Avoidance Syndrome and  Dysregulated Eating Behaviors 


Bariatric clinicians at The American Association of Bariatric Counselors have identified a frequently undiagnosed shame based dysfunctional psychological disorder that is pervasive amongst many obese patients that can help explain relapses: AVOIDANT PERSONALITY DISORDER DSM-5 30

As the diagnosis suggests, the main coping mechanism of those with avoidant personality disorder is avoidance. This chronic disorder is so deeply rooted, that shame riddled obese patients will avoid the pain of confronting anything that conjures up their obesity shame.

Feelings of shame triggers avoidant behaviors; interruption of self-monitoring, scale use, exercise, mindful eating, weight gain and especially not keeping appointments at your office/clinic This can explain how a minor weight gain can become a full blown relapse.

How Avoidant Personality Disorder Leads To Avoidance Syndrome and  Dysregulated Eating Behaviors

The best way we can explain how the Avoidance Syndrome leads to dysregulated eating behaviors and weight gain is by telling by a real story. There are many ways that this story can begin but this is the version that most patients identify with and how the story was told to me by a patient.


This completes part three our three part best practices series:

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Part 1: Why Would Somebody Lose All The Weight and Then Gain It Back?

Part 2: Treating the Shame of Weight Gain

Best Practices: Treating the Shame of Weight Gain

Most folks that go on diets lose weight and most of the time gain it back. And often gain back more than they lost. Even bariatric surgery is wrought with substantial regains.

 Bariatric practitioners have identified a most prevalent shame based diagnosis:

Avoidant Personality Disorder, that is common to many that have weight relapses/collapses.  As the diagnosis suggests, the main coping mechanism of those with avoidant personality disorder is avoidance. They will avoid most things that elicits their deep feelings of personal shame, like weight gain.  As a result they are most vulnerable to relapse/collapse stages.

Anecdote: Julie was introduced to a group of patients seeking surgery, as a successful patient that lost and keeps off 60 pounds for over five years. Julie interrupted and said, “That’s not true”.  I gain back about 60 pounds every couple of years but instead of completely relapsing, I gain and lose 2-3 pounds about 20 times every couple of years”.

Prudent bariatric counseling had taught Julie that weight gain is a typical expectancy following weight loss and no longer avoided that expectancy and viewed her lapses as part of her recovery and not worthy of shame or guilt.

Reducing Shame Narrative for Rational Cognitive Therapy:

Most intuitive, naturally thin people, without weighing themselves, or consciously censoring their food choices stay within a weight range… they do go up and down the scale, but stay within a tight range. Using them as our index we realize that weight gain is a natural occurrence. But here lies the difference, most diet veterans or surgical patients that have intentionally lost weight eventually start regaining weight. But they do not have that compensatory intuitive mechanism that allows them to stay within a tight range of their desired lower weight. If we know in advance that weight gain is simply a typical expectancy following weight loss, why view that as a failing? Why feed into that irrational belief system of weight gain and failure? It is that very belief that can elicit shame and avoidance behaviors and that is how a manageable lapse becomes a relapse/collapse.

Learning How to Gain Weight Without Shame:

Learning how to shamelessly accept and not avoid the expectancy of weight gain is an important stage for long-term obesity recovery. When a patient does reach their desired weight goal or during the weight-loss process, asking them to surplus calories and gain a pound or two (lapse) and then reverse it, is prudent relapse prevention counseling. That is a lifelong behavioral skill they will need, long after they have left our care. When we praise patients for confronting a lapse and then reversing that lapse, they reduce both weight and shame importantly they learn to master a skill they will likely need forever. Ironically, realistic patient preparation to prevent relapse/collapse is teaching patients how to gain weight with both their and your approval.

Dr. Brené Brown: “Shame Is Lethal” | SuperSoul Sunday | Oprah Winfrey Network

The price of shame | Monica Lewinsky



Why Would Somebody Lose All The Weight and Then Gain It Back?

Nobody really wants to be fat …that’s why we try over and over again to lose weight, only to gain it back.  Even bariatric surgeries have substantial re-gains.

We don’t know a single dieter or surgical patient who has suffered with the burdens of obesity, lived a lifetime of quiet desperation, a life plagued with obesity shame, dashed diet dreams and self-blame …that doesn’t desperately want to be thin … and then they remarkably accomplish that impossible dream and lose all the weight. We don’t know anyone that willingly wants to gain it all back, that is the last thing they want,  but too often that is the heartbreaking reality. (must see video)

The Heartbreak of Ali Vincent

So, I ask you, why would a person that has the passion, diligence and fortitude to finally achieve their lifetime dream and lose (let’s say) 100 pounds regain their weight? Why wouldn’t they simply lose a couple pounds when they start regaining weight, instead of waiting until they completely relapse? After all, these are the same people that have proven their hardiness and will power by losing all that weight… it just doesn’t seem to make sense. Continue reading

Researchers Identify “The Missing Link”

A New And Important Metric, In Understanding Why Some People Are Thin And Others Thick Despite Similar Caloric Intake.

Researchers from the American Association of Bariatric Counselors have completed an important bariatric science research project that identifies a primary cause of a most prevalent category of obesity.

Dr. Brandon Davis

Dr. Brandon Davis Ph.D, CBC

Lead researcher, Dr Brandon Davis, a psychologist and Board Certified Bariatric Counselor commented, “Our research has identified a new metric that we call the Metabolic Factor, which can be thought of as the missing link in understanding why some folks are thin and others thick despite similar caloric intake. It can also explain why many dieters and bariatric surgery patients relapse and regain weight lost. Obese individuals with a low metabolic factor (hypo-metabolic) lend support to a genetic predisposition to a very prevalent category of obesity. The tools and the methodology we developed to diagnose and quantify an individual’s Metabolic Factor are currently available. This study’s findings indicate that Metabolic Factor seems to be a stable characteristic within a person despite significant weight loss. We expect this discovery to be a game changer in the understanding of obesities and helping patients and bariatric health professionals make informed  decisions regarding care and treatment.” Continue reading

Emotional Impact of Words


Emotional Impact of Words

Words can have a very powerful emotional impact.  Words break hearts and it is harder to mend a broken heart than a broken bone. Many hurtful words that have found their way into our vocabularies are derived from the diet industry.

For best bariatric practicesLOSE THESE WORDS

If patients are given a prescription for a medication for high blood pressure, or diabetes and their pressure or glucose is not reduced, we would not use the words fail of failure for the patient, but rather the medication failed or was ineffective.
However when an obese patient is prescribed a diet or has weight loss surgery and their weight is not reduced they become the failure. We can be successful or unsuccessful in our endeavors to change… not failures
Failure has a sense of permanence and is “stuck” in the belief systems of many…we want to “unstuck it”.

Whether referring to infidelity, or cheating on an exam or taxes,cheating has profound moral and ethical connotations and is easily internalized. Cheaters are dishonest, deceptive or unfaithful. Certainly adults have the right to deviate from their diet plans. That is choice…. not cheating.

Food is not our moral compass and is neither good nor bad. All food contains nutrients and provides energy and cannot be labeled as healthy or unhealthy or good or bad. These words feed into the diet mentality and fuel the perfectionist, all or nothing forbidden food behaviors. Certainly some foods could be of advantage or disadvantage to specific medical conditions but this does not moralize them nor make them inherently good, bad, healthy or unhealthy.

All food contains nutrients and calories. Calories in excess of one’s individual needs results in the storage of adipose tissues….fat. Therefore, there are no specific foods that make you fat or can be considered fattening. All nutrition in excess of need results in weight gain…not any specific food choice.

We are part of the problem when we continue to label food with emotionally charged words like, fattening, good and bad, healthy or unhealthy. Then when patients deviate from diet plans we imply they are cheaters and failures.  Most of the patients we see have lived lives riddled with fat shaming. By continually using these words we provoke additional feelings of guilt and shame and then wonder why patients resist keeping honest food records for us to review.

Fat shaming (Fat Shaming in the Doctor’s Office Can Be Mentally and Physically Harmful) is as old as medicine and has never cured obesity. Best practices in genuine bariatric care requires sensitive awareness of the profound psychological burden associated with obesity, a burden that we can counteract by personally ridding ourselves of words that break hearts.

(APA)  Fat Shaming in the Doctor’s Office Can Be Mentally and Physically Harmful

Weighted Down by Stigma

In 1985 the US National Institutes of Health convened the first major conference on Obesity, The Health Implications of Obesity. Medical experts scientifically validated what MDs were anecdotally seeing in their practices, the relationship between obesity and the adverse effects on health and longevity.

Despite the experts being mostly MDs and having determined that obesity was associated with life threatening diseases like diabetes, CVD, certain cancers and even premature mortality, in their consensus statement they noted thatObesity creates an enormous psychological burden. In fact, in terms of suffering, this burden may be the greatest adverse effect of obesity.”

As early as 1985 they were wise enough to know that being weighted down by the stigma of obesity, the “psychological burden,” created greater human suffering than all the myriad of life threatening diseases associated with obesity.

Of Greek origin, Stigma refers to a marking or tattoo that was cut or burned into the skin of criminals, slaves, or traitors, to visibly identify them as blemished or morally polluted. These individuals were to be avoided or shunned. Obesity has become that stigma, the very visible marking that results in chronic psychological suffering.

That very stigma continues to riddle the lives of millions, in the workplace, in education, in health care, in romance and even within families. Being Weighted Down By Stigma, takes its toll with lifelong stress, and gets under the skin, worsening physical health and ironically exacerbates weight gain. (Weighted Down By Stigma.  (see full text below).

Prudent best practices in bariatric counseling recognize the dual diagnosis of obesity and mental illness and focuses on stigma reduction to achieve weight reduction.

Julie Rochefort – Shift the Focus

Weighted Down By Stigma (full text)