In my first session with one of my clients who has anorexia, she told me she’d been in denial about how disordered her eating had become, because her weight was in the “normal range.” It wasn’t until she developed medical complications, including fainting spells and slowed heart rate, that she realized she needed help.
This made me think about a patient who came to me seeking weight loss at the clinic I worked at several years ago. She was in a significantly larger body, and she told me she couldn’t lose weight despite eating almost nothing. I believed what she was telling me about how little she was eating. (Unfortunately, I’m sure many providers would have assumed she was lying.)
I thought, “She does not need weight loss…she has a restrictive eating disorder.” I shared my concerns with her doctor (who was my boss) and she agreed with me. But the patient never came back for a follow-up visit. I still wonder if she ever got the kind of help she needed.
It’s about the behaviors and mindset, not the weight
I have clients who have recovered from eating disorders and who are not in thin bodies. Maybe they never were, or maybe they’re not anymore. They become anxious every time they go to the doctor, fearing that someone — maybe not their doctor, but maybe a nurse or medical assistant — will pressure them to be weighed, or make a comment on their weight.
I have clients who lost weight because they have an eating disorder, and were praised for their weight loss by their doctor, further fueling their eating disorder.
So if you think that behaviors such as…
- Restricting calories, macros, foods or food groups
- Bingeing
- Purging
- Refusing to eat food you didn’t prepare yourself
- Refusing to eat in front of other people
- Secret eating
- Extreme food fears
- Compulsive exercise
- Continuing to exercise when you’re injured
…are OK or even positive if you’re not “too thin,” I would like to gently tell you that you’re wrong.
Eating disorders such as anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder (ARFID), and other less-defined eating disorders that cause distress and impair life functioning are mental health disorders that can cause serious medical complications. This is true regardless of what someone weighs.
Unfortunately, the weight-centric healthcare system feeds stereotypes about what eating disorders “look” like. Even though you can have anorexia at any size, you’re much less likely to be diagnosed if you are not “underweight.” You can have binge eating disorder at any size but you’re much less likely to be diagnosed if you’re not “overweight.”
This weight-centrism doesn’t stop at the point of diagnosis. It can even extend into actual eating disorder treatment.
Barriers to appropriate care
Researcher Erin Harrop, who I interviewed in 2019 ago for The Seattle Times (“Anorexia knows no body type — and thinking otherwise can be a barrier to treatment”), wrote about their experience with receiving treatment for anorexia in an inpatient treatment center twice — once with “typical” anorexia and once with “atypical” anorexia.
“Though I presented with the same behavioral, emotional, and cognitive symptoms of severe anorexia during two separate inpatient hospitalizations, I experienced radically different treatment from providers when I presented as an emaciated, typical anorexia patient and when I presented as a starving, fat-identified, atypical anorexia patient years later.”
(I should mention that “atypical” anorexia — basically when someone meets all of the diagnostic criteria for anorexia, except that their weight remains at or above the “normal” range — isn’t really atypical, because more people have “atypical” anorexia than have “regular” anorexia.)
Earlier this year, Harrop published a research study titled, “’Recover-But Not Too Much’: Experiences of Weight-Centric Care and Weight Stigma in Higher Levels of Care for Eating Disorders.” The study found that although patients with atypical anorexia often require higher levels of care, they faced difficulty even getting admitted to an eating disorder treatment program.
If they were admitted, they often were not provided with meal plans that offered adequate nutrition and calories to help their body recover from the effects of starvation — because they weren’t “underweight.”
There are far too many stories of patients with “atypical” anorexia being assigned to binge eating therapy groups because they don’t “look” like someone with anorexia. Not only does the mean they aren’t getting the treatment they need, but the treatment they do receive could further trigger their restrictive eating disorder behaviors.
You don’t have to be underweight to be sick enough
In her 2019 book, “Sick Enough: A Guide to the Medical Complications of Eating Disorders,” doctor Jennifer Gaudiani, founder and medical director of the Gaudiani Clinic, writes:
“In my clinical experience, many individuals with atypical anorexia nervosa don’t believe they have an eating disorder because they aren’t stereotypically emaciated. This is only reinforced by society and by medical providers who not only miss the eating disorder but praise such patients for their weight loss and presumed ‘health’ when, in fact, the behaviors being used are the opposite of healthy…Individuals with atypical anorexia nervosa, regardless of body shape and size, are unquestionably sick enough to seek treatment and recovery.”
Every body of every size who struggles with eating disorder symptoms deserves to have the same quality of care. No matter where one of my eating disorder clients falls on the weight spectrum, I want them to:
- Be (or become) medically stable
- Eating enough food to meet their body’s nutrient and calorie needs
- Restore their body’s weight to where it’s meant to be (if they were restricting and weight suppressing)
- Manage emotions and stress without binging, purging or restricting
- Address unhelpful and/or incorrect thoughts about their bodies
- Be able to fully engage in life — including all situations involving food
- Be able approach exercise/movement in a way that is life-affirming, not life-stealing
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Related Post:
Eating disorders are underdiagnosed. Stereotypes play a big role.
Disclaimer: All information provided here is of a general nature and is furnished only for educational purposes. This information is not to be taken as medical or other health advice pertaining to an individual’s specific health or medical condition. You agree that the use of this information is at your own risk.
Until next time,
