Article Discusses How to End Weight Stigma in Eating Disorders Treatment

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It’s Eating Disorder Awareness Week. There is a lot of weight stigma and anti-fatness within the eating disorders community, including in major organizations, and the 2022 article Dismantling weight stigma in eating disorder treatment: Next steps for the field by Mindy L. McEntee, Samantha R. Philip and Sean M. Phelan focuses on defining the problem and suggesting solutions.

They begin by establishing that weight stigma is a common “socially acceptable and pervasive form of prejudice and discrimination” and that it presents and emerges “on individual, interpersonal, institutional, and societal levels.”

In terms of treatment, they point out that “In addition to the lack of evidence that intentional weight loss produces improved health outcomes independent of behavior change, decades of research indicate that the majority of individuals are unable to effectively reduce their body size long term. Weight loss, then, is neither a prerequisite for improved health nor an appropriate target for treatment.” (emphasis is theirs)

They also quote the brilliant Deb Burgard saying “we find it hypocritical to prescribe practices for heavier people that we would diagnose as eating disordered in thin ones.”

They note six dimensions of weight stigma in eating disorders treatment:

Reliance on unsupported weight-based classifications

Here they point out how the use of BMI and terms like “ob*se”* and “overw*weight” pathologize bodies based on size. They explain that the use of a (low) BMI as part of the diagnostic criteria for Anorexia Nervosa (AN) has been particularly problematic in the diagnosis of Anorexia Nervosa leading to “higher-weight individuals being labeled with “atypical anorexia nervosa” (AAN) despite being the more common presentation of AN. AAN is often perceived as less severe (66), which may prevent higher-weight individuals with severe restrictive pathology from receiving immediate and life-saving services” Highlighting that weight stigma can, in fact, be fatal.

Provider diagnosis and treatment recommendations

Here they point out that weight stigma leads to multiple issues in terms of higher-weight people’s ability to get diagnosed, and receive appropriate treatment for, eating disorders. They note that higher-weight people are less likely to be diagnosed and experience longer delays before they get treatment. Finally, they point out the problematic nature of higher-weight people who are in ED treatment being prescribed lower calorie diets than the rest of their cohort (literally prescribing food restriction to people with active eating disorders,) and programs that offer a combination of Binge Eating Disorder (BED) treatment and weight loss treatment. I would point out that this also ignores the evidence that BED is actually driven and exacerbated by the restriction that is the hallmark of weight loss treatment and, again, that there is no reason to believe that the weight loss treatment offered by these programs will actually lead to anything approaching long-term, significant weight loss. As they eloquently put it “Such treatment conflates recovery from an ED with goals and activities that may have contributed to its development.”

Weigh-ins without adequate rationale or communication

In this section, they discuss how monitoring weight is often part of eating disorders treatment. They point out that requiring weigh-ins can “reinforce the false notion that weight is a stronger indicator of health than dietary habits, physical activity, and other health behaviors,” explaining that “to date, no dismantling studies have identified the utility of measuring weight in ED treatment.”

They also point out the problems with using weight to mark ED treatment “progress” and “recovery.” They acknowledge that weight restoration is a crucial component of some treatments, but explain that without any “empirical consensus” about what the target rates should be, there is often a default to the use of the deeply problematic and weight-stigma driving BMI. Defining “healthy weight” based on BMI for people who are higher-weight “may represent significant weight suppression, or at least expect patients to prioritize weight gain as healthy and important right before reversing that expectation and calling “excessive” weight gain unhealthy.”

They recommend that “From a harm reduction standpoint, if weigh-ins are required, it should be clearly communicated to the patient why they are necessary, how they fit within a more comprehensive treatment plan, and how weight stigma will be addressed. Doing this once at the start of treatment is likely insufficient.”

Treatment (unintentionally) reinforcing the fat-phobic attitudes

Here they discuss various ways that treatment providers, even when they are well-intentioned, can reinforce anti-fat beliefs. This includes when patients express concerns about loss of control by promising that they will ““not allow them to go overboard.” They explain that “Whether intended as a means of building rapport or increasing patient buy-in, this sentiment reinforces fat phobia and perpetuates the idea that a higher weight symbolizes gluttony or unhealthiness.” They also discuss the issues with language reframing in CBT. One example they offer is phrases like “you are not fat, you have fat” which “fail to challenge the underlying assumption that fat = bad while minimizing the life experiences of those in larger bodies.” They also discuss the problem that patients’ fear of fatness is often only addressed “in the context of reality testing distorted cognitions rather than questioning the weight-centric practice of equating weight and fat with health” which, they point out, means that “As such, body image is often addressed in ways that reinforce fat-phobic attitudes rather than challenge weight stigma .”I would describe as the difference between reassuring a patient by saying “You’re not fat” (which, regardless of intention, can leave them with the sense that fat is a bad thing, but they aren’t it) versus reassuring a patient by saying (or at least adding) “there’s nothing wrong with being fat.”

Discontinuity of care/lack of provider communication

Here they point out that even if patients manage to get appropriate weight-neutral healthcare, that may not be consistently applied by other practitioners. They give the example of a primary care provider recommending weight loss or congratulating weight in a higher-weight patient with anorexia if they aren’t frequently in contact with the ED team and/or are failing to read the chart.

Provider endorsement of negative stereotypes

In this section they discuss providers who have been overheard judging the “quality, quantity, and/or type of food patients select, particularly in outpatient settings where this involves patient choice (e.g., “they are just eating junk”).” They also discuss providers overheard “making assumptions about a patient’s motivation or effort in treatment (e.g., “they aren’t even trying anymore”) and casual comments that impart judgment based on body weight, shape, or size (e.g., “I’ve been so lazy lately, [the way] my pants [fit] are telling me I need to get back to running”). They point out that “even if such comments are directed at coworkers rather than patients, they perpetuate a culture of weight stigma and are more likely to cause harm than help.”

They also point out that interventions that are presented to healthcare providers that are intended to reduce weight bias Interventions to reduce weight bias among healthcare providers have focused on “controllability of weight, increased empathy, self-reflection/awareness of personal biases, cognitive dissonance, and/or contrasting negative personal attitudes with positive social consensus with little evidence of effect.” They also point out that these interventions are generally judged based on “immediate changes in provider attitudes (rather than provider behavior or patient outcomes)” Also, they explain that they happen in the context of weight-centric healthcare “,thereby failing to address sociocultural factors affecting provider behavior.” They conclude that “the complexity of this issue suggests the need for multilevel interventions to shift from a weight-centric to weight-inclusive paradigm and evaluate observable changes in provider behavior, clinic policies and workflows, and patient outcomes.”

I want to point out that a huge issue here is that weight loss companies, including and especially big pharma like Novo Nordisk and Eli Lilly (and their astroturf organizations like The Ob*sity Action Coalition and The Ob*sity Society,) are trying to co-opt the discussion of weight stigma (that has been happening among fat activists and weight-neutral health advocates for decades) and market themselves (and the doctors and researchers on their payroll) as “weight stigma experts” with a message that boils down to “We don’t want to stigmatize higher-weight people but we do want to eradicate them from the earth and make sure no more ever exist” which is a profitable message for the weight loss industry, bu6t a harmful one for higher-weight people.

In good news, the article’s authors offer these suggestions to begin to address the issue:

Acknowledge the influence of weight stigma on current ED treatment

• Understand and communicate with patients, policy-makers, and other providers that weight is not synonymous with health and, accordingly, weight is inadequate as a criterion for ED diagnosis or recovery

• Re-examine the rationale for and unintended effects of weighing in ED treatment

Shift from weight-centric to weight-inclusive care practices and philosophy

• Stop recommending or engaging clients in weight loss or weight management

• Focus on modifiable health behaviors (regardless of weight status, with respect for an individual’s history), for the purpose of improving quality of life rather than moralization of health and health behavior

• Ensure treatment plans and goals function to increase a client’s flexibility in behavioral responses (rather than “managing” their weight)

• Work to increase client autonomy, access to care, and social justice across the weight spectrum by explicitly addressing weight stigma in treatment

Increase provider education and competency

• Promote widespread dissemination of weight-inclusive care as an empirically-supported alternative to the weight-centric medical paradigm in training programs for anyone working with clients to improve health

• Encourage use of functional behavioral assessments and other direct health measures instead of reliance on weight/BMI

• Utilize shared treatment plans to enhance provider communication and continuity of care

• Build in mechanisms to increase accountability for provider weight bias, prioritizing meaningful behavior change and structural interventions to reduce stigmatizing behaviors (versus unrealistic expectations of trying to “eliminate” personal bias)

Prioritize addressing gaps in research and clinical care

• Increase clinical training and research with diverse populations to better understand variability in symptom presentation and how to assess ED severity across the weight spectrum

• Incorporate and evaluate the effects of addressing weight stigma as an explicit part of treatment, particularly at areas in which weight is interconnected with other areas of historical bias and social marginalization (race, gender, sexual orientation, class, ability, etc.). Such research should utilize mixed methods to better contextualize findings

• Policies should be regularly reviewed and responsive to the data, including increased funding for weight-inclusive care (rather than additional weight loss interventions)

The bottom line is that the Eating Disorders Community has a weight stigma problem at some of the highest levels and in some of the most prestigious organizations and it must be solved. This article is an excellent step in that direction.

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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.