We are failing to prevent, diagnose, and treat eating disorders. Weight Stigma is to Blame.
In my role as the Clinical Assessment Program Manager at Project HEAL, I have personally assessed and reviewed hundreds of clinical assessments for folks seeking eating disorder care. Many have never received an eating disorder diagnosis, though they have been experiencing difficulty with their relationship with food and their body for decades. Some have received treatment many, many times, but recovery still evades them. The years of eating disorder behaviors have taken their toll, physically and mentally. Yet, when we discuss body image and weight, almost everyone says “I can’t imagine weighing more than I weigh now” or “I cannot imagine ever being happy unless I lose weight”.
We are failing to prevent, diagnose, and treat eating disorders, and weight stigma is to blame.
Eating Disorder Prevention
We are not born hating our bodies. If you have ever been in the presence of a young child who has first discovered their toes, their head, their nose, you see the curiosity in their eyes as they reflect on these new wonders. Fast forward just a few years and nearly a third of children age 5 to 6 choose an ideal body size that is thinner than their current perceived size (Hayes and Tantleff-Dunn, 2010).
Exposure to the thin ideal through media and social media is a well-documented concern among those in charge of caring for children and adolescents. However, parents, teachers, and coaches themselves are also influenced by messages of diet culture and place their insecurities and fears onto children.
Unfortunately, these fears and insecurities are likely to be enhanced by a visit to a child’s pediatrician, particularly if a child is of a higher weight. Released in early 2023, the American Academy for Pediatrics, Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity encourages offering “treatment options early and at the highest available intensity".
In recent years, parents and pediatricians have been focused on battling the “childhood obesity epidemic”. In a recent post on her site Kids Eat in Color, registered dietitian Jennifer Anderson eloquently notes what is wrong with focusing on the “childhood obesity epidemic”. She goes on to note that what is actually happening in the United States is a “child health crisis”.
“To call what is happening to children an “obesity epidemic” makes it a problem on the child and the family’s individual choices. The only solution is ‘less fat’ (via diets, drugs, or surgery). “Our kids (from low to high weight) now have hypertension, high cholesterol, eating disorders, type 2 diabetes, and mental health struggles are much more… in numbers that are astonishing”.
Why then, are we focusing on weight?
Anderson goes on to note that weight is focused on because “it’s convenient. When it’s a problem of individual choices, we don’t have to consider/fix systemic healthcare and food injustices.”
I would additionally state that it is anti-fat bias, and it has been plaguing the adult healthcare system for decades. I hear from beneficiaries daily that they were offered or even given bariatric surgery to “treat” their “ob*sity”, but are left with a permanently altered digestive system and a damaged relationship with food and their body. The same individuals who are readily offered bariatric surgery are often denied joint replacements. These replacements, which would greatly reduce their pain and increase their quality of life, are deemed “too risky” because of anesthesia. Where was the concern about anesthesia risk for the bariatric surgery?
The message seems to be that if you are fat, you are undeserving of care.
Eating Disorder Diagnosis
Even with its revisions, the DSM 5-TR creates barriers to accurately representing how clients who are not underweight experience eating disorders. At Project HEAL, we do many assessments where individuals meet the criteria of Anorexia nervosa, restricting type, except their weight is not low enough. They have to be given a diagnosis of Other Specified Feeding or Eating Disorder – Atypical Anorexia. While we explain to beneficiaries the limits of the DSM-5-TR and that treatment should be pursued with the same intensity as folks meeting the criteria for anorexia nervosa, restricting type, it still hits people with the impression that “I’m not sick enough”.
Another tricky piece diagnostically is individuals who experience restriction and purging, but are not underweight. The diagnosis of bulimia nervosa is inappropriate, because the individual does not engage in binge eating. The diagnosis of Other Specified Feeding or Eating Disorder – Purging Disorder is the best fitting, but it doesn’t highlight the occurrence of restriction. The diagnosis of anorexia nervosa: binge eating/ purging type is the only diagnosis that acknowledges restriction and binge eating or purging (not a requirement of both), but the individual has to meet the anorexia criteria of “significantly low weight”. The message to beneficiaries is clear: “I’m not low-weight enough to meet the diagnosis that best depicts what I am experiencing”.
Eating Disorder Treatment
Treatment should be the place where, while restoring the body to a nourished state, clients with eating disorders should be unlearning anti-fat bias. Often, this is not the case. In their article “Dismantling weight stigma in eating disorder treatment: Next steps for the field” authors McEntee, Philip and Phelan (2023) note that treatment often unintentionally reinforces fat-phobia attitudes. Efforts to reframe language within CBT, such as using phrases such as “you are not fat, you have fat” fail to challenge the underlying assumption that fat is bad and minimizes the life experiences of those in larger bodies.
While working as a psychiatric tech in the mid-2000s, I often heard horrible things said about clients in larger bodies during team meetings. When a client previously diagnosed with anorexia nervosa was returning to us for treatment years later, this time in a larger body with the diagnosis of binge eating disorder, the dietitian remarked “She let herself swing too far the other way, you cannot let that happen.” When another client presented in treatment for restriction, other providers dismissed the seriousness of her symptoms. “If she was really engaging in restriction, she would be smaller”.
Anti-fat bias is even experienced by folks who are underweight in treatment. Dave Dunn discusses this in his book Love, Crowd Out, Forgive, Accept. “The majority of professionals we worked with, including eating disorder specialists, set my daughter’s target weight range too low. As long as her BMI was over 19, most professionals seemed to conclude that weight was not an issue, even though she was not getting her period, had a low pulse, and was struggling with strong ED thoughts. She once spent four weeks in a residential treatment program and it took me two weeks (half the time she was there!) to get the treatment team to look closely at her growth chart, from which it was obvious that she was below her ideal weight”.
Future Direction
As long as weight remains an indicator of health in the United States, we are going to continue to see eating disorders rise. There is no one set cause of eating disorders and there are numerous biological, psychological, social, and familial factors that may predispose someone to an eating disorder. However, weight stigma in the healthcare system is a modifiable risk factor (Brochu, 2018), something we have control over, that can reduce the risk of eating disorders and poor health outcomes more generally.
