"Obesity" Is Not An Eating Disorder

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I recently wrote about an NBC News article that included a quote from Tom Hildebrandt, PsyD who runs the Hildebrandt Lab at Mount Sinai in New York, which houses Mount Sinai’s Center of Excellence in Eating and Weight Disorders.

I promised that I would write a separate article about their troubling conceptualization of higher-weight as an eating disorder, and this is that article.

Content note: this piece will discuss eating disorders and weight stigma, please take care of yourself. You can skip the screen shots and indented sections to reduce harm.

The heart of the issue here is that they seem to consider simply existing in a higher-weight body to be an eating disorder. I came to that conclusion because they have it on a bulleted list of Types of Eating Disorders on a page labeled Eating Disorders:

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They also have this on their homepage

We have more than a decade and a half of experience helping children, adolescents, and adults with eating disorders. Our psychologists, dieticians, social workers, and psychiatrists work as a team to diagnose and treat anorexia nervosa, bulimia nervosa, binge eating disorder, ob*sity, and other conditions… Eating and weight disorders are complex mental health disorders

Eating disorders are absolutely complex bio/psycho/social disorders that can do incredible harm and can be fatal. The problem is that “ob*sity” simply does not qualify.

To be clear, they aren’t the only ones making this mistake, but they doing it with the power of a massive and very well regarded institution and so I will talk about this specific case with the understanding that these issues apply broadly.

I’ve written extensively about the false claim that “ob*sity” is a “chronic lifelong disease” and some of the same issues apply including and especially that ob*sity is simply a body size. On their “ob*sity” page, Dr. Hildebrandt’s lab says “Ob*sity means you have excessive body fat” and “Doctors measure ob*sity by calculating your body mass index (BMI), which is the ratio of weight in kilograms to height in meters.” It’s actually a ratio of weight to height in any measurement, but that’s neither here nor there.

We know that BMI is deeply problematic on many levels, but beyond that, notice that their own definition says nothing about eating or shared behaviors in any way. This stands opposed to actual eating disorder diagnoses which have shared symptomatology which is used to diagnose them.

Their definition rests on stereotypes about how higher-weight people eat. The “ob*sity” page on their website says

“The most common cause of ob*sity is overeating.”

They don’t’ offer any research to support this, but state it as if it’s fact. They also admit that other factors including genetics and other medical conditions can be involved, but they fail to point out that, for example, the most common outcome of intentional weight loss attempts is weight regain, with up to 66% regaining more weight than they lost. (They also discuss higher rates of “ob*sity” in “African Americans” and “Latinos” but failed to mention that, for example, BMI was created using white bodies. I urge them, and everyone, to read books like Fearing the Black Body – The Racial Origins of Fat Phobia by Dr. Sabrina Strings and Belly of the Beast – The Politics of Anti-Fatness as Anti-Blackness by Da’Shaun Harrison to have a better understanding of these issues.)

At any rate, the suggestion that an eating disorder can be diagnosed based on a height weight ratio or body fat percentage is ludicrous. It also does a lot of harm because it suggests that eating disorders are simply a matter of weight. They make a similar mistake on their page about anorexia nervosa when they state:

“If you have binge/purge anorexia, your weight is very low whereas bulimia nervosa patients have body weights that are not critically low, but may still be unhealthy for that individual.”

This is dangerous misinformation. People of all sizes can have all types of eating disorders. The most recent edition of the Diagnostic and Statistics Manual (DSM-5) specifically includes the information “Atypical anorexia includes those individuals who meet the criteria for anorexia but who are not underweight despite significant weight loss. Research studies have not found a difference in the medical and psychological impacts of anorexia and atypical anorexia.” (“Atypical anorexia” is a controversial diagnosis since it’s not so much “atypical” as “previously ignored” but that’s a subject for another day.) I’ll also point out that the DSM-5 does NOT include “ob*sity” as a feeding or eating disorder.

As Project Heal points out:

Less than 6% of people with eating disorders are medically “underweight.”

High weight people with eating disorders are exponentially more likely to be encouraged to engage in eating disorder behaviors (restriction, over-exercise, etc) in order to lose weight than to be screened for an eating disorder by their doctors.

The misinformation being trumpeted by “Mount Sinai Center of Excellence in Eating and Weight Disorders” is only likely to exacerbate these issues and given that eating disorders can be fatal, that is a very serious problem.

It also seems to be a problem that they are actively part of, since they offer a “weight management” program that claims (without citing any evidence) that their program can help “you or your child make lifestyle changes that support weight loss and ongoing maintenance.” Given 100 years of data that finds that only a tiny fraction of people actually experience significant, long-term weight loss, I find this difficult to believe.

In addition to having their own maintenance program, Dr. Hildebrandt’s lab performs research for the diet company Noom.

So, is it just me or is this study essentially - which is better - Noom or Noom?

Dr. Hildebrandt also holds equity in Noom:

So, to sum up, I believe that, based on their current webpage, the work of the Mount Sinai Center of Excellence in Eating and Weight Disorders under the Hildebrandt lab is likely to hamper the ability of higher-weight people who have actual eating disorders to get diagnosed while simultaneously misleading people into believing that simply existing in a higher-weight body is an eating disorder for which, apparently, weight loss (likely in the form of prescribing behaviors that are, in fact, red flags for eating disorders) is a treatment?

Again, they are far from the only group making these mistakes, and they may be very well-meaning. Still everyone who is making these mistakes must stop if we are to have any chance of actually appropriately diagnosing and treating eating disorders in people of all sizes.

In the meantime, there are some excellent ideas here about practical changes that could be made.  

Edit: Chevese Turner let me know that Thomas Hildebrand was one of the original members on the Research Advisory Council for the (deeply problematic) National Eating Disorders Association (NEDA).

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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.