October 18, 2022

"[A]typical anorexia nervosa, an increasingly common yet little known eating disorder... shares all the same symptoms as anorexia nervosa, except for extreme thinness...."

"Those with atypical anorexia, doctors observed, suffer the same mental and physical symptoms as people with anorexia nervosa, even life-threatening heart issues and electrolyte imbalances. They restrict calories intensively; obsess about food, eating and body image; and view their weight as inextricably linked to their value. They often skip meals, eat in secret, adhere to intricate rules about what foods they allow themselves to consume and create unusual habits like chewing and spitting out food. Others exercise to the point of exhaustion, abuse laxatives or purge their meals. But unlike those diagnosed with anorexia, people with atypical anorexia can lose significant amounts of weight but still have a medium or large body size.... To the outside world, they appear 'overweight.'... Many people with anorexia describe the illness as a battle between two selves. One is a maniacal superego, hellbent on control at all costs in a misguided attempt to find safety....The second is... no longer concerned with being quiet and obedient or apologizing for her existence. And, perhaps most important, she has no interest in making herself small."

"'You Don’t Look Anorexic’/New research shows that our assumptions about eating disorders are often wrong — and that many larger-bodied people are starving themselves" (NYT).

53 comments:

Enigma said...

What about bulimia? As typical of academics who want to make a name for themselves, the creator of "Atypical anorexia nervosa" is slicing up a traditional definition. This new concept is not meaningfully different from similar documented conditions. They should just do what happened with autism place all eating/anxiety disorders on a 'spectrum' a la Greta Thunberg.

https://www.healthline.com/health/eating-disorders/anorexia-vs-bulimia#signs-and-symptoms

See a bizarre spin on the pros of Greta's autism spectrum diagnosis here:

https://thehill.com/changing-america/well-being/468091-opinion-activist-greta-thunbergs-autism-doesnt-hold-her-back/

Jamie said...

I'll have to see the science on this. I don't doubt for a moment that there are people of larger size who suffer from eating disorders - I know some - but what is the metabolic situation that allows them to maintain overweight despite serious calorie restriction? Yes, convince your body that you're starving and it'll try to hang into all the weight it can, but surely there are limits - which I would interpret as "these 'nontraditional anorexics' aren't restricting calories anywhere near as much as those who end up in the hospital looking like concentration camp victims."

I feel for anyone who struggles with eating and weight in these ways. It must absolutely suck. I just fight the so-common running battle with weight gain in middle age and that sucks.

One of these days I'm going to have to try the paywall avoidance strategies some here have described.

Owen said...

I am sorry to say that I can’t summon much interest in this topic. Not because I don’t care about sick people and their suffering —I emphatically do— but because everything the NYT touches turns to politically correct mush.

Science is about falsifiable hypotheses. Unless the NYT can supply some, I see little reason to study its words. “Atypical anorexia” sounds like a contradiction in terms: if people lose weight, they’re sick, and if they don’t lose weight, they’re still sick, just trust the Experts. Meh.

West TX Intermediate Crude said...

I'm pleasantly surprised that NYT allows a story related to anorexia nervosa to be published. It's an exact analogue to transsexualism- the delusional belief that the body I see in the mirror is the not body I feel I have.
Treating the delusion of anorexia with gastric bypass would be malpractice, legally, medically, and literally.
Treating the delusion of "I think I'm a boy" with "top surgery" is also malpractice.

Maybe some people will draw a conclusion and help to put this madness to an end.
It could also go the other way- 6 year old girls seeing "The Little Mermaid" and then having their feet sliced off to have a fin fitted. Anything to make a little girl happy.

Christopher B said...

Fundamentally all of these syndromes appear to be about two things, agency and control.

Keep telling people they have no agency to control critically important parts of their existence, and the need to feel some mastery will assert itself in the areas where they feel they do have control.

Sebastian said...

OK, some people are insane in the way they deal with food and body size. But what exactly is the rationale for spelling out the insanity in detail in the NYT?

retail lawyer said...

Good to see anorexia back in the MSM. It dropped out when delusions became OK, to make room for acceptance of girls who thought they were boys. Some delusions are fine but others bad.

Wince said...

I suffer from bulimia amnesia.

I binge but I forget to purge.

Ann Althouse said...

"OK, some people are insane in the way they deal with food and body size. But what exactly is the rationale for spelling out the insanity in detail in the NYT?"

Obesity is one of the biggest health problems, and we don't know how to deal with it. The article is about women who put a lot of effort into to doing things that cause more health problems and it may not be taken seriously because they also don't even get thin. So, people who are obese have complex eating disorders and just trying to lose weight might only make matters worse.

How would you help them? Just call them "insane." "Insane" people need help. You're just announcing that YOU don't care. If you don't care, don't read the article, but many people do care and many people are the people that you call "insane."

Aggie said...

There is demonstrably a ton of evidence that shows that these eating disorders exist and are deeply rooted in psychological problems. And also, that it often requires intervention and classical therapy to resolve them (although therapy is not always successful). But it is also true that we are in an age where society's inhabitants have learned that they can issue demands for attention from complete anonymous strangers, and get it. And receive a little dopamine rush of gratification when it happens.

One things hasn't changed though. Fat people and skinny people alike lose weight when they don't eat enough, and will eventually starve to death if they keep it up. There is no such thing as a person that cannot lose weight.

Jupiter said...

Say, what percentage of these people are female?

Levi Starks said...

I’m skeptical.
I just can’t get those photos/film reel shots of German concentration camp survivors out of my head.
If you genuinely starve yourself, eventually you you’ll be nothing but skin and bones.

Night Owl said...

Obesity is such a problem in our country that even the anorexics are overweight?

Christopher B said...

So, people who are obese have complex eating disorders and just trying to lose weight might only make matters worse.

Yes, some people who are obese have eating disorders. So do some people who are very skinny. So do some people whose weight is proportional to their body size.

You appear to be asserting that all people who are obese and unable to lose weight have an eating disorder that is made worse by attempting to diet. Is that really what you mean?

gilbar said...

adhere to intricate rules about what foods they allow themselves to consume

how topical! I've been adhering to intricate rules about what foods i allow myself to consume,
and went this morning to the doctor office for (another) blood test. They eposted the results within 30 min.
My HEMOGLOBIN A1C is NOW down 1.3% since July (to 5.3%). I've Also lost 35 pounds!

I see my doctor on thursday, but i DOUBT that she'll have a problem with it.. Which is TOO BAD!
I MISS carbohydrates :(

Howard said...

Many of those habits I employ to keep my 19-yo physique and stamina from the days on Crew. I have very strict rules on food choice and limits, regularly skip meals and intermittent fast, and train like a maniac.

As I found out on the Peterson Huberman dopamine podcast, these are hacks that promote healthy activities.

P&H go on to talk about how pathological dopamine hacking leads to depression mania and addiction.

I'm going to have to have a second listen because the discussion is so dense, it's hard to absorb it all.

https://m.youtube.com/watch?v=z-mJEZbHFLs

Rob C said...

Shouldn't we be giving these people "Slender Affirming Care" immediately and not questioning their mental state?

Achilles said...

Ann Althouse said...

Obesity is one of the biggest health problems, and we don't know how to deal with it. The article is about women who put a lot of effort into to doing things that cause more health problems and it may not be taken seriously because they also don't even get thin. So, people who are obese have complex eating disorders and just trying to lose weight might only make matters worse.

We do know how to deal with it.

Every person is different with different numbers of fat cells and different base metabolic rates. But people are also very similar in how they react to different types of food.

The primary problem is Carbs.

Every person in the world could be healthy without carbohydrates. They are not necessary for anything that your body needs. Every essential function your body performs is possible with fat and water.

Carbs are cheap and easily manufactured and sold at a substantial markup. Corporations like carbs because they have a better profit margin than meat.

Carbohydrates are just not good for you. We are meant to be in Ketosis. Carbohydrates take you out of Ketosis and cause your body to produce insulin. If you eat carbohydrates you will also be constantly hungry throughout the day.

I could give you a diet plan where you get to eat until you are stuffed all day and men will hang out around 12-15% body fat and women around 20-25%. That is 6 pack territory.

With a couple extended fasts I can show you how to bring your visceral fat to almost 0.

daskol said...

Fat-Ass Anorexic would make good punk band name.

daskol said...

I don’t know about this new diagnosis, but makes a lot of sense that overweight to obese women would be characterized as having an eating disorder.

Jersey Fled said...

Little known?

B. said...

Not much science cited in that story. I wonder what these women really eat every day. Who pays for all this rehab and therapy?

West TX Intermediate Crude said...

"Obesity is one of the biggest health problems, and we don't know how to deal with it."

Disagree, esteemed hostess.
Eating less cures obesity 100% of the time.
A more accurate statement is that we don't have a way do deal with obesity that does not require self-sacrifice, discipline, and lifestyle change.
How can a metabolic disease transition from rare to common over the course of a few decades?
It's not a disease, it's a lifestyle choice. To be sure, encouraged and aggravated by government, corporations, social groups, and evolution, and maybe most individual people are not strong enough to resist all of that.
I actually have a degree in biology, and I can tell men from women >99% of cases. I also can assure anyone that consuming fewer calories (A) than he or she burns (B) will lead to weight loss 100% of the time.
Getting (A) less than (B) is difficult for most, and psychologically impossible for many people. It is impossible for none of them.
(B)>(A) is the cause of obesity; (A)<(B) is the resolution.
We just don't want to do difficult, unpleasant things, and call it a disease.

Achilles said...

Ann Althouse said...

How would you help them? Just call them "insane." "Insane" people need help. You're just announcing that YOU don't care. If you don't care, don't read the article, but many people do care and many people are the people that you call "insane."

What people need to understand to deal with this is how our brains work specifically with respect to Dopamine and Serotonin.

Dopamine is generally released by pathways that start in the mouth. Serotonin generally by pathways that start in the gut.

Serotonin is released generally in response to amino acids that are detected in your food and produces feelings of satiation.

Dopamine is generally produced by "tastes" in your mouth that your body associates with something you want to eat and leads to feelings of desire and hunger. There are three general categories of "tastes" that include "Yum!", "Meh," and "YUCK!"

You can program YUM and Meh. You can't do much about Yuck. If you don't like something you don't like it. You can't turn something to Yuck, but you can turn it to Meh and you can make your mind find it repulsive. I have done this with potato chips and donuts.

Another thing people get Dopamine from is signaling superiority. I don't think fat shaming is a good plan. Helping people understand why they feel the way they do is a better plan and then teach them how to modify how they feel.

People also get dopamine by getting attention. Some people use their obesity to offend others and force them to accept it.

Jake said...

Sounds like Oprah

Michael K said...

Buster Crabbe's daughter Sandy died of anorexia nervosa when she and I were in college. It was poorly understood then and not much better now if that article is accurate.

Yancey Ward said...

What about atypical atypical anorexia vervosa? Surely that is the next mental mental disease to be studied.

WWIII Joe Biden, Husk-Puppet + America's Putin said...

We all need to be taught how to eat and make friends with food and understand how nourishment works.

I think anyway. Start early - in Jr. High - when girls start to realize they are judged by their looks (like it or not)

mtp said...

This article's thesis is false. It may be true that some morbidly obese people are malnourished, or have electrolyte imbalances. But it is not true that a person can severely restrict calory intake and remain obese. The laws of thermodynamics are not suspended in dieters.

On one of the Discovery Channel geek shows years back, I watched a 700 lb woman estimate her daily intake at about 2000 calories. The producers estimated her intake at about 25,000 calories.

Rabel said...

I clicked the link. I'm still laughing at the photo and caption.

It's like a skit from an old Saturday Night Live.

Tina Trent said...

Is bulimia not covered by insurance? The article is all about insurance. There is science, and there is insurance.

What we need to understand more about is the AMA versus insurance lobbyists.

Gabriel said...

Ever hear of "breatharians"? They claim to live without food. They fall into two categories:

1) Those who refuse to be rigorously tested to see if they live without food. These people are subsequently caught eating.

2) Those who accept being rigorously tested to see if they live without food. In every case, the test has had to be stopped because the "breatharian" was clearly going to die.

You cannot believe what people say about their food intake.

Lem the artificially intelligent said...

Like Penn Jillette said: We eat for a winter that never comes.

Why isn’t obesity, overeating considered just as harmful as anorexia?

What if anorexia is our specie reaction to all the overeating going on?

What if our specie connects us with each other in ways we have not yet discovered?

Maybe anorexia is a signal we’re misinterpreting. Who knows?



William said...

America is divided into two groups of people: the morbidly obese and the anorexics. There's so much damn temptation and it's never ending. I live in a land of bakeries, pizza parlors, and first rate restaurants. It's gotten really bad with all this outdoor dining. All that food, lovingly prepared and fresh from the kitchen. The food withdrawal pangs are constant and occasionally peak with blinding intensity. Sometimes I double over in pain and frustration when I pass by a particularly golden pile of fries.....I'm hungry all the time and I'm ten pounds overweight. There's no help for it.

gahrie said...

Atkins type (no carb) diets work, I know I've been on them. The problem is, as soon as you go back to a normal diet, the weight comes back. It requires a lifestyle change.

My main problem isn't what I eat, it's what I drink. I've broken several addictions, including dipping tobacco, I just can't stay off of Mountain Dew though.

Sebastian said...

Althouse: "we don't know how to deal with it."

Well, "we" do. Achilles explained. WW is a good second best--it's not just about "losing weight." Go on it, stick with, and you're set. Of course, depends on what the meaning of "deal" is. Some "disordered" (better than "insane"? why?) people can't deal with with what they have to do.

"The article is about women who put a lot of effort into to doing things that cause more health problems"

And have done so for many years. Very troubled (better than "insane"?) people--deliberately, knowingly, persistently doing things that harm themselves.

"How would you help them?"

What kind question is that? An anonymous commenter on a blog should know how to help complete strangers with disorders even "experts" barely understand, who knowingly sabotage their own health, and who are unable to do the things that solve their problem? And who is "them"--from a media description we are supposed to be able to infer the full complexity of their ills, the same for all of "them"?

"Insane" people need help."

Well, yes. My point was why the disorders needed to be spelled out in detail in the NYT. How does that "help"? We already know that obesity is a big problem. We already know that there are many people who have a "disordered" relationship to food and their own bodies. Normally the Althouse mode is to question the presentation and resist the play for easy sentiment. It's the one I prefer.

"You're just announcing that YOU don't care."

How so? No more and no less than you or anyone else here.

kcl766 said...

Sebastian, I agree. WeightWatchers works. It does if you follow the program. That's a big if. I lost weight with the WW program in 2001 and have never been more than 2 pounds above my "goal weight" in the 21 years since. It takes work that most people don't want to do - like reading every single label of every product you purchase. I know metabolism is important, but I have seen absolutely huge people lose 50-75-100 pounds using the WW program. It works.

n.n said...

Probably a poor diet lacking fat and protein that supply sustainable nutrients, energy, and stimulate a satiated reflex. The American people and our [unPlanned] Posterity are some of the richest, disordered populations on Earth.

Michael K said...

On one of the Discovery Channel geek shows years back, I watched a 700 lb woman estimate her daily intake at about 2000 calories. The producers estimated her intake at about 25,000 calories.

When I was a resident at LA County I was working in the ER one night when a 700 pound woman came in. Her chief complaint was that she was afraid of starving because she could not get out of bed anymore.

A couple of days later, I got a surgery consult request for her as they suspected appendicitis. Talk about an "Oh, Shit" moment! I operated on her as there was no way to tell accurately. The incision was a foot long and a foot deep. I took out her appendix, which looked normal.

The Pathology came back as "periarteritis of the appendiceal artery." She eventually died of it.

stunned said...

The P&H discussion was very good. Thank you for posting that link.

Balfegor said...

I think the science is pretty much settled on calories. Our bodies are a machine that works on the Micawber principle. If caloric intake exceeds caloric expenditure, you gain weight (could be fat, could be muscle, depending). If caloric expenditure exceeds caloric intake, you lose weight (again, could be fat, could be muscle). The body can do funny stuff on the margin -- maybe it processes X more efficiently than Y, or Z switches your metabolism over to building up fats or whatever -- but big picture, there's no way to lose weight unless expenditure > intake. Similarly, aside from some water weight on the margin, you only gain weight if intake > expenditure.

The problem we have with obesity is that while we know exactly what needs to happen, it's just really hard to trick the body (and the mind) into eating less. There's probably a point at which you're so obese you're stuck at an equilibrium where it's practically impossible to increase your physical activity and reduce your caloric intake enough to lose weight without damaging your body but if you tackle it when you're still in the overweight/borderline obese BMI, it's mostly just psychology. You can still lose weight easily by just eating less.

I don't know what's going on with obese anorexics, but matter can't be created from nothing. It's going into their bodies somehow.

SDaly said...

World War III will solve the problem.

DLNE said...

Most anorexia comes with a diagnosis of depression, anxiety, and sometime with OCD, self harm, etc. It really is terrible and takes a toll on the entire family. Treatment quality is spotty and it is a life-long battle. Anorexia has the highest mortality of any mental illness. If your family has avoided it, consider yourself blessed.

DLNE said...

Most anorexia comes with a diagnosis of depression, anxiety, and sometime with OCD, self harm, etc. It really is terrible and takes a toll on the entire family. Treatment quality is spotty and it is a life-long battle. Anorexia has the highest mortality of any mental illness. If your family has avoided it, consider yourself blessed.

Howard said...

Whole food omnivorous lots of veggies olives fruit oatmeal meat sardines salmon and cod livers. No more than 200-caloriws of Dave's Bread or corn tortillas per day. Peanut butter. Olive oil. I don't do dairy because it's inflammation producing. No sugar, fruit juice, honey syrup, soda, alcohol, seed oils white bread and especially no pizza. I eat between 8am and 2pm.

I'm never Hungry. If you eat crap, you'll feel like crap.

Assistant Village Idiot said...

Superego has nothing to do with it. It is a physical illness that looks psychiatric because it has behavioral outcomes and attached emotions.

Scott Patton said...

Balfegor said.. at 1:58
"...The body can do funny stuff on the margin..."
That is a pretty wide margin though. Pick x number of people that eat the same and burn the same. I'll bet there's a lot of variation.

realestateacct said...

Carrie Fisher used to claim she had all the symptoms of anorexia nervosa except the weight loss. I believe she thought she was joking.

H said...

I'm not sure that anyone wants to hear my sad story, but I've been diagnosed with "anti-acyclical-atypical-anorexia-nervosa" (AAAAN). (Thanks in advance for all your kind thoughts and prayers.)

H said...

I'm not sure that anyone wants to hear my sad story, but I've been diagnosed with "anti-acyclical-atypical-anorexia-nervosa" (AAAAN). (Thanks in advance for all your kind thoughts and prayers.)

Balfegor said...

Re: Scott Patton:

That is a pretty wide margin though.

Not really, though -- if you're in sustained caloric deficit, you'll lose weight. Do it too fast, and maybe you'll hurt yourself. So the target is just that narrow band below net zero where different approaches to achieving caloric deficit may work better for different people.

In my 20s, I tried to lose weight by exercising and eating "healthy" foods, but while that works for some people, sweating on exercise machines just made me hungry (and contra all the people telling that I was supposed to feel good after exercise because of endorphins, I consistently felt gross, sticky, and irritable every time I exercised) so I ate more and gained weight year after year. In my late 20s I realised that the solution for me was much simpler: just eat less. That has worked well for me and been pretty lasting. Over a span of years, my weight does tend to drift up again but never to where it was when I was doing at least an hour on the treadmill daily and then gorging myself on pots of rice. And it's never been especially difficult to get it back down now that I figured out which variable in the equation is easiest for me to move.

But other people might find other variables easier to adjust, or might need a more careful diet to avoid the kinds of psychological (or physiological or whatever) traps that led me to overeat after sustained exercise. What you're actually trying to do to lose weight is the same for everyone, after all. The margin is just which strategy works best to keep you in the right negative balance.

Ex-PFC Wintergreen said...

I was about 10 pounds above my ideal weight for several years after college, but I really struggled with obesity after the FDA published the Food Pyramid in 1992 - you mean that bread and pasta are healthy??? Sign me up! And about 80 pounds later, my weight stabilized…about 90 pounds too high. Stayed that way for quite a while, until I discovered Gary Taubes’ Good Calories, Bad Calories and his hypothesis (he was very careful to not call it a theory) that obesity was a disease of fat dysregulation - for people (like many Americans) who are not genetically well adapted to significant carbs in the diet, eating carbs causes insulin to be produced, which prevents the body from using stored fat, and at the same time directing the liver to convert the carbs to fat and store that fat. Since the body is thereby prevented from using most of the energy in the food, and prevented from using the stored energy in our adipose (fat) tissue, our hunger isn’t satiated and we overeat and gain weight. The fix is to drastically reduce carbs in the diet, increase fat intake (eating fat doesn’t make you fat), eat moderate amounts of protein, all of which tamps down the insulin response that kicked off this chain of events and allows the body to use stored fat for energy.

Of Taubes’ hypothesis, some of it - particularly the insulin response and how increased insulin drastically reduces existing fat usage and increases new fat storage - is well-established human biochemistry. Other parts are more speculative and have not necessarily been established in the lab. But it is absolutely true that humans don’t need to consume carbs to be healthy (that experiment was done in the 1920s), and a low-carb-high-fat diet has been clinically shown to reverse Type II diabetes.

For me, I found the LCHF way of eating to not be all that difficult on the eating side - after about a week, I found I was not hungry between meals and was able to eat to satiety and still lose about 2 lbs per week. I lost about 60 lbs altogether over about six months, my various health indicators including A1C were running in the right direction. I kept the weight off for another six months of being less restrictive, and now have gained about 20 lbs back after more-or-less abandoning LCHF over the last eight months. The problem I’ve had with this way of eating is not the eating part; I like the food one eats on a LCHF diet - but it requires a substantial commitment in time to prepare the food and that time has been in short supply in the last year due to what I’ll call “family” issues. I’m working the logistics issues involved in getting back on this plan and should be good to go in the near future, at which point I’ll get to run the experiment again.

My “gut” feeling is there are many ways to lose weight, none of them easy. For me, LCHF worked as long as made the time for the food prep (that was the “not easy” part for me). If you’re in a similar situation, you might want to think about it.

And yes, it is possible to be fat and semi-starving yourself, if you’re a Type II diabetic and your insulin is chronically quite high and your diet is high in carbs. If you eventually cut calories enough, insulin levels will drop enough so your body can get access to stored fat, but there is an in-between zone where the fat tissue is still mostly off limits because of high insulin. Whether that’s what’s going on with the people described in the article…further deponent sayeth not.

LH in Montana said...

One thing that doesn't help is that all the governmental agencies, medical establishment, pharmaceutical companies, etc., are in complete agreement that we should all be eating low fat/high carb despite pretty obvious evidence that doesn't work. Some people have discovered that low carb/high fat diets help them lose weight, feel satiated, eliminate their chronic conditions without medication, and generally feel better. But once they get their cholesterol checked, their doctor will want to put them on medication despite many studies showing how wrong we've been about cholesterol.

Doctors don't make you healthy. They simply medicate your symptoms.

So, how are most obese people supposed to figure this out? I can imagine their doctors are not very kind -- assuming they go to see them at all -- and they keep telling them the same things about less fat, more carbs.

Even for someone like me who reads a lot about health and nutrition, it's really difficult to know what to believe. You almost have to form your own opinion and shut out all the other noise, which tends to be overwhelmingly loud.

Therefore, I have compassion for these people. They clearly have no idea how to help themselves and no one is helping them either.