It is estimated that one in five eating disorder sufferers have a high body mass index (BMI), placing them in either the overweight or obese category.
According to Dr Phillipa Hay, director of Sydney's Wesley Eating Disorders Centre, many of these people have traditionally had their eating disorders left undiagnosed, instead being enrolled in weight loss programs which neglect mental health concerns.
A new form of eating disorder treatment developed in Sydney is especially for high-BMI patients.
"It has been our experience at Wesley that these people have been under-detected and under-recognised," she said, adding that some patients assume they must not have an eating disorder, because they are not underweight.
"We've had people who have had bulimia nervosa their entire life and just were not aware that it was an eating disorder."
Now, Dr Hay has co-founded the first ever hospital treatment plan designed specifically for eating disorder patients with high BMIs.
The HAPIFED program (named as a "Healthy APproach to weIght management and Food in Eating Disorders") launched last week. It is believed to be the first program to provide the cognitive behaviour therapy – a form of psychotherapy focused on self-help strategies to change negative thoughts and behaviours – associated with eating disorder treatment to high-BMI patients.
Patients enrol in a 12-week program, comprising both cognitive behaviour therapy sessions and other group sessions more in line with a traditional weight loss program: eating a weekly supervised meal and having discussions about emotion regulation, weight maintenance, appetite regulation, body image, and exercise habits.
The program was previously trialled by a small group of 11 participants in a study published last year. Of the eight participants who completed the intervention, 75 per cent of participants lost weight over the period, and 75 per cent also demonstrated reduced eating disorder symptoms.
A 2017 University of Sydney analysis of self-reported rates of obesity in addition to an eating disorder between 1995 and 2015 found a 7.3-fold increase in reports of binge eating disorder among the obese population. Reports of obesity alongside strict dieting and fasting behaviours increased by 11.5 times over the period.
According to Dr Hay, the majority of people with a high BMI who also have an eating disorder have binge eating disorder, or a non-purging form of bulimia nervosa, which sees the sufferer engage in fasting and compulsive exercise instead of engaging in practices like vomiting or using laxatives.
Dr Hay said the objective of the HAPIFED program is to provide a weight loss program which is focused less on weight and more on the act of eating.
"We've worked for a number of years with people who are underweight, with people who have anorexia nervosa, to help them learn to eat again in a nutritious and good way," she explained, adding that patients need to have a good relationship with food, their bodies and themselves.
Although eating disorders are increasingly being recognised in people who are not underweight, there is still an incorrect perception that they can only be experienced by a certain type of person: young, female, and thin.
"Actually, [eating disorders] can occur for people of all sizes, genders, and socioeconomic groups in the community."
Non-BMI indicators that someone might have an eating disorder
Eating disorders in people who are not underweight can be difficult for loved ones to detect, although there are some signs to keep in mind.
"Someone who is binge eating may be spending a lot of their income on food," Dr Hay says, adding that the person may be particularly spending a lot of money on food "which then disappears".
Withdrawal can also be a sign that someone is developing an unhealthy relationship with food.
"People with an eating disorder may stop eating with you," Dr Hay says, Often people who have high BMIs stop eating with other people because they feel that other people are judging them and stigmatising them for what they are eating, and also because they may have been bingeing."
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