By Louise D Metz MD
With National Eating Disorders Awareness Week upon us, this is a good time to dispel misconceptions about eating disorders. There are many common stereotypes about eating disorders. When we think about people with eating disorders, many imagine a cisgender white woman in a thin body, which is how eating disorders are often depicted in our society. However, eating disorders occur in people of all genders, ages, races, ethnicities, socioeconomic statuses, and body sizes. We cannot look at an individual and know if they have an eating disorder or what eating disorder they may have.
Myths about eating disorders and body size
In particular, the assumptions about body size and eating disorders are inaccurate and harmful. In this society, we all carry weight bias, which refers to negative weight-related attitudes, beliefs, and assumptions about people based on weight, and this can affect the way that we view eating disorders. Healthcare providers are not immune to this bias, and it can influence how we as providers assess and treat eating disorders.
It is often assumed that every person in a small body with an eating disorder has anorexia nervosa and that every person in a large body with an eating disorder must have binge eating disorder, but this is a myth. So what is the reality about eating disorders and body size? All types of eating disorders occur in individuals of all body sizes. This includes anorexia nervosa, binge eating disorder, bulimia nervosa, and other eating disorder diagnoses. This also means that any disordered eating behaviors, including restriction of food intake, binge eating, excessive exercise, compensatory behaviors (intended to counteract or undo the effects of eating), and others, could be occurring in individuals of any body size.
Eating disorder diagnoses across the weight spectrum
Contrary to the myths about body size and eating disorders, anorexia nervosa can and does occur in people across the weight spectrum. Anorexia nervosa is characterized by restriction of food intake with low body weight, fear of weight gain, and body image disturbance. A separate diagnosis, atypical anorexia nervosa (AAN), includes all of the criteria for anorexia nervosa (AN) except that the individual’s weight at presentation is within the “normal” range or higher. This condition is very often overlooked by healthcare providers. In fact, people with AAN have been shown in studies to have lost more weight over a longer period of time by the time that they are diagnosed compared with those with AN. Weight bias also often leads people to think that individuals who have anorexia nervosa in larger bodies must not be as sick as those in smaller bodies. However, what we know from research is that AAN carries the same medical complications as AN, such as slow heart rate, low blood pressure, and loss of menses.
Atypical anorexia nervosa is not atypical at all. It is a serious, often undiagnosed condition that should not be classified separately from anorexia nervosa. It is the behaviors and associated malnutrition, not the body size, that leads to the medical risks of anorexia nervosa.
Just as anorexia nervosa occurs across the weight spectrum, the same is true of other eating disorder diagnoses. Despite this fact, individuals in larger bodies with certain disordered behaviors are sometimes given a different eating disorder diagnosis when compared with someone in a thin body with the same behaviors.
Binge eating disorder is not a condition that only occurs in people in larger bodies; it can be experienced by people of any body size. In addition to binge eating behaviors, individuals with binge eating disorder very often engage in restrictive eating or dieting, which can drive the binge eating behaviors. Bingeing can be the body’s natural survival mechanism in response to restriction and starvation. While an individual in a larger body who engages in behaviors of restriction and binge eating is diagnosed with binge eating disorder, an individual in a thin body who engages in these same behaviors of restriction and binge eating may in some cases be diagnosed with anorexia nervosa (binge eating/purging type). Similarly, an individual in a larger body diagnosed with bulimia nervosa may experience the same behaviors as an individual in a smaller body diagnosed with anorexia nervosa, binge eating/purging type. Restriction along with binge eating with compensatory behaviors can occur in both conditions.
Restrictive eating in people in larger bodies with eating disorders can lead to signs and symptoms of malnutrition that may be missed by healthcare providers due to weight bias. Severing the false connection between behaviors and body size is crucial in understanding the nuances of eating disorder conditions and their potential complications.
Eating disorder behaviors and diagnoses occur across a diversity of body sizes, and it is clear that eating disorders occur on a spectrum. Not everyone fits into the perfect diagnostic boxes and some may move between conditions over time. There are overlaps of diagnoses particularly when we look at eating disorders in diverse body sizes. Though diagnostic categories are important and have changed in a positive direction over time, there are many limitations. Focusing on behaviors rather than body size, no matter the official diagnosis, is important in making sure that an individual with an eating disorder receives the care that they need.
Harms of dieting
Malnutrition occurs in all body sizes. This applies not only to those diagnosed with eating disorders, but to those who are engaging in restrictive diets, including those prescribed by healthcare providers. The behaviors involved in dieting can be similar behaviors to those that occur in people with eating disorders, and can also carry medical risks in people of all body sizes. In the setting of severe restrictive diets, we can see signs and symptoms of malnutrition, such as fatigue, poor concentration, dizziness, irregular or loss of periods, vitamin deficiencies, slow heart rate, ketones in the urine, elevated liver tests, and constipation, which can occur irrespective of body size. In addition, dieting can often lead to the development of eating disorders.
As Dr. Deb Burgard, a psychotherapist and one of the founders of the Health at Every Size® movement has eloquently stated, “ We prescribe for fat people what we diagnose as eating disordered in thin people”. In some people, the eating behaviors are prescribed and praised, and in others they are treated as pathological. When a healthcare provider recommends dieting and weight loss, it is a prescription for disordered eating and malnutrition.
Eating disorders and their complications occur on a continuum and across the spectrum of diverse body sizes. Their existence is intertwined with diet culture and weight stigma within our society and weight-centric healthcare system. By acknowledging our weight bias and how it affects our perceptions of eating disorders, it can help us to not just improve the care for people with eating disorders, but can help us see the harm in the way that weight is approached in healthcare.
- Work of Erin Harrop MSW, PhC, as presented at the International Conference on Eating Disorders.
- Sawyer et al. Physical and Psychological Morbidity in Adolescents With Atypical Anorexia Nervosa. Pediatrics. April 2016. 137 (4).
- Jenkins et al. Weight suppression as a predictor variable in the treatment of eating disorders: A systematic review. J Psychiatr Ment Health Nurs. 2018 Jun;25(5-6):297-306
- Berner et al.Menstrual cycle loss and resumption among patients with anorexia nervosa spectrum eating disorders: Is relative or absolute weight more influential? Int J Eat Disord. 2017 Apr;50(4):442-446
- Deb Burgard, PhD https://www.medicaldaily.com/biggest-loser-weight-loss-slow-metabolism-384465
- National Eating Disorders Association. www.nationaleatingdisordersassociation.org