Addressing Weight Stigma in Obesity and Eating Disorders

Dr. Ellen Csepe // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses eating disorders & obesity, the relationship between mood & disordered eating, binge eating as the most common form of disordered eating, and the role of the physical therapist in eating disorders.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

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ELLEN CSEPEGood morning everybody and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a teaching assistant with the modern management of the older adult division coming to you live from Littleton, Colorado. I'm an outpatient physical therapist who practices with the same question in mind every day. Why aren't physical therapists more involved in managing one of the most pressing health crises in the world today. Obesity. On today's Leadership Thursday, we're going to discuss eating disorders in those with obesity. To feel complete in our treatment of those with obesity, we have an obligation to understand the link between eating disorders and obesity. This is a very nuanced topic with a lot of viewpoints and a lot of new research, but I want to be respectful of your morning and keep this discussion succinct and have this framework for today. First, we're going to open about how mood disorders and obesity are related. Then we'll talk about the most common eating disorder that affects people with and without obesity. Then we'll talk about our number one job as clinicians to avoid provoking disordered eating and then what we can do pragmatically if we suspect our patient is struggling with an eating disorder. So to open us up, for those of us who have never struggled with an eating disorder or obesity, having an issue with your weight can just seem like a physics equation gone wrong. Too many calories in, not enough calories out equals obesity. But for those who are struggling with their weight, this oversimplified physics equation really overlooks the emotional and mental language that can come with struggling with your weight or your perception of your weight. We see obesity as a complex biopsychosocial chronic disease with this framework in mind that it is anything but simple. And thinking that there's a simple solution and a simple fix can often make this problem worse in treating our patients. MOOD & OBESITY ARE RELATED So to start, obesity and mood disorders are related. Obesity and depression frequently occur together and actually there's a bi-directional relationship between mood disorders like depression and obesity. In fact, depression can be a risk factor for obesity and obesity can be a risk factor for depression. This risk and this association is the strongest in women. eating disorders are mental health disorders. The DSM-5 identifies eating disorders as mental illnesses that are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning. And in fact, eating disorders can be life-threatening and have the highest mortality rate of any mental illness. Eating disorders have their own diagnostic criteria in the DSM-5, and those eating disorders with diagnostic criteria include pica, rumination disorder, ARFID or avoidant restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. Anecdotally, many clinicians feel apprehensive discussing weight, exercise, and eating habits in part because they're aware that executing these conversations poorly can have adverse impacts on their patients and their mental health. But as clinicians, we have to know the basics of diabetes, cancer, Graves' disease, ALS, MS. And if we feel confident making dietary recommendations to our patients, For things like protein intake, calorie deficits, and reducing added sugar in our diet, we want to at least be aware of the most common eating disorder that will likely impact our patients. So we understand that there's a correlation between mood disorders and obesity. BINGE EATING AS THE MOST COMMON EATING DISORDER Now let's talk about the most common eating disorder that we're gonna see in our practice. So binge eating disorder is the most commonly recognized eating disorder among people with and without obesity. So it doesn't matter if you have obesity or not, this is likely going to be the most common eating disorder that a patient will suffer from. So eating disorder, let's understand this a little bit more so that we can really clearly understand what this looks like in our practice. So binge eating disorder is characterized by eating a large amount of food in a short period of time, all while feeling the loss of control during this episode and immense shame and guilt afterwards. So you might be thinking, well, do I have binge eating disorder? I chowed last weekend. There's a difference. Having unhealthy eating habits or chowing or going crazy now and again is not the same thing as an eating disorder. An eating disorder is not a choice. A diet is a choice. You can choose to not be a vegan anymore. You cannot choose to not have an eating disorder. And that's the best way to summarize the differences between diets and eating disorder. But binge eating disorder has some specific characteristics. Eating a large period of food over a short period of time without the feeling of control. Eating faster than normal. Eating until uncomfortably full. Eating large amount of food even when not physically hungry. Eating alone because of embarrassment with how much one is eating. and feeling disgusted with oneself, depressed, or very guilty afterwards. So this is a very common diagnosis that we'll see in the clinic. Other unhealthy weight control behaviors that would be reflective of disordered eating could include vomiting, skipping meals, fasting, laxative or diuretic use, smoking to manage appetite, and consuming stimulants to reduce appetite. So these behaviors aren't the same thing as having an eating disorder, but we should know that these behaviors are rarely successful in managing weight and, more importantly, can lead to depressive symptoms and eating disorders in the future. So we summarized the most common eating disorder that we'll likely see as clinicians. Now let's talk about our number one job. THE ROLE OF PT: PROVIDE AN ENVIRONMENT FREE OF STIGMA ABOUT WEIGHT So our number one job as clinicians is to provide an environment for our patients free of weight stigma. For us to be psychologically informed clinicians who want to help those with obesity, We have to be aware of how impactful weight stigma can be on disordered eating. Weight stigma implies that people who struggle with their weight are lazy, less adherent, less motivated, less deserving of empathy, sloppy, mean, have decreased willpower, are unsuccessful, or are otherwise unpleasant. And unfortunately, it's very common among healthcare providers. A recent survey of nurses suggested that 24% of nurses would see people with obesity as repulsive. and that 12% of nurses surveyed didn't want to touch those with obesity. These feelings are not only unhelpful, but they're really hard to hide. If you're repulsed by your patients, it's probably going to show on your face. And actually, a recent 2023 systematic review it'll be in the comments below on this Instagram post, looked at how weight stigma impacted disordered eating. So studies that looked at relationships between disordered eating and internalized weight stigma showed that weight stigma is helpful, unhelpful across the board in managing weight and can actually really commonly provoke disordered eating habits. So the studies reviewed looked at actual experienced weight stigma anticipated weight stigma, so for example, the fear of being judged by others, like if you're going to go out in a bathing suit, having that apprehension that you're going to be judged, and then internalized weight stigma, so the personal belief that you are lazy, unmotivated, have less self-control because of your body habitus. And the systematic review suggested that across the board, experiencing weight stigma made outcomes worse. And in several studies would suggest that experiencing weight stigma from a medical provider immediately caused a binge eating event afterwards. So not only are those weight stigma beliefs that we hold as providers unhelpful, they can make the problem much, much worse and can even cause a binge event for those with binge eating disorder. So I challenge you today to reconsider how you face obesity. If you have biases against those with obesity, I really challenge you to recognize with empathy how hard it is to lose weight and to manage your weight. Recognize that when we lose weight, our bodies fight to get that weight back by changing our hormone levels, our ghrelin levels go up, increasing our hunger, our leptin goes down, decreasing our satiety, and our bodies perpetually try and return to that weight that we lost. It's hard. Our world and our food landscape have changed significantly in the past 50 years. You don't have to grow an Oreo. You could go and buy them from the grocery store, and those are quick, low-nutrient calories that you can access without having to do any physical labor. It is extremely difficult to maintain weight, and those with obesity need our help and support in their journey to manage their health for the long term without judgment or weight stigma from providers. I recognize that obesity is a huge problem that our culture and our entire world face. I know that you likely agree if you're listening to this podcast. Weight issues are hard to manage and where we should start is with empathy and dignity and respect and compassion with those with obesity. SUMMARY So we talked about how mood disorders and obesity are related. We talked about the most common eating disorder, binge eating disorder, that affects people with and without obesity. We talked about our number one job as clinicians to make sure that we provide an environment free of weight stigma for our patients. And last, if you suspect that your patient is struggling with an eating disorder like binge eating disorder, we have some options. You can ask, have you ever struggled with an eating disorder? Or do you know if you have an eating disorder? Just as easily as we can acknowledge depression or anxiety on a past medical history form, we can identify eating disorder or disordered eating habits. Within the past 24 hours, a previous patient of mine shared that he had an eating disorder, but is only now getting treatment after years of struggling because nobody asked. So our job as clinicians, if we suspect somebody has an eating disorder, it's totally within our scope to ask. And if they say yes, you can refer them to the National Eating Disorder Association. The link will be below in the comments. Or this is a completely, this is not an ad, but there's an online virtual service called Equip Health that takes major medical insurances and provides mental health therapists, dietician, and medical provider support, as well as mentors who have overcome eating disorders and are there to help your patients. So we have lots of resources. To summarize, mood disorders and obesity are linked and we have to understand that as clinicians. Binge eating disorder is the most common eating disorder that we'll see for those with and without obesity. Our number one job as clinicians is to provide an environment free of weight stigma for our patients. And if you suspect that your patient has an eating disorder, ask and offer pragmatic support with a referral to another dietician or mental health therapist or an online program. Thank you so much guys. I know that we recognize that obesity is a growing problem in our world and you being a part of this podcast and a part of this team really reflects your genuine empathy and caring for those who are struggling. Thank you so much for being here and I hope you have a wonderful rest of your day.

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