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.
Cynthia M. Bulik, PhD, FAED, (BA, University of Notre Dame; MA, PhD, University of California, Berkeley) is Distinguished Professor of Eating Disorders in the Department of Psychiatry in the School of Medicine at the University of North Carolina at Chapel Hill, where she is also Professor of Nutrition in the Gillings School of Global Public Health, and director of the UNC Center of Excellence for Eating Disorders.
She developed treatment services for eating disorders both in New Zealand and in the United States. Her research includes treatment, laboratory, epidemiological, twin, and molecular genetic studies of eating disorders.
She is a recipient of several awards including the Eating Disorders Coalition Research Award, the Academy for Eating Disorders Leadership Award for Research, the Price Family National Eating Disorders Association Research Award, IAEDP Honorary Certified Eating Disorders Specialist Award, and the AED Meehan/Hartley Award for Advocacy.
Dr. Bulik is past president of the Academy for Eating Disorders, past Vice-President of the Eating Disorders Coalition, past Associate Editor of the International Journal of Eating Disorders, and Chair of the Scientific Advisory Council of BEDA.
She is passionate about translating science for the public and has appeared on many national shows including the Today Show, Good Morning America, CBS This Morning, Katie, Dr. Oz, and Dr. Phil. Her works has been featured in the New York Times, the Washington Post, USA Today, Newsweek and Time. Dr. Bulik holds the first endowed professorship in eating disorders in the United States. Read more at www.cynthiabulik.com.
Moving Beyond Goldilocks and the Three Bears in Eating Disorders
Taking some liberty with the fairy tale, once upon a time (i.e., now), people thought about eating disorders in much the same way Goldilocks experienced the three bears’ chairs. Too big, too little, or just right. Lore had it that people with binge eating disorder were overweight, people with bulimia nervosa were “normal weight,” and people with anorexia nervosa were underweight. It’s time to revise that fairy tale.
Pardon my focus on numbers here, but they are necessary to make my point. As a prime example, what do we do with Susan, the 15 year old patient who weighs 180 pounds at 5’4” (BMI of 30.9 kg/m2 an 97th percentilefor age and sex), who loses 60 pounds in two months, whose hair starts falling out, stops menstruating, is lethargic, depressed, and refuses to eat. She thinks she looks fat and is deeply fearful of regaining weight?
A cross sectional inspection of her growth chart after this rapid weight loss reveals that her BMI is 20.6 kg/m2 and she is in the 58th percentile for her age and sex. A pediatrician could take a cross sectional look at her height and weight and actually praise her for being in the healthy weight range. Everything else about her presentation screams anorexia nervosa, except the low weight criterion.
A longitudinal look at her growth trajectory, however, would and should set off alarm bells. Prior to DSM-5 (APA, 2013), if someone cared enough to ask about her psychological symptoms, she might have been given a diagnosis of eating disorders not otherwise specified (EDNOS). EDNOS is no more in DSM-5. The current DSM-5 “Feeding and Eating Disorders” criteria do provide us with a way of indicating that her presentation is more than just EDNOS, and, in fact is a variant of anorexia nervosa. Under the “Other Specified Feeding or Eating Disorders” category, “Atypical Anorexia Nervosa” can be diagnosed if an individual meets all of the criteria for anorexia nervosa except that, despite significant weight loss, the individual’s weight is within or above the normal range. This designation could open doors for recognition of a serious illness in an otherwise “normal” weight adolescent, and facilitate appropriate treatment and coverage.
Another piece of the flawed fairy tale is that BED only occurs in individuals who are overweight or obese. This misses out on a sizeable percentage of individuals with BED who find themselves in the normal weight range. Especially now that DSM-5 has done away with the non-purging subtype of bulimia nervosa (which many of us never really understood in the first place), we all need to remain vigilant for BED at any size. As we roll out BED awareness to the community, we do not want people in the normal weight range to think that they don’t have the disorder because they are not overweight or obese. Same holds with clinicians. We do not want them to ever develop the misconception that BED only walks hand in hand with overweight. A recent article by Dingemans and van Furth (2013) showed that psychological features such as eating disorder pathology and depression characteristic of BED do not differ depending on whether the sufferer is overweight or normal weight. However, as feared, “nonobese” individuals with BED were less likely to receive treatment than their higher weight counterparts. BED carries psychological and medical burden regardless of the individual’s size. Banish the thought that the only ill effects of BED are due to excess weight. BED is a psychiatric disorder with both psychological and physical effects that are independent of weight.
The final piece of the fairly tale that needs to be rewritten is that bulimia only occurs in individuals who are normal weight. In fact, although anorexia nervosa binge-purge subtype is diagnosed when an individual meets the low weight criterion for anorexia nervosa, otherwise, bulimia really doesn’t care how large or small you are. We have observed an increase over time in BMIs in individuals with bulimia nervosa in clinical trials (Bulik et al., 2012). Perhaps this increase is only mirroring the changing BMI trends in the general population, but it illustrates that we all need to think out of the weight box when thinking about all eating disorders.
Once again we find ourselves in a situation as a field of having to reprogram seemingly indelible misconceptions about weight and eating disorders. The take home message is something along the line of, “Eating disorders at every size.” If you are a sufferer, family member, advocate, or health care practitioner, examine your own misconceptions about weight and eating disorders, and if they are there, rewrite your own story line to recognize that eating disorders can and do occur at every size.
The author is a consultant for Shire Pharmaceuticals.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association Press.
Bulik CM, Marcus MD, Zerwas S, Levine MD, La Via M. (2012) The changing “weightscape” of bulimia nervosa. American Journal of Psychiatry, 169, 1031-1036.
Dingemans AE, van Furth EF. (2013) Binge Eating Disorder psychopathology in normal weight and obese individuals. International Journal of Eating Disorders, 45, 135-13.