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Difficulties in Detecting Eating Disorders in Both Normal and Higher Weight Patients

Experts from Eating Recovery Center's Chicago-area programs describe the problem of timely screening among normal and higher weight patients as well as how providers and eating disorder specialists can improve identification and treatment.

The theme of NEDAwareness Week 2016 is “3 Minutes Can Save a Life: Get Screened. Get Help. Get Healthy,” underscoring the importance of early detection and intervention in the treatment of eating disorders. In addition to NEDA’s free, anonymous online screening designed to reveal a need for professional help, healthcare providers play an important role in screening patients at risk for eating disorders.

Unfortunately, certain categories of patients are often overlooked for screening in clinical settings, and well-meaning directives from healthcare professionals can actually intensify existing challenges with food, eating, exercise and body image.   Overlooking eating pathology and focusing exclusively on body weight is particularly problematic among higher weight patients with eating disorders.  In fact, it is estimated that 30 to 40 percent of higher weight patients attempting to lose weight meet diagnostic criteria for binge eating disorder (BED) and/or bulimia nervosa (BN).

“Medical providers’ conventional prescribing practices like dieting, restriction and daily weighing can contribute to more bingeing, more shame and more weight gain in patients struggling with binge eating,” explains Susan McClanahan, PhD, CEDS, Founder and President of Insight, Chief Development Officer of Eating Recovery Center and Assistant Professor of Psychiatry at Northwestern University. “Well-meaning weight loss directives from healthcare professionals are intended to mitigate the serious health risks posed by high weight, but they can lack sensitivity to and understanding of this very real and very serious eating disorder behavior.”

Across the healthcare field there is limited recognition of the biological components of obesity including how weight is influenced by genetics, physiological factors and loss-of-control eating behaviors. “Even among providers, our cultural rhetoric around obesity suggests that we have 100 percent control over our weight and that it is willpower that drives weight loss and overall health,” explains Julie Friedman, PhD, Vice President, Comprehensive Overeating Recovery Effort (CORE) program at Eating Recovery Center, Insight and Assistant Professor at the Northwestern University Feinberg School of Medicine. “The reality is that a complex set of hormones influence and determine hunger and satiety cues as well as how we feel, think and behave around food.  Your weight and your eating behaviors are largely determined by neurobiology rather than your ‘motivation’ or drive to lose weight. In addition, a patient who is actively binge eating  will need to address these behaviors for both physical and emotional health and this need is often overlooked in the context of asking patients to merely ‘lose weight.’”

Clinical settings in which weight loss directives are particularly common include:

  • Primary care—In an effort to help patients avoid health complications, primary care providers will often prescribe a low calorie diet or intentional restriction of certain food groups to help facilitate weight loss.
  • Surgical/orthopedic—Patients are often told that they can not have a necessary surgery or joint replacement until they lose weight. Surgery can be essential to improving health-related quality of life which, ironically, when compromised has been shown to worsen loss-of-control eating and binge eating.
  • Fertility—There are clearly defined weight limits for IVF and other assisted reproductive technologies. The emotional toll of fertility challenges combined with the psychological distress associated with binge eating can be overwhelming. Women told to lose weight in this setting often increase bingeing behavior, which causes an inflammatory response in the body that worsens any underlying insulin resistance.
  • Workplace wellness—While non-clinical, these programs are implemented by employers and insurance companies to encourage weight loss as a means for healthy living. “Despite the fact that BED predicts metabolic syndrome and decreased workplace productivity above and beyond BMI, employers’ focus on BMI and the idea of ‘treating’ weight in the workplace can contribute to reinforcing the cultural zeitgeist of weight as being easy to control if you simply eat less and exercise more,” adds Dr. Friedman.

In addition to a lack of screening by health care providers, normal and higher weight patients don’t often see themselves as having an eating disorder. They tend to minimize maladaptive overeating and instead attribute their failed weight loss and food issues to moral failing (“I am a bad dieter” or “I have no willpower”). Once they learn about the diagnostic criteria for binge eating, they often recognize behaviors that have been evident since childhood.  Even among those patients that do acknowledge that binge eating is an issue, there is a lot of shame associated with seeking traditional eating disorder treatment. “Patients view binge eating disorder as the ‘bad kind’ of eating disorder, as if individuals with anorexia or bulimia are beautiful people who are excelling at their eating disorder and achieving the desired weight loss,” adds Dr. McClanahan.

The health care community can play an important role in facilitating eating disorder screenings for all patients, including those with weight concerns. Regardless of area of practice or specialty, providers can implement these strategies to improve identification of binge eating and related disorders:

For all healthcare providers:

  1. Don’t make any assumptions about a patient based on their weight, and screen all patients for eating disturbances. Before telling a patient to lose weight, screen for issues related to binge eating. Utilize easy, self-report questionnaires available online, or just ask a few simple questions that may indicate a need to refer the patient to an eating disorder specialist.
    • Do you feel like you have episodes where you eat more than what most people would eat in the same time period?
    • Do you experience any distress around your eating, including guilt, shame or regret?  
    • Do you often sneak food or eat alone due to embarrassment over what or how you are eating?  
    • Do you feel like your eating is out of control?  
  2. Help change our cultural health paradigm from “weight loss” to “overall health.” Widespread endorsement of weight loss to improve our lives has fostered acceptance of the idea that it’s no big deal to restrict in an effort to achieve a “healthier” (thinner) physique. This think is so prevalent yet is contraindicated for the millions of Americans struggling with eating disorders, including binge eating.

For eating disorder providers:

  1. Be thorough in probing for different types of loss-of-control eating, including but not limited to night eating, nocturnal related eating, eating past satiety, impulsive eating and compulsive food behaviors like hiding food, food obtaining and eating food out of the garbage—at assessment.
  2. Educate patients about the legitimacy and seriousness of binge eating. Despite becoming an official eating disorder diagnosis in the DSM-V (2013), the cultural narrative around overeating and obesity remains largely rooted in laziness and lack of willpower rather than the very real biological and genetic factors that prime a subset of the population to overeat.
  3. Target eating behaviors specifically. While many psychological interventions address comorbid mood and anxiety symptoms, the research is clear that eating behaviors must be addressed directly for long-term remission from binge eating. To effectively address BED, normalizing food intake through a structured, non-restrictive meal plan is crucial in conjunction with psychological support and development of healthy coping skills. Refer to higher levels of care and multidisciplinary care when outpatient therapy alone is not yielding results.


Experts from Eating Recovery Center’s Chicago-area programs describe the problem of timely screening among normal and higher weight patients as well as how providers and eating disorder specialists can improve identification and treatment.

The Eating Recovery Center family of programs adopts a thoughtful, evidence-based approach to treating binge eating (with or without compensatory behaviors). All levels of care for female and male adults, adolescents and children are available at 27 treatment centers across the country. Additionally, Eating Recovery Center, Insight offers the innovative Comprehensive Overeating Recovery Effort (CORE) program in Chicago, Illinois. Adults and adolescents struggling with weight-related comorbidities (who do not engage in compensatory behaviors) may benefit from this medically supported, non-diet weight management program in addition to—or following—eating disorder treatment.

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