Unintended Consequences

What's worse—obesity or eating disorders?

Posted Nov 18, 2013

Childhood obesity rates are decreasing among preschoolers and plateauing among adults, the Centers for Disease Control and Prevention reports. But does America’s war on obesity have a dark side? With all eyes on obesity, we may be working to solve one serious health issue but creating another: eating disorders.

Although people don’t typically think of obese and overweight teens as a high-risk population for developing eating disorders, a recent report in Pediatrics sheds light on the seriousness of the risk.

The Pursuit of Health Leads to a Deadly Disorder

Overweight and obese teens are acutely aware of their size. They hear it from every direction—their parents, their friends and the media, to name a few—that something is wrong with them and they need to change. Young people don’t want to have high blood pressure by the time they graduate college or get bullied about how they look. So they do what most Americans do: go on a diet.

And like many Americans, some get frustrated that the results are not always instant or sustainable over time. In an attempt to lose weight, a subset of adolescents may develop disordered eating behaviors, including bingeing, purging, exercising compulsively, abusing laxatives, or drastically restricting calories.

Among the many problems with dieting is that the focus becomes the number on the scale, rather than the individual’s health and well-being. It’s particularly dangerous for children and teens whose bodies are still developing. Dieting may lead to cravings, overeating and weight gain, and is also a leading risk factor for developing an eating disorder.

So which problem is more pressing, obesity or eating disorders? Obesity has been linked to high blood pressure and cholesterol, sleep problems, Type 2 diabetes, asthma, and other health concerns. The health consequences of eating disorders can be severe, ranging from heart-rate abnormalities, heart attack and bone loss to digestive problems, kidney damage and depression. Eating disorders also have the highest mortality rate of any mental illness.

Ultimately, it’s not a question of which is worse or which deserves more attention, but rather recognizing that there are two sides to our nation’s weight concerns—obesity is one extreme, eating disorders are another—and we must address both.

A Health Care Blind Spot: ‘Too Fat’ to Have an Eating Disorder?

When an overweight teen loses weight, parents and health care providers consider it a victory, even when it ordinarily would be cause for concern. So focused on the end—normal weight and a lower risk for weight-related illness—few question whether the means used to achieve the weight loss are healthy.

Since obese young people with eating disorders may still be considered overweight, doctors tend to be on the lookout for anything but eating disorders. Even when presented with textbook symptoms, such as losing a significant amount of weight in a short time or no longer menstruating, some doctors overlook eating disorders as a possible diagnosis.

By the time an eating disorder is diagnosed, overweight teens often have serious medical complications. Since many U.S. hospitals only admit patients who meet specific weight criteria and insurers may not provide coverage to those who do not meet these criteria, finding effective treatment is another hurdle.

How many obese teens are suffering from eating disorders? The research doesn’t exist yet, but a number of studies have revealed that a significant percentage (in some hospitals, as many as half) of patients treated for eating disorders were previously overweight. This means that many people struggling with eating disorders do not fit the stereotypical image.

What to Look For

The line between healthy weight loss and disordered eating can be blurry. At what point should parents and health care providers be concerned? Here are a few signs that should prompt further inquiry:

Obesity. Obesity is not only a risk factor for physical health concerns such as diabetes and high blood pressure but also mental health issues such as eating disorders. Both obesity and eating disorders can have shared roots in low self-esteem and control and should be seen as overlapping, not distinct, disorders.

Weight Loss. Adolescence is a high-risk time for eating disorders. At least 6 percent of adolescents suffer from eating disorders, and more than half of high school girls and 30 percent of boys report disordered eating behaviors such as fasting, using diet pills or laxatives, vomiting, or binge eating.

Since teens do not typically lose a lot of weight without effort, any type of considerable weight loss—particularly if it occurs over a short period of time—should signal the need for further inquiry by parents and health care providers. The question is whether they’re choosing nutritious foods and exercising moderately or bingeing, purging, skipping meals or engaging in other disordered eating behaviors.

Preoccupation with Food and Weight. Regardless of weight, if an adolescent’s thoughts and behaviors revolve around food and weight, this is a warning sign that should not be ignored. Other signs include over-exercise, avoiding meals or eating only certain foods, and having an intense fear of gaining weight.

Revising Our Message

Science is calling upon us to question many of our assumptions about obesity. In recent years, we’ve learned that overweight individuals can be healthier than thin people. They can also struggle with eating disorders.

Still, our public health campaigns and media attention have been squarely focused on obesity. Do anti-obesity campaigns push teens to develop eating disorders? By themselves, probably not, but they may send a message that overweight teens are not good enough as they are. Without question, they don’t capture the whole story.

We are long overdue in revising our message. The most effective treatment for obesity isn’t necessarily weight loss, but rather the pursuit of health and self-acceptance. These are the factors that will empower teens to make sustainable changes to improve their health long term.