Tara-Leigh Tarantola thought she knew what a person with anorexia looked like: "This really tiny, little, thin girl who won't eat." In other words, not her son, Zachary Haines, a happy-go-lucky teenager who once had a football player's bulky build.
But when Haines was hospitalized last spring after dropping more than 100 pounds, Tarantola for the first time heard the diagnosis applied to her child.
"I broke down because I couldn't believe that a doctor was telling me that he could have died at any moment, yet all of these other doctors wouldn't even take me seriously," says Tarantola. She had repeatedly pleaded with a primary-care physician, two endocrinologists, a liver specialist and nutrition experts to address Haines's exercise and eating patterns, which she knew were making him sick. "They kept telling me how wonderful it was that he had lost 100 pounds."
Like many people with eating disorders, Haines had restricted his caloric intake, exercised excessively and obsessed over his physique. He was irritable, constantly cold and doubled over with stomach pains after eating. At one point, his pulse dropped to 26 beats per minute (anything below 40 can send someone to the emergency room).
"All of the signs were there," Tarantola says.
But because Haines was once considered obese and never dropped to what the body mass index charts indicate as "underweight," his dramatic weight loss was overlooked, even applauded. For more than a year, the clinicians "didn't seem to think anything was wrong," says Haines, now a sophomore in recovery at Temple University in Philadelphia.
Haines's experience is all too common, says Leslie Sim, PhD, a psychologist at the Mayo Clinic who's found that obese teenagers are just as likely to develop eating disorders as the general population (Pediatrics, 2014).
"The public … assumes that people who are obese don't have any willpower or are lazy — that they're somehow different from people who develop anorexia," she says. "But we find that's definitely not the case. In fact, they may be even more vulnerable."
More concerning, Sim recently found that eating disorder diagnoses are delayed an average of nine months among patients who were once overweight or obese when compared with patients who were never overweight (Journal of Adolescent Health, 2014). That's alarming because the earlier an eating disorder patient is treated, the better the outcome, she says.
Other psychologists are finding that obesity and eating disorders share risk factors, such as depression, body dissatisfaction, anxiety, weight-related teasing or a combination of them all. For some obese people, such as those who undergo bariatric surgery, the dieting process itself may trigger an unhealthy obsession with controlling food intake. Others still may face unintended consequences of well-intentioned interventions designed to combat the national obesity crisis.
Similar problems, different extremes
To some, overweight or obese people may seem to have the opposite problem of people with anorexia or other restrictive eating disorders: One group eats too much, the other, too little.
But these populations may be more alike than different, says psychologist Melissa Napolitano, PhD, a professor of prevention and community health at the George Washington University Milken Institute School of Public Health. "It seems that there's this common underlying set of risk factors that might set someone up for both eating disorders and overweight or obesity," she says, such as engaging in dieting behaviors, being particularly influenced by the media's perpetuation of the thin ideal, being highly dissatisfied with their bodies and being victims of weight-related teasing ( Health Education Research , 2006). They also struggle with "over-under control of their eating," such as restrictive eating patterns and binge eating, and placing too much emphasis on their shape and weight, Napolitano says.
People with obesity and eating disorders may also be one and the same — swinging from one extreme to the other. Michael Lowe, PhD, a psychologist at Drexel University, has found that "weight suppression" — or the difference between someone's current weight and highest weight since reaching adult height — is linked to both anorexia and bulimia. In other words, the bigger the gap is, the more severe and difficult to treat the eating disorder may become (Journal of Abnormal Psychology, 2013).
He's also found that the more weight-suppressed people are, the more likely they are to regain weight in the future. It's a phenomenon akin to yo-yo dieting, but among people whose bodies are predisposed to being overweight and who have other eating disorder risk factors such as poor body image, anxiety or depression, that cycle can be disastrous, Lowe says.
"An eating disordered individual who gains weight will do extreme things — including fasting, laxative abuse, vomiting, excessive exercise — to get the weight off again," he says. "But by losing weight, they're increasing their level of weight suppression, which makes binge eating and weight regain more likely."
Lowe and his colleagues describe this cycle as "a biobehavioral bind." They stress that health-care providers should inquire about a patient's weight history in any clinical evaluation, be it medical or psychological. That, they say, can be more telling than body mass index, which only shows how a person's height and weight compare to the general population, not how realistic it is in the context of his or her own body.
"You see these kids [whose BMIs] are presenting at the 50th percentile, but are sicker than kids at the 10th percentile — girls who aren't menstruating, their hair is falling out, they're fatigued, their estrogen is low, their thyroid levels are low," Sim says. "You can't use BMI as a marker of how severe someone's illness is."
A positive feedback cycle
The slope from dieting to disordered eating can be particularly slippery among people who were or are overweight or obese because their weight loss is often cheered.
"Early in that process, they feel much better and most people who know them say, ‘Gee, you look great!' and that only further reinforces what they're doing," Lowe says. "Whereas most dieters fail in their goal of long-term weight loss, these few percent of individuals ‘succeed' too well."
That was the case for Michael Foley, a George Washington University junior who tried to lose weight halfway through his freshman year. The 5' 10" English major was motivated by the people around him, who were slimmer than those in his Ohio hometown.
"It was kind of that desire to fit in, and saying, ‘I'm in college now, and I really want to make myself the best possible version of myself,'" says Foley, who was 215 pounds at his heaviest. "And physically, that means I have to drop about 50 pounds."
So he began exercising 30 to 60 minutes a day and replaced his large servings of pasta with well-balanced meals including yogurt, lentils and berries. Soon, he felt and looked healthier and happier, and the people around him told him so. "Everything was going really well," he says.
But then Foley realized that if he worked out a little more and ate a little less, he could lose more weight — and faster. If he worked out a lot more — sometimes up to six hours a day — and ate a lot less, he could lose even more even faster. He ended up dropping 50 pounds in just three months. "I was so terrified to gain any of my weight back," says Foley, who maintained the loss by restricting his eating further, often eating only one full meal every two days.
Still, no one expressed concern — not even his therapist. "I wasn't too skinny, I wasn't emaciated, I was never throwing up," Foley says. "It was something that wasn't visible."
Eating disorder symptoms among people who were once overweight can be exacerbated by well-founded fears of weight gain, particularly if they were bullied about their size in the past, says Cynthia Bulik, PhD, who directs the University of North Carolina's Center of Excellence for Eating Disorders. She says patients with anorexia who have histories of overweight or obesity often worry that treatment will cause them to balloon back to their former weight, rather than to settle at a happy medium.
"What we hear over and over again is, ‘I don't want to go back,'" Bulik says. "It's on the one hand a theoretical fear, but on the other, it's a very lived fear."
Other research on people who have undergone bariatric surgery for weight loss suggests that the dieting process itself may spark an unhealthy obsession with food and control in patients who otherwise had little or no eating disorder pathology. Take Melanie, a patient described in a 2013 paper in Eating Disorders: The Journal of Treatment & Prevention. The 40-year-old never reported feeling uncomfortable with her body or preoccupied with food. She opted for the surgery out of concern for her future health.
But during recovery and beyond, Melanie "was a totally different person," her family reported. She intensely feared weight gain, avoided family gatherings and ate only 500 calories a day, despite doctors' orders to eat much more. A year and a half after the surgery, she was admitted to an eating disorders treatment center with many symptoms of anorexia.
Bulik says her program has seen "way too many" patients like Melanie. "They start losing weight and that feels good and they do it well and then they cross that line into pathology. Once that happens, it's no longer under the patient's control."
The study authors recommend that health-care providers discuss the risk factors for eating disorders among bariatric surgery patients, and monitor them closely during recovery.
Unintended consequences
The National Institute of Mental Health estimates that fewer than 5 percent of Americans will be diagnosed with an eating disorder in their lifetimes, but more than two-thirds of Americans are overweight or obese, according to the Centers for Disease Control and Prevention.
"We need to make sure we focus and help people who are overweight and obese develop healthier lifestyles and develop healthier patterns," Napolitano says. "And there are some — likely very few — who might take it to an extreme, but we need to balance the fact that we know 17 percent of our youth are already obese and 32 percent are overweight."
But some eating disorders experts worry that well-intentioned interventions aiming to combat the national obesity crisis might play into the development of eating disorders, particularly among those whom the messages target.
"You can imagine someone who is a good kid who's doing everything right and who's predisposed to weigh more [gets] messages saying, ‘You're lazy and unhealthy and you need to change,'" Sim says. "How could you not incorporate that?"
One 13-year-old girl did, as described in a 2013 paper in Eating Disorders: The Journal of Treatment & Prevention . After seeing a classroom presentation on the importance of healthy eating, she restricted her food intake and amped up her exercise. Six months later, with a body mass index in the third percentile, she was hospitalized for anorexia nervosa.
Another 14-year-old was hospitalized with an eating disorder after his school implemented a program focused on eating less fat and more low-calorie carbohydrates and exercising more. He was so determined to be "the best" that he exercised up to four hours a day, and ate only chicken, fruit and vegetables, the authors report.
Such cases underscore the importance of research to back and evaluate obesity prevention interventions, Bulik says. They also call for a renewed focus on healthy behaviors, experts say.
"For both obesity and for eating disorders, there's such media pressure about what the perfect body should be, how easy it seems that people can change their body shape, and we know it's not that easy," Napolitano says. "So I think we all need to re-shift our focus somewhat on what is realistic, what are realistic health behaviors and make sure that we send out realistic messages."