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In March, World Obesity Day (March 4) and National Purple Ribbon Day (March 15), dedicated respectively to raising awareness about obesity and eating disorders, follow each other just days apart. However, it is not always clear how these two public health issues are, in many ways, two sides of the same coin and should be addressed together in both prevention and treatment.

NUTRITION AND PSYCHE: A COMPLEX RELATIONSHIP

The human relationship with food is extremely complex due to the many affective and symbolic values, both conscious and unconscious, that have always accompanied the simple act of eating. Over the past half-century, eating habits have become even more complicated, making nutrition a field of study that has attracted an enormous number of medical-biological and psycho-social research studies.

CONTRADICTORY PRESSURES OF MODERN SOCIETY

When analyzing the causes of this phenomenon, one cannot overlook the major role played by conflicting pressures and contradictory prescriptions. On one hand, an obesogenic environment has developed, characterized by an overabundance of high-calorie foods and a gradual reduction in energy expenditure due to decreased physical activity and thermoregulation. On the other hand, there is the idolization of thin and muscular bodies, which has become a global stereotype. Meanwhile, medicine and nutritional science have bombarded society with dietary recommendations, lists of healthy foods, and a variety of so-called “magical” and restrictive diets.

OBESITY AND EATING DISORDERS: A SILENT EPIDEMIC

This has created a conflicting landscape in which obesity has exploded worldwide, along with dissatisfaction with body image and harmful eating behaviors.

Over the past four decades, the global prevalence of obesity among adults has tripled, while among children and adolescents, it has increased eightfold. In the third millennium, for the first time in human history, the number of people with excess body weight has surpassed the number of undernourished and underweight individuals, whereas four decades ago, the ratio was the opposite.

WHEN FOOD BECOMES A PROBLEM

Against the backdrop of these profound social and economic transformations, various dysfunctional eating behaviors, such as uncontrollable binge eating, nighttime eating, emotional eating, compulsive snacking, selective cravings, and even food addiction, can contribute to the development of obesity. Conversely, other harmful behaviors, such as severe dietary restrictions, self-induced vomiting, laxative and diuretic abuse, and compulsive exercise, are often adopted to counteract or prevent weight gain.

Cases of anorexia nervosa have increased, appearing at younger ages and increasingly among males, with a relentless pursuit of extreme thinness, often to a degree incompatible with health and even life itself. Additionally, cases of atypical anorexia nervosa, a severe condition in which individuals are not underweight but experience drastic and unhealthy weight loss within a few months due to self-imposed diets and extreme practices, are becoming increasingly common.

NEW EATING DISORDERS

A new category has emerged in diagnostic classifications: Avoidant/Restrictive Food Intake Disorder (ARFID). This condition describes cases in which insufficient food intake is not driven by a fear of gaining weight or excessive concern about body shape. However, it is still associated with severe physical damage, psychological distress, and social, emotional, and occupational difficulties.

Orthorexia nervosa refers to an obsessive pursuit of “healthy” foods, which, when extreme, can dominate personal and family life. In severe cases, it can even be life-threatening, particularly when imposed on small children.

Drunkorexia (sometimes translated into Italian as “drinkoressia” or “potoressia”) is another alarming trend. In medical-psychological literature, it is also known by the acronym ICB-WGA (Inappropriate Compensatory Behaviors to Avoid Weight Gain from Consuming Alcohol). This disorder involves skipping meals or inducing vomiting before or after binge drinking to counteract caloric intake and prevent weight gain. It is increasingly common among young people of all genders, adding the dangers of alcohol abuse to those of extreme eating behaviors.

Unhealthy eating patterns can persist or develop anew after obesity surgery (post-bariatric eating disorders), manifesting as overly restrictive eating, self-induced vomiting, compulsive snacking, and uncontrolled eating.

EATING DISORDERS: BEYOND FOOD

Obesity and disordered eating behaviors are deeply intertwined, often occurring together or in sequence. They share several characteristics and risk factors, both genetic and psycho-social (e.g., excessive focus on food and eating, fluctuations between overeating and undereating, body image dissatisfaction, depressive feelings, and low self-esteem).

For this reason, the term non-homeostatic eating disorders has been coined, encompassing all conditions in which people eat either more or less than what is necessary to meet daily energy needs or, in childhood, to support growth.

These factors should be carefully considered when shaping public health policies, prevention and treatment programs, resource allocation, clinical service organization, and professional training for healthcare providers.

*Massimo Cuzzolaro is a medical doctor and psychiatrist. For over thirty years, he has taught Psychiatry, Clinical Psychology, Eating Disorder Psychopathology, and Mental Hygiene at the Universities of Rome Sapienza and Tor Vergata, in both the Faculties of Medicine and Surgery and Psychology. He currently teaches as a contract professor in university master’s programs and continuing education courses (ECM). He was one of the founders of the Italian Society for the Study of Eating Disorders (SISDCA), where he also served as president, and of the Italian Society for the Study of Obesity (SIO).

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