Is it possible that a mental illness holds the secret to treating obesity? That’s what some leading eating disorder experts propose. In their opinion piece “Long-term weight loss maintenance in obesity: Possible insights from anorexia nervosa” published in the International Journal of Eating Disorders, Dr. Loren Gianini and her colleagues suggest that anorexia nervosa may provide a framework for understanding long-term weight loss maintenance in people at higher weights.


Anorexia nervosa is an eating disorder that afflicts approximately 1% of women and has the highest risk of death of any psychiatric disorder. About 10% of patients diagnosed will die from the disorder. This high mortality rate results from starvation and metabolism collapse, as well as suicide.
In people across the weight spectrum, significant long-term weight loss and maintenance is a rare occurrence. In fact, it is so unusual that scientists have created a national registry to study these unicorns. The National Weight Control Registry (NWCR) is an online database of approximately 10,000 individuals who report to have lost at least 30 lbs and maintained the weight-loss for at least 1 year.


It turns out, these individuals have a lot in common with people diagnosed with anorexia nervosa. In their article, Gianini et al (2017) report that both individuals with anorexia nervosa and individuals on the NWCR:

• Eat a diet low in fat and calories and restricted in diet variety
• Deviation from this rigid diet is associated with weight regain, even amongst individuals who have maintained weight loss for several years
• The longer that individuals maintain substantial weight loss, the less likely they are to regain weight and the more likely they are to report needing fewer strategies, less effort, and less attention to maintain weight loss. Over time, the behaviors that support weight loss maintenance become ingrained and automatic (perhaps one of the reasons that chronic anorexia is so difficult to treat). 
• Are physiologically primed for weight regain. Both groups have lower resting energy expenditure, lower levels of leptin (the satiety hormone) and thyroid hormone, and higher levels of ghrelin (the hunger hormone) than non-weight reduced BMI-matched controls. They have metabolic profiles that oppose further weight loss and promote weight gain, yet they override these powerful biological drives to maintain their weight loss. 

In people at lower weights, these behaviors are considered an eating disorder in need of treatment. In people at higher weights, these behaviors are considered good health and encouraged by medical professionals.

Why do we prescribe in one group and treat in another? Isn’t what is good for the goose good for the gander?
In our fat-hating culture, we are indoctrinated to believe that health is marked by body weight and thinner is almost always better. Fat people are encouraged to lose weight by any means necessary. This paper perpetuates the myth that fat people can’t be anorexic because weight loss is always healthy, even when it results from starvation. 

 

Despite the similar behavioral and neural mechanisms involved in anorexia nervosa and weight loss maintenance at higher weights, Gianini et al clarify that they “are not suggesting that the weight loss of individuals on the NWCR is pathological.” In fact, what they are suggesting is that further research be conducted to inform interventions to facilitate these behaviors in the higher weight group and interrupt the behaviors in the lower weight group. Let’s spend taxpayer money to help fat people learn the magic sauce that people with anorexia have mastered

 

As I mentioned in my recent post “The Hidden Faces of Eating Disorders,” eating disorders are under-diagnosed in people at higher weights. There are tons of stories online about people who were told they were too fat to be anorexic and denied treatment until they finally lost enough weight to meet the BMI requirement for the diagnosis, at which point their disease was far more progressed, chronic, and entrenched—making for a worse prognosis than if the disease were treated at an earlier stage. The DSM-V (the newest edition of the psychiatry diagnostic guide) moves away from rigid weight criteria in the diagnosis of anorexia nervosa. While the DSM-IV had previously required individuals to have a body weight less than 85% of expected, the DSM-V has the more subjective criteria of “significantly low body weight.” Despite these diagnostic changes, clinicians rarely consider that “significantly low” differs from individual to individual. Not everyone is meant to occupy the same body size and shape.

When we endorse a one-size-fits-all model, we prescribe weight loss to everyone at higher than “normal” weights and always view this weight loss as healthy.
Anorexia nervosa is a vicious disease with dire physical and emotional consequences. Fatness does not protect against it; in fact, people at higher weights are at increased risk due to the tremendous pressure to lose weight. Rather than viewing anorexia nervosa as a tool to help fat people lose weight, the rigid restrictive dieting and preoccupation with weight and shape evidenced by people on the NWCR may signal widespread eating disordered symptoms among people at higher weights. Instead of devoting resources to trying to increase this eating disordered behavior, the real need is for more resources dedicated to the identification and treatment of eating disorders across the weight spectrum.