‘There’s a huge fatphobia problem in the eating disorder world’: Even in treatment, weight stigma fails patients

“There is little consensus about how to protect young people seeking treatment for eating disorders from harmful ideas about weight, or whether treatments for obesity and eating disorders can safely coexist at all within the medical system. And while the vast majority of eating disorder professionals would never prescribe weight loss to somebody recovering from an eating disorder, each clinician’s approach to treatment is affected by their individual beliefs about, and understanding of, obesity. The strong disagreements within the profession about how to best address obesity and weight stigma may leave patients susceptible to inappropriate or harmful care. [..]

Clinicians often fail to identify eating disorders in larger patients to begin with. One study found that patients with atypical anorexia (which means they have the same disorder as anorexia, but don’t appear extremely underweight) suffer for over 11 years on average before receiving a diagnosis.

Eating disorder professionals know that, once diagnosed, people with active eating disorders should not be counseled to lose weight, no matter their size. But weight bias still exists among eating disorder professionals, and it can have unintended consequences for people trying to recover. [..]

Not only can weight stigma threaten the recovery of eating disorder patients who happen to occupy larger bodies, many eating disorder experts worry that any clinical attempt at weight loss puts people, especially adolescents at higher weights, at risk for eating disorders. Recent research has shown that almost a quarter of children and adolescents from 16 countries display disordered eating habits. That increases among those with higher BMIs.

Some eating disorder experts see any treatment aimed at weight loss as a form of weight stigma. “I don’t think that there should be any form of treatment for obesity. And I realize that I am at the extreme of this opinion,” [psychologist and the founder and clinical director at the Louisville Center for Eating Disorders Cheri] Levinson said.

But others see a clear difference between clinical treatment for obesity and other, potentially harmful practices. Obesity is associated with a wide range of diseases, and clinicians broadly see much reason to pursue weight loss treatment for youth.

“I think you have to make a distinction between evidence-based interventions and dieting. When people put themselves on diets, they often are not healthy approaches to eating,” said Jennifer Wildes, an associate professor and director of the Eating Disorders Program at the University of Chicago. Practices like skipping meals, cutting out entire food groups, or exercising excessively should not be recommended by clinicians, she said. [..]

Some experts, like Wildes, say that there are actually similarities between eating disorder treatment and behavioral weight management. Behavioral weight management often involves counseling from multiple clinicians on lifestyle topics like nutrition, exercise, problem-solving, and more.

“Some of these basic building blocks of what we do in eating disorder treatment early on and also in what [the AAP guidelines] referred to as behavioral weight management have a lot of those same tenets,” UNC’s Peat said.

Both clinicians treating eating disorders and those treating obesity will also recommend patients self-monitor their eating, said Wildes. That doesn’t mean paying attention to calories, she noted, but to context — what time a person is eating, where they are, and how they feel. Peat and others noted that behavioral weight management, a core recommended therapy in AAP’s new obesity guidelines, has been shown to modestly help people with binge eating disorder. [..]

The stakes can get higher when screening youth for potential surgical weight loss interventions. Schreyer of Johns Hopkins works both with youth struggling with eating disorders and those age 16 and older who are considering bariatric surgery. When teens come in for potential bariatric surgery, she meets with them for six months beforehand, as does a nutrition team and a psychologist. If Schreyer detects symptoms of disordered eating, she’s firm that any weight loss treatment is not appropriate for the person.

She is lucky, she said, that the team she works with respects these decisions. It’s a sign that, “there’s a possibility to make this work,” she said.”

Full article, T Gaffney, STAT News, 2023.4.25