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NEDC e-Bulletin

Number Thirty-Five

Conflicting Messages: Examining the challenges of Stigma and the Growing Link Between Binge Eating Disorder and Obesity.


Integrated Health Promotion is an essential approach to health messages in the public domain where there is a focus on weight, diet, fitness and body image. What integrated health messages strive to achieve is the promotion of public health information that ‘does no harm’ when offering advice or direction on what to eat, how to look or how to exercise. All health professionals who participate in public health and physical wellness messaging - medical, allied, complementary, fitness and weight loss, as well as the media - have a common responsibility, indeed an opportunity, to work together to achieve this goal when publishing health material or advertisements about physical appearance, body shape, or weight.

The NEDC has undertaken much research into the damaging effects of conflicting weight-related health advertising.We have also contributed to the development of the MindFrame Media Guidelines to promote safe management of mental health reporting in the media.
The common theme of the promotion of a healthy lifestyle is eating a diverse and nutritious diet full of fresh, unprocessed foods; exercising for movement, society and fun; and an attitude of acceptance and respect for one’s body, whatever shape or size. Some public advertisements that focus on physical appearance and weight loss, however, have been found to be triggering to people at risk of an eating disorder, and similarly, some messages aimed to prevent the behaviours and patterns associated with eating disorders may be seen to conflict with the efforts of the health promotion efforts of the overweight and obesity health advisers. Ads that focus on body shaming, stigma and other physical stereotypes run at cross purposes to the outcomes that are central to overall public health.

This month’s e-bulletin examines some of the commonalities between eating disorders and overweight and obesity. In particular we focus on the secrecy, shame and stigma that surround Binge Eating Disorder (BED), and the shared behaviours, health outcomes and challenges between BED and obesity.

Contents

1. The Stigmas Associated with Binge Eating Disorder

2. Binge Eating Disorder and Obesity - Growing Links

3 Additional Research Articles on BED and Obesity - NEDC Knowledge Hub

4. Download our Binge Eating Disorder Fact Sheet here.

 

The Stigmas Surrounding Binge Eating Disorder and Obesity


The stigmas surrounding appearance, weight and body image are aspects of social prejudices that are all too common in the field of eating disorders. Breaking down societal stigma is a key focus of mental health and eating disorders sectors. Two areas that experience a heightened level of stigma is Binge Eating Disorder, and Obesity.

What we know

  • Binge eating can be underpinned by feelings of shame and guilt
  • Binge eating often occurs during times of stress, anger, boredom or distress
  • Individuals often feel great deals of fear around what reactions they will face in speaking out about their concerns

Research shows that fear can stem from two major areas, these are; 1. Internalised weight bias and 2. Societal bias around Binge eating disorder.

What is internalised weight bias (IWB)?

Internalised weight bias, can be described as, self-directed weight bias deriving from self beliefs and attitudes, that are contributed to by societal and cultural factors (Pearl, White, & Grilo, 2014b). This wide spread bias, both internal and external, can lead to strong internalisation of negative messaging (Durso et al., 2012).

Multiple studies have shown that IWB is strongly linked to other mental health concerns such as depression, self-esteem issues and a variety of other psychological issues (Durso et al., 2012; Pearl, White, & Grilo, 2014a; Pearl et al., 2014b). There has been much literature that has explored to support the links between stigma and its impacts on those who are overweight and obese and found that weight gain due to binge eating or otherwise may heighten risk for poor psychosocial outcomes such as depression and anxiety, particularly among females (Anderson et al., 2007; Ball et al., 2008; Bjerkeset et al., 2008; Jorm et al., 2003).

Studies have shown that there is a direct link between BMI and overall health-related quality of life, however more research on relationships between health and self-stigma is minimal and there is a need for additional research to fully understand the impacts (Pearl et al., 2014b).

Societal weight bias and stigma

Anti-obesity messages are everywhere – in news, in entertainment, and in public health campaigns. We are constantly being told that fat is bad, and the only road to health and happiness is to lose weight. Obesity-reduction strategies in the form of community-based interventions and social marketing campaigns often emphasise the desirability of an idealised body weight or shape through dieting and physical exercise (Bombak 2014). However there is no evidence to show that these strategies prompt or result in weight loss. Instead, popular ideas about fatness and health may inadvertently stigmatise the individuals they intend to help, and may be a risk factor in the development of eating disorders, such as BED (Schwartz & Henderson, 2009; Waddie & Diddie 2003).

Our environment, societal views and opinions can have quite an impact on how we position ourselves within the world. Therefore the way that obesity and binge eating is perceived can have a substantial impact on the way in which treatment is approached. Current approaches by health practitioners and within health promotion/media have focused on weight, shape and size; this raises the question: Do our current methods for addressing obesity also address de-stigmatisation?
Studies have uncovered a deep rooted bias within society against individuals that are overweight or obese with many, including health care providers, being of the opinion that obese individuals are lazy, lacking will-power and are undisciplined (Puhl et al 2013; Teachman & Brownell, 2001, Schwartz et al., 2003;Foster et al., 2003).

Many public health campaigns aimed at reducing obesity employ social marketing tactics designed to arouse emotional responses including fear, shame, humiliation, concern about being unattractive or undesirable, and disgust (Lupton, 2013). Disgust is a shock tactic employed in anti-obesity campaigns by public health authorities in many countries including Australia (Lupton, 2013). Through the implementation of these tactics it has been shown that negative stigmas around obesity increase.
By focusing on weight as the problem and weight loss as the solution, messages intended to motivate individuals to be healthier can be more effective if framed in ways that foster confidence and self-efficiency to engage in healthy behaviours, rather than in ways that imply personal blame or require solitary effort. It is therefore important that weight-related public health messages consider the potential that these messages may have for promoting adverse or unintended consequences.

What are the potential implications to these biases/stigmas?
- Individuals my take a longer time to express concerns or worries about BED due to personal fears around being judge, unearthing feelings of shame and or guilt
- Later access to treatment could mean an increase of complexity and severity upon presentation
- Misperception could cause signs and symptom to be missed. Additional health issues could arise as a result of a missed diagnosis or action plan.
 

Reference List

Anderson, S. E., Cohen, P., Naumova, E. N., Jacques, P. F., & Must, A. (2007). Adolescent obesity and risk for subsequent major depressive disorder and anxiety disorder: prospective evidence. Psychosomatic Medicine, 69(Mdd), 740–747.

Bjerkeset, O., Romundstad, P., Evans, J., & Gunnell, D. (2008). Association of adult body mass index and height with anxiety, depression, and suicide in the general population: The HUNT study. American Journal of Epidemiology, 167(2), 193–202.

Bombak, A. (2014). Obesity, health at every size, and public health policy. American Journal of Public Health, 104(2), 60–68.

Durso, L. E., Latner, J. D., White, M. a., Masheb, R. M., Blomquist, K. K., Morgan, P. T., & Grilo, C. M. (2012). Internalized weight bias in obese patients with binge eating disorder: Associations with eating disturbances and psychological functioning. International Journal of Eating Disorders, 45(3), 423–427.

Foster, G. D., Wyatt, H. R., Hill, J. O., McGuckin, B. G., Brill, C., Mohammed, B. S., Klein, S. (2003). A randomized trial of a low-carbohydrate diet for obesity. The New England Journal of Medicine, 348(21), 2082–2090.

Lupton, D. (2013). Revolting Bodies : the Pedagogy of Disgust in Public Health Campaigns Sydney Health & Society Group Working Paper No . 4 Department of Sociology University of Sydney, (4).

Pearl, R. L., White, M. A., & Grilo, C. M. (2014a). Overvaluation of shape and weight as a mediator between self-esteem and weight bias internalization among patients with binge eating disorder. Eating Behaviors, 15(2), 259–261.

Pearl, R. L., White, M. a., & Grilo, C. M. (2014b). Weight bias internalization, depression, and self-Reported health among overweight binge eating disorder patients. Obesity, 22(5), 142–148.

Puhl, R. M., Gold, J. A., Luedicke, J., & DePierre, J. A. (2013). The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice. International Journal of Obesity, 37(11), 1415–1421.

Schwartz, M. B., Chambliss, H. O., Brownell, K. D., Blair, S. N., & Billington, C. (2003). Weight bias among health professionals specializing in obesity. Obesity Research, 11(9), 1033–1039.

Schwartz, M. B., & Henderson, K. E. (2009). Does obesity prevention cause eating disorders? Journal of the American Academy of Child and Adolescent Psychiatry, 48(8), 784–786.

Teachman, B. a, & Brownell, K. D. (2001). Implicit anti-fat bias among health professionals: is anyone immune? International Journal of Obesity and Related Metabolic Disorders : Journal of the International Association for the Study of Obesity, 25(10), 1525–1531.

Jorm, A. F. (2003). Association of obesity with anxiety, depression and emotional well being:a community survey. Australian and New Zealand Journal of Public Health, 27(4), 434–440.

Wadden, T. a, & Didie, E. (2003). What’s in a name? Patients' preferred terms for describing obesity. Obesity Research, 11(9), 1140–1146.

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The Growing Links Between BED and Obesity

The increasing incidents of obesity are an important issue in global public health and the World Health Organisation estimates that around 1.5 billion adults are overweight (Hung-Yen et al., 2013). Alongside this staggering figure is the prevalence of binge eating disorder (BED), reported as the most common of all eating disorders, with between 6 and 8% (or 360 - 480 million) identified as having BED (Lin et al., 2013; Grucza et al., 2007).

So let’s examine the link. As Masheb, Grilo and Rolls (2011) suggest, obesity is not a diagnostic criterion for BED. However, the two are so strongly associated that most persons with BED who present for treatment are obese and at increased risk for other medical and psychiatric morbidity. Both BED and obese adults sight body dissatisfaction, eating related psychopathology and body image disturbances [Myer, L., Wiman, A. M., 2013).

De Zwaan as early as 2001,pres that approximately 30% of those participating in weight loss programs and 70% of individuals involved in Overeaters Anonymous, or national equivalents, displayed BED (De Zwaan, 2001).

Available evidence suggests that Binge Eating Disorder (BED) may be the most common eating disorder, with more than 6% of the population revealing that they participate in binge eating behaviours (Grucza, et al., 2007). BED is found to have high instances of comorbid psychiatric health problems, such as anxiety, depression, mood disorders, and substance misuse. There is also increasing evidence that a significant proportion of people who have been diagnosed with BED have a Body Mass Index (BMI) greater than 30, which is the measure for obesity. In fact, in those actively seeking treatment for obesity, it is estimated that somewhere between 15% up to 50% of people meet the DSM-V diagnostic criteria for comorbid BED (Myers & Wiman, 2014). Conservative estimates rest on around 25-30%.

Our challenge in the future is to understand better the ways in which BED and obesity coexist and to find treatment strategies that will relieve the distress and dysfunction due to the disordered eating, as well as enhance appropriate weight loss or, at a minimum, prevent further weight gain.

(Yanovski, 2003)

There is no evidence to support a ‘single solution’ to obesity or eating disorders. There are no simple solutions that ‘fix’ the complex and inter‐related problems of obesity, body dissatisfaction and eating disorders. Each condition is influenced by a complex interplay of biological, social and environmental factors. The way in which each condition is addressed will influence the environments in which the other conditions develop.
If the notion of a single ‘best approach’ is dismissed, the evidence suggests that promoting healthy eating, activity and body satisfaction through multiple social and environmental channels that embrace collaboration between sectors, will have the best chance of success.

At times, the obesity and eating disorders sectors disseminate potentially conflicting messaging in the public domain and consumers’ forum. Concerns have been raised that some obesity prevention initiatives increase anxiety about body shape and weight in at-risk groups, unwittingly prompting unhealthy weight loss activities, particularly amongst children and adolescents.

(Susan Paxton, Professor of Psychology, School of Psychology and Public Health, La Trobe University).

Similar concerns have been raised that public messages that are sensitive to the risk factors of eating disorders may in fact condone obesity (O’Dea, 2005b; Mann et al 2007).
The ideal approach is for obesity and eating disorder prevention programs to be integrated, with experts from each field engaging in the development and evaluation of communication strategies. Current initiatives should be examined and evaluated for their impacts on obesity and eating disorder risk. The emphasis must be on an integrated and collaborative approach to the development and dissemination of weight-related public health messages and information that targets different audiences and engages them with consistent, clear messages.

By building our understanding of the overlap between obesity and eating disorders, we are empowered to promote a healthy, fulfilling society for all. Eating disorders and obesity are amenable to early intervention strategies and there is room to improve the efficacy of prevention activities and treatment expenditure. Directing investments to evidence-based prevention initiatives that promote holistic health approaches to nutrition, body image, obesity and eating disorders is essential.

References

Grucza, R. A., Przybeck, T. R., Cloninger, C. R., 2007, Prevalence and correlates of binge eating disorder in a community sample., Comprehensive Psychiatry, Washington University School of Medicine, pp 124-31.

Lin, H., Huang, C., Tai, C., Lin, H., Kao, Y., Tsai, C., Hsuan, C., Lee, S., Chi, S., Yen, Y., 2013, Psychiatry disorders of patients seeking obesity treatments, BMC Psychiatry, http:/www.biomedcentral.com/1471-244X/13/1

Masheb, R. M., Grilo, C. M., Rolls, B. J., 2011, A randomised controlled trial for obesity and binge eating disorder: Low-energy-density dietary counseling and cognitive behavioural therapy, Behaviour Research and Therapy, Vol. 49, pp 821-29.

Myers, L. L., Wiman, A. M., 2014, Binge eating disorder: a review of a new DSM diagnosis, Research on Social Work Practice, Vol. 24, pp 86-95.

Yanovski, S. Z., 2003, Binge eating disorder and obesity in 2003: Could treating an eating disorder have a positive effect on the obesity epidemic?, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethseda, Maryland.

de Zwaan, M., 2001, Binge eating disorder and obesity, International Journal of Obesity, Vol. 25, pp 51-55.


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Additional Research Articles on BED and Obesity - NEDC Knowledge Hub

 BED and Obesity

When understanding eating disorders and their relationship with other physical conditions, it's important to be well-informed. The NEDC has curated a collection of topic specific articles, housed in our Knowledge Hub that can help you get started on the information path.

 

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NEDC Binge Eating Disorder Fact Sheet


The NEDC produces evidence-based resources and fact sheets in all areas of eating disorders. Download this fact sheet on Binge Eating Disorder to get the facts and share the right information.

 
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