much.   This, of course, sends the message to the person with BED to eat less than they are eating.  We have seen, time and time again, that in a 24 hour monitored, controlled setting (with no access to food in between routine meals and snacks), the BED patient may lose little to no weight even on a very modest calorie plan and not bingeing.  What we have come to understand is that every body is different, and weight loss is not always associated with being on a lower calorie level. There is more and more science becoming available to us to help us understand how and why this may be the case.  So the result of good treatment is that the person with BED may enter into a period of stable recovery, with overall improved mood, outlook, functioning, and no bingeing or over-eating, and this newly found state of recovery is not associated with weight loss.

So when a well-intentioned person tells a person with BED (who may be larger size), that they should eat less because they are eating too much, and that this eating less will make them thinner and also healthier, and the BED patient does as s/he is told, yet does not lose weight from the lowered calorie level, and/or ends up with rebound over-eating, this is not helpful to the patient!  In addition to the confounding emotional consequences, the patient with BED is led to what is perhaps an even more serious medical consequence.

The temporary weight loss sometimes experienced from restriction and dieting, very predictably does not last.  The person is likely then to ricochet out of the restriction phase and begins binge.   This bingeing can lead to weight gain over time.  The “serial dieter” repeatedly goes from restriction to bingeing, and over time may gain more and more weight.  This cycle is called weight cycling and can lead to very serious medical/physical (and emotional) consequences.  The medical consequences of weight cycling (which can include damage to the heart and cardiovascular system, reduced bone mass, increased risk of gall-stones, physical weakness, and depression and impulsivity) may in fact be more serious and life threatening the consequences of “stable obesity”.

The BED patient faces many complicated situations on a daily basis, which can compromise their overall health and well-being.   Thankfully, the new DSM-V will address Binge Eating Disorder and with that we can hope that the illness will be treated with the seriousness that is warranted.  Eventually, I hope that it will be recognized that placing a Binge Eating Disorder patient on a restrictive diet is not only crazy making, but neglectful of the complex scenario the patient is faced with.  I hope that one day, doctors will not be rated as the number two source of weight stigma (second to family members).

The war on obesity may be as much or more about weight stigmatization as it is about a concern for health but beyond this, the war on obesity may be fueling the BED patient to binge and weight cycle.  How can this be considered healthful?

Einstein said, “We cannot solve problems by using the same kind of thinking we used when we created them” and my mom used to say to me, “Wendy, the road to hell is paved with good intentions”.  I always knew my mom was saying something important to, but when it comes to Binge Eating Disorder and the complicated scenario the patient is faced with, this saying is truer now more than ever.

(c) Wendy Oliver-Pyatt, MD, FAED, CEDS all rights reserved