**Abstract**

Eating disorders, the most lethal of all the psychiatric disorders, are frequently misdiagnosed as benign weight management problems, which contribute to their being underdiagnosed and under-reported. Though eating disorders are typically first identified through easily discernible weight change, their unseen origins lie in genetic propensities, neurobiology, environmental and family influences, inborn temperament, and trauma. Non-integrative, behaviorally based weight management solutions that call for dieting and meal plans alone, by ignoring the psychological underpinnings and neurobiological origins of dysfunctions driving these disorders, can potentially lead to loss of life and/or life quality. Conversely, generic psychotherapy protocols typically fail to address and enforce the behavioral prerequisite to re-feed the malnourished eating disordered brain and body, which is required to optimize therapy outcomes. It is for the intuitive and skillful diagnostician to determine whether the patient's desire for weight change is based on healthful autonomous discretion or on the dictates of compulsions based in lifethreatening pathology, thus informing treatment. Eating disorders are disorders of the core Self of self-regulation, self-perception, self-esteem and self-care, affecting life spheres far exceeding eating-lifestyle and weight management. Healing weight management problems requires integrative diagnosis and care, re-establishing one's healthy relationship with food, weight, and eating, as well as with one's re-integrated core self.

**Keywords:** weight management, diets, dieting, obesity, disordered eating, eating disorders, anorexia nervosa, bulimia nervosa, obsessive compulsive disorder, binge eating disorder, purging, food restriction, healthy eating, exercise bulimia, refeeding edema, diabulimia

#### **1. Introduction**

Most individuals seeking advice about weight management issues approach healthcare professionals with the intention of improving their health, well-being, and appearance by losing weight and altering their metabolic function. Typically, first responders, be they parents, nutritionists, physicians, nurses, coaches, or personal trainers, offer non-integrative behavioral approaches to weight management in the form of prescriptive diet plans. In the absence of underlying pathology or compulsions that may drive dysfunctional eating behaviors, such simple solutions may be adequate. But when the origin of an individual's desire and efforts to lose weight resides in underlying eating pathology, purely behavioral solutions can mask potentially life-threatening dysfunctions. Sometimes hiding in plain sight, otherwise benign disordered eating (DE) habits may ultimately take on an element of compulsivity, leading to chronic illnesses such as heart disease, diabetes, and/or as heart disease or diabetes and/or the eventual onset of a life-threatening clinical eating disorder (ED) in genetically susceptible individuals. It is for the astute and intentional diagnostician to sniff out, intuit, or otherwise identify the potential for pathological origins within a constellation of seemingly benign weight management dysfunctions by determining whether a patient's desire for weight change is based on healthful, autonomous discretion or on the dictates of a tyrannical and potentially lethal eating disorder. Overlooking the nature and severity of DE behaviors or warning signs of a clinical ED can carry dire consequences. By partnering with the patient to affirm or negate a diagnostic hunch, the clinician informs appropriate treatment, promoting disease prevention or the achievement of a timely and sustainable problem resolution. systems, developmental life stages, and self-concept issues culminating in body image perception and preoccupations. The confluence of normal child development and early bodily maturation, environmental triggers gleaned through social media, attitudes in the home, and peer pressure can lead to high-risk responses in teens and young adults which might include dieting, excessive exercise, abuse of diet pills, purging, food restriction, or eating only when hungry/skipping meals. In response to a societal disconnect between biology and culture, as girls grow older, they are expected to grow smaller. Studies show that 42% of first to third grade girls wish to be thinner [1] and, in the attempt to change one's natural body shape and size, 81% of 10-year-old girls feel better about themselves when they are dieting [2], creating a greater risk of obesity in adulthood. 25% of American men and 45% of American women are dieting on any given day [3], giving rise to cravings, malnutrition, metabolic dysfunction, and increased overweight once the individual "falls off the dieting wagon." It has been reported that 35% of "occasional dieters" progress to pathological dieting and DE, and as many as 25% progress to partial or full syn-

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis…*

It is for the perceptive and responsive diagnostician to determine at what point, along the healthy eating continuum, eating behaviors cross the thin line between normal eating and various forms and degrees of eating pathology and compulsions. A patient of mine with binge eating disorder (BED) assumed that she was in "remission" until, "It suddenly occurred to me that this was not just about having an extra piece of pie … this was starting to feel like an all-out binge." Pathology exists when food, exercise, or the abuse of dietary substances is used to resolve emotional problems or in response to posttraumatic stress; when food serves purposes other than satiating hunger, fueling the body, or sociability; when the act of eating evokes guilt and fear; when eating habits become inflexible, immoderate, imbalanced, and excessive; when compulsive thoughts, such as calculating caloric intake, and preoccupations about becoming fat preclude other thinking, interfering with learning and normal daily function; and when attitudes and beliefs about food and eating are

*When a child who is a healthy eater runs out the door without breakfast because (s)he is late for the school bus, she will surely want to snack during the morning or eat a bigger lunch to make up for the calories lost. The child with an ED who runs out the door without breakfast does so because (s)he would otherwise be wracked with fear, anxiety, and guilt that the calories she might ingest would make her fat. This child would feel compelled to calculate how many calories (s)he can allow herself to ingest throughout the rest of the day so as not to gain a single ounce.*

**3. Weight management diagnosticians face multiple challenges**

cate to clinicians is often not accurate or comprehensive; and what patients request of health professionals is frequently not what they need. Falling between the cracks of accurate assessment and appropriate treatment, DE and potentially

lethal ED all too frequently remain misunderstood, underdiagnosed, and undertreated [5] by myopic, underinformed physicians, psychotherapists, and nutritionists who lack an integrative "big picture" perspective of the possible existence of underlying, co-occurring diagnoses that need to be revealed, monitored, and treated. The diagnosis of a clinical ED remains elusive, with more than

one half of all cases remaining undetected [6].

In the face of weight management issues, information that patients communi-

drome eating disorders [4].

*DOI: http://dx.doi.org/10.5772/intechopen.92152*

misguided.

**163**

#### **2. The continuum of healthy eating**

The nature and quality of eating patterns reside along a continuum that includes eating behaviors and self-care. Along the span of this continuum, healthy eating patterns may evolve into disordered eating patterns, potentially leading to deadly ED in genetically susceptible individuals. At one end of the continuum, healthy eating behaviors mark the achievement of a fit and effectively functional body capable of sustaining its own ideal set point weight through healthy eating and selfcare (**Figure 1**). At the opposite end of the continuum, life-threatening ED represent the tip of an underlying emotional, physiological, and neurobiological iceberg. A clinical ED marks the fragmentation or loss of the core self and, with it, the patient's lost capacity for self-regulation, self-trust, self-esteem, and self-care. Feelings of guilt and of shame typically foster secrecy, denial, and reluctance to seek or sustain care. Ambiguous and inconstant DE behaviors exist somewhere between the polarities of healthy eating and potentially life-threatening ED. Some DE patterns that may appear to be pathological may actually represent variations of normal and benign behaviors, being shared by otherwise healthy eaters. As an example, healthy eaters who choose to indulge excessively in the lavish offerings of dessert buffets, typically consider such an opportunity benign and not-to-be-missed, guiltfree, gastronomic sensory and aesthetic delight.

The evolution of dysfunction along the eating continuum is influenced by the melding of eating lifestyle with genetic propensities, inborn temperament, value

#### **Figure 1.**

*Along the continuum of healthy eating, the evolution of healthy eating to DE, and from DE to a clinical ED, represents a journey of developing pathology; likewise, recovery from eating pathology represents a journey in the opposite direction, towards developing health.*

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.92152*

systems, developmental life stages, and self-concept issues culminating in body image perception and preoccupations. The confluence of normal child development and early bodily maturation, environmental triggers gleaned through social media, attitudes in the home, and peer pressure can lead to high-risk responses in teens and young adults which might include dieting, excessive exercise, abuse of diet pills, purging, food restriction, or eating only when hungry/skipping meals. In response to a societal disconnect between biology and culture, as girls grow older, they are expected to grow smaller. Studies show that 42% of first to third grade girls wish to be thinner [1] and, in the attempt to change one's natural body shape and size, 81% of 10-year-old girls feel better about themselves when they are dieting [2], creating a greater risk of obesity in adulthood. 25% of American men and 45% of American women are dieting on any given day [3], giving rise to cravings, malnutrition, metabolic dysfunction, and increased overweight once the individual "falls off the dieting wagon." It has been reported that 35% of "occasional dieters" progress to pathological dieting and DE, and as many as 25% progress to partial or full syndrome eating disorders [4].

It is for the perceptive and responsive diagnostician to determine at what point, along the healthy eating continuum, eating behaviors cross the thin line between normal eating and various forms and degrees of eating pathology and compulsions. A patient of mine with binge eating disorder (BED) assumed that she was in "remission" until, "It suddenly occurred to me that this was not just about having an extra piece of pie … this was starting to feel like an all-out binge." Pathology exists when food, exercise, or the abuse of dietary substances is used to resolve emotional problems or in response to posttraumatic stress; when food serves purposes other than satiating hunger, fueling the body, or sociability; when the act of eating evokes guilt and fear; when eating habits become inflexible, immoderate, imbalanced, and excessive; when compulsive thoughts, such as calculating caloric intake, and preoccupations about becoming fat preclude other thinking, interfering with learning and normal daily function; and when attitudes and beliefs about food and eating are misguided.

*When a child who is a healthy eater runs out the door without breakfast because (s)he is late for the school bus, she will surely want to snack during the morning or eat a bigger lunch to make up for the calories lost. The child with an ED who runs out the door without breakfast does so because (s)he would otherwise be wracked with fear, anxiety, and guilt that the calories she might ingest would make her fat. This child would feel compelled to calculate how many calories (s)he can allow herself to ingest throughout the rest of the day so as not to gain a single ounce.*

#### **3. Weight management diagnosticians face multiple challenges**

In the face of weight management issues, information that patients communicate to clinicians is often not accurate or comprehensive; and what patients request of health professionals is frequently not what they need. Falling between the cracks of accurate assessment and appropriate treatment, DE and potentially lethal ED all too frequently remain misunderstood, underdiagnosed, and undertreated [5] by myopic, underinformed physicians, psychotherapists, and nutritionists who lack an integrative "big picture" perspective of the possible existence of underlying, co-occurring diagnoses that need to be revealed, monitored, and treated. The diagnosis of a clinical ED remains elusive, with more than one half of all cases remaining undetected [6].

appearance by losing weight and altering their metabolic function. Typically, first responders, be they parents, nutritionists, physicians, nurses, coaches, or personal trainers, offer non-integrative behavioral approaches to weight management in the form of prescriptive diet plans. In the absence of underlying pathology or compulsions that may drive dysfunctional eating behaviors, such simple solutions may be adequate. But when the origin of an individual's desire and efforts to lose weight resides in underlying eating pathology, purely behavioral solutions can mask potentially life-threatening dysfunctions. Sometimes hiding in plain sight, otherwise benign disordered eating (DE) habits may ultimately take on an element of compulsivity, leading to chronic illnesses such as heart disease, diabetes, and/or as heart disease or diabetes and/or the eventual onset of a life-threatening clinical eating disorder (ED) in genetically susceptible individuals. It is for the astute and intentional diagnostician to sniff out, intuit, or otherwise identify the potential for pathological origins within a constellation of seemingly benign weight management dysfunctions by determining whether a patient's desire for weight change is based on healthful, autonomous discretion or on the dictates of a tyrannical and potentially lethal eating disorder. Overlooking the nature and severity of DE behaviors or warning signs of a clinical ED can carry dire consequences. By partnering with the patient to affirm or negate a diagnostic hunch, the clinician informs appropriate treatment, promoting disease prevention or the achievement of a timely and sustainable problem resolution.

The nature and quality of eating patterns reside along a continuum that includes eating behaviors and self-care. Along the span of this continuum, healthy eating patterns may evolve into disordered eating patterns, potentially leading to deadly ED in genetically susceptible individuals. At one end of the continuum, healthy eating behaviors mark the achievement of a fit and effectively functional body capable of sustaining its own ideal set point weight through healthy eating and selfcare (**Figure 1**). At the opposite end of the continuum, life-threatening ED represent the tip of an underlying emotional, physiological, and neurobiological iceberg. A clinical ED marks the fragmentation or loss of the core self and, with it, the patient's lost capacity for self-regulation, self-trust, self-esteem, and self-care. Feelings of guilt and of shame typically foster secrecy, denial, and reluctance to seek or sustain care. Ambiguous and inconstant DE behaviors exist somewhere between the polarities of healthy eating and potentially life-threatening ED. Some DE patterns that may appear to be pathological may actually represent variations of normal and benign behaviors, being shared by otherwise healthy eaters. As an example, healthy eaters who choose to indulge excessively in the lavish offerings of dessert buffets, typically consider such an opportunity benign and not-to-be-missed, guilt-

The evolution of dysfunction along the eating continuum is influenced by the melding of eating lifestyle with genetic propensities, inborn temperament, value

*Along the continuum of healthy eating, the evolution of healthy eating to DE, and from DE to a clinical ED, represents a journey of developing pathology; likewise, recovery from eating pathology represents a journey in the*

**2. The continuum of healthy eating**

*Weight Management*

free, gastronomic sensory and aesthetic delight.

*opposite direction, towards developing health.*

**Figure 1.**

**162**

*A patient of mine had been treated by a psychiatrist for 7 years, during which time, she never told him that she vomited 30 times a day, for fear of his finding her "disgusting" and therefore refusing to treat her. This physician failed to "read between the lines" of her symptoms and to intuit and investigate the presence of an ED from the constellation of personality traits, temperament, and behaviors that she did reveal to him. Through our work together, she came to understand her problem and her self. The quality of our relationship led to the improvement of all her significant relationships—with food, with her self, and with others.*

healthier.'" The term "healthy eating" not infrequently becomes a euphemism for food restriction, or 'clean eating,' potentially triggering the onset of orthorexia in ED individuals. Further complicating the diagnostic process, ED symptoms vary appreciably from patient to patient, with; every ED a 'thumbprint.' Fully half of the ED population suffers from the difficult-to-identify condition called "other specified feeding or eating disorder" (OSFED), previously known as "eating disorder not otherwise specified" (EDNOS) [7]. OSFED describes atypical AN (without low weight) and atypical BN or BED (with lower frequency of behaviors, purging disorder, and/or night eating syndrome). Patients who do not meet the strict diagnostic cutoffs for full criteria for AN and BN often remain undiagnosed despite the seriousness of their illness, foregoing or delaying necessary treatment [8]. Patients with clinical ED are often reticent, within a diagnostic interview, to divulge a stigmatized disorder. A recent discovery, important for its potential to reduce the degree of stigma that is associated with ED nondisclosure revealed that 20% of the neurobiology of AN could be derived from metabolic genes (possibly activated by a state of starvation) [9].

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis…*

**3.1 Myths and misconceptions regarding clinical ED abound**

individuals are exceedingly thin."

*DOI: http://dx.doi.org/10.5772/intechopen.92152*

body and multiple pathways in the brain [10].

*3.1.1 The physician's role in weight management detection*

look opportunities for early disease recognition.

charts, precluding early disease prevention.

represent a "clean bill of health."

of ED:

**165**

Consider the following examples of decoys to the recogntion and understanding

• People mistakenly assume that AN is easy to spot, believing that "all anorexic

restoration of weight marks a full recovery from an ED. In fact, ED recovery is marked by neurobiological, emotional, cognitive, and behavioral changes that lead to the reintegration of the individual's core self and the normalization of body fat mass and sexual hormones, which have a widespread impact on the

• Despite the widely accepted misconception that ED represent an incurable "life sentence," about half of those individuals with AN or BN attain a full recovery, 30% achieve a partial recovery, and 20% show no substantial improvement [11].

Though early detection of ED warning signs is pivotal in disease prevention and/ or promoting a timely recovery, the medical community has been known to over-

• Because signs of an ED rarely appear in blood tests until advanced stages of disease, normal test results in early stages of ED are often misconstrued to

• Pediatricians frequently overlook the significance of precipitous weight loss in children when their numbers fall within the range of normal on the growth

amenorrhea, erroneously assuming that hormone replacement will counteract

• Gynecologists regularly prescribe birth control pills for ED patients with

or reverse bone loss and improve reproductive functionality [12].

• It is a commonly believed misconception that an AN individual's full

The unique requirements of weight management issues demand the uniquely specialized skills of an informed, intentional, and intuitive diagnostician, capable of hearing what has not yet been spoken. Within the context of initial history-taking, the nature of weight-related dysfunctions is likely to remain elusive in the absence of an active probe for problem origins in pathology. The diagnostician's enlightened line of questioning will substantiate, or negate, such a presence, revealing the subtleties of distinctions between the nature of eating behaviors as they reside along the healthy eating continuum. When eating behaviors do appear to cross the line into pathology, the diagnostician takes on the role of crisis interventionist, through immediate responsiveness to the needs of the moment through an investigation into the past. Because the patient's quality of life may depend upon assessment accuracy, the obligation for first responders or clinicians to detect, explore, and interpret issues yet to be unearthed becomes a unique challenge within the confines of the limited timeframe of a single-session weight management consultation. On high alert for potentially unseen issues, the proactive first responder must be prepared to offer psychoeducation, a plan of action, and, where appropriate, referrals to collaborating experts and/or higher-level treatment milieus. If it looks like a duck and acts like a duck, it is for the responsible practitioner to treat it like a duck, unless proven otherwise, even before the assignment of a definitive diagnosis.

*Esther was a 29-year-old woman who came to treatment for depression, poor selfesteem, and relationship problems. In response to her description of her college days during which she spoke of herself as perfectionistic, highly compulsive, anxious, and depressed, I chose to wonder aloud if she had ever struggled with an ED or other eating-related issues. "My God!" she responded. "How did you know? I have never told a soul!" By understanding the nature of her personality structure and recognizing characteristics of her emotional functioning, I was able to intuit and surmise the possible existence of a past ED, which upon inquiry, I discovered had yet to be fully resolved. Following the tenet of John Muir, "If we try to pick out anything by itself, we find it hitched to everything else in the universe." By following my hunch and having made this discovery, I was able to launch the ED treatment process immediately.*

Where the clinician's depth and breadth of understanding of weight management issues is limited and non-integrative, the patient is liable to leave the treatment office with a diet plan in hand, yet without a practicable and sustainable solution for pressing weight-related concerns. More significantly, the loss of a timely and poignant opportunity for the patient to discover unknown problem origins and aspects of self and personality represents a lost opportunity for self-reflection, selfawareness, and self-integration, all leading to healthier lifestyle choices.

Factors further clouding the differential diagnosis of eating-related pathology include the elusive assessment of evolving and ambiguous DE patterns, and the widespread misunderstanding and erroneous information surrounding the issues of eating, weight control, and ED. In asking my ED patients what triggered the onset of their ED, a frequently heard response is that they "started to diet in an effort to lose weight, and ultimately found themselves feeling compelled to eat 'healthier and

*Discretion or Disorder? The Impact of Weight Management Issues on the Diagnosis… DOI: http://dx.doi.org/10.5772/intechopen.92152*

healthier.'" The term "healthy eating" not infrequently becomes a euphemism for food restriction, or 'clean eating,' potentially triggering the onset of orthorexia in ED individuals. Further complicating the diagnostic process, ED symptoms vary appreciably from patient to patient, with; every ED a 'thumbprint.' Fully half of the ED population suffers from the difficult-to-identify condition called "other specified feeding or eating disorder" (OSFED), previously known as "eating disorder not otherwise specified" (EDNOS) [7]. OSFED describes atypical AN (without low weight) and atypical BN or BED (with lower frequency of behaviors, purging disorder, and/or night eating syndrome). Patients who do not meet the strict diagnostic cutoffs for full criteria for AN and BN often remain undiagnosed despite the seriousness of their illness, foregoing or delaying necessary treatment [8]. Patients with clinical ED are often reticent, within a diagnostic interview, to divulge a stigmatized disorder. A recent discovery, important for its potential to reduce the degree of stigma that is associated with ED nondisclosure revealed that 20% of the neurobiology of AN could be derived from metabolic genes (possibly activated by a state of starvation) [9].
