Eating Disorders

The Role of "Feeling Fat" in Eating Disorders

What is it and how to address it

Posted Aug 06, 2020

Feeling fat is an experience reported by many people, especially women, but the intensity and frequency of this feeling appear to be far greater among those with eating disorders, whether they are underweight, normal weight, or overweight. There has been very little research on feeling fat in eating disorders; indeed, remarkably little has been written about it, although the term is used in many languages around the world. 

Feeling fat is not an emotion (i.e., being happy, sad, afraid, surprised or angry) or a physical sensation (i.e., feeling full or swollen), but it fluctuates in intensity from day to day and even within a day, while actual body weight is more stable (Figure 1).

 Riccardo Dalle Grave, MD
Figure 1. The diagram illustrates how feeling fat can rise, peak, and fall even as body weight remains relatively stable.
Source: Riccardo Dalle Grave, MD

Feeling fat, through the lens of cognitive behavior theory for eating disorders, seems often the result of the mislabeling of certain emotions and bodily experiences. It is an important target for the treatment since it tends to be equated with being fat, whatever the individual's true weight and shape. Why this happens is not known, but it could be a consequence of the longstanding and severe concern about weight in people with eating disorders. In turn, feeling fat reinforces dissatisfaction and prompts dieting, and so needs to be addressed.

The important role of feeling fat in the maintenance of eating disorders has been supported by some studies showing an association between its baseline intensity and the achievement of normal weight at 6 and 12 months after treatments both in adults and adolescents with anorexia nervosa.

Enhanced cognitive behavior therapy (CBT-E), a treatment recommended by the main international guidelines for adults and adolescents with eating disorders, addresses feeling fat within the “Body Image” module with the following strategies and procedures.

First, patients are helped to understand that feeling fat fluctuates from day to day and throughout the day, while body shape barely changes within such a short timeframe. Therefore, something else is likely to be responsible for the fluctuations in feelings of fatness. Indeed, feeling fat appears to result from a mislabeling of certain experiences: 

  • Body awareness (in those who are dissatisfied with their appearance)
  • Adverse physical states
  • Adverse emotional states

Second, patients are educated to identify the experiences that trigger feeling fat and to address them directly. Over time, this results in patients no longer equating feeling fat with being fat, and it ceases to be a maintenance mechanism. The strategy includes three steps:

  1. Identifying ‘peak’ times for feeling fat
  2. Identifying their triggers
  3. Addressing the triggers directly

Patients are encouraged to ask themselves, immediately after each peak, the following two questions:

  1. “Has anything happened in the last hour that might have triggered my feeling fat?”
  2. “What else am I feeling just now (in addition to feeling fat)?”

Then the patients are helped with determining how best to address these triggers directly and immediately; here are some examples of how to do so:

  • Heightened body awareness triggers (e.g., comments on appearance, body checking, physical contact, being sweaty, body wobbling, tight clothing). These require reappraisal with or without behavior change (e.g., looser clothes) and a continued focus on addressing body image.
  • Adverse physical state triggers (e.g., feeling bloated, premenstrual, full, hungover, or sleepy). Require reappraisal with or without behavior change (e.g., having a nap).
  • Adverse emotional state triggers (e.g., feeling depressed, lonely, bored, unloved). Require reappraisal and application of the problem-solving procedure.

Over this time, the frequency and intensity of feeling fat generally gradually wanes, and patients become able to stop equating it with being fat. Once this happens, feeling fat loses its potency in reinforcing the patients’ shape concerns.

References

Calugi, & Dalle Grave. (2019). Body image concern and treatment outcomes in adolescents with anorexia nervosa. International Journal of Eating Disorders, 52(5), 582-585. doi:10.1002/eat.23031

Calugi, El Ghoch, Conti, & Dalle Grave. (2018). Preoccupation with shape or weight, fear of weight gain, feeling fat and treatment outcomes in patients with anorexia nervosa: A longitudinal study. Behaviour Research and Therapy, 105, 63-68. doi:https://doi.org/10.1016/j.brat.2018.04.001

Dalle Grave, & Calugi. (2020). Cognitive behavior therapy for adolescents with eating disorders. New York: Guilford Press

Fairburn. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford Press.