BEDA promotes cultural acceptance of, and respect for, the natural diversity of sizes, as well as promoting a goal of improved health, which may or may not include weight change. The views expressed by our featured bloggers are their own.
Chelsea Fielder-Jenks, M.A., is a Licensed Professional Counselor Intern in Austin, Texas. She works with adults and adolescents in both group and individual counseling settings under the supervision of Dr. Millie Cordaro, LPC-S. Chelsea is a staff therapist at Hill Country Recovery Center, a DBT-based outpatient clinic in Austin, Texas that specializes in treating eating disorders as well as other behavioral and emotional concerns. At Hill Country Recovery Center, Chelsea conducts individual therapy and facilitates the Adolescent Intensive Outpatient Program for Eating Disorders. Chelsea blogs regularly at CFJCounseling.com/blog. To learn more about Chelsea, please visit her website, CFJCounseling.com.
“You don’t look like you have an eating disorder”
As a clinician who works with individuals suffering from eating disorders, I cannot tell you how many times I’ve heard similar words spoken. These statements have been made in many contexts, using a variety of pronouns (he/she/they/you/I); however, in my experience, these statements are almost always made in an attempt to gage the presence or severity of an eating disorder.
These statements may be well-intentioned – take for example the hopeful words of a parent whose child has just received an eating disorder diagnosis, “My son is doing fine; he’s at a healthy weight.” Or ill-intentioned – say, a judgment of an unknown passerby, “She looks like she has an eating disorder.” They may also be words told to oneself to downplay the severity of an eating disorder – “I don’t have a problem; I am at healthy weight” or “I am not thin enough to have anorexia.”
These kinds of statements are what weight stigma looks like when viewed through an eating disorder lens.
They tend to follow the logic of one of these two, seemingly opposite, statements: 1) “They look like they have an eating disorder,” or 2) “They don’t look like they have an eating disorder.” I want to highlight the fact that these statements only seem to be opposing. Yes, they appear as opposites because one statement says, “look” and the other says, “don’t look,” but, in fact, they are not very different from one another at all. Rather, they both equally assume that someone may or may not have an eating disorder based solely on their weight.
Weight stigma has inundated our culture to the point where, somehow, appearance has become the yardstick for which the presence or severity of an eating disorder is measured, with an “underweight” or “obese” appearance being the primary indicators of an eating disorder and a “normal weight” appearance being indicative of having no eating disorder. Thus, if you are underweight or obese, you must have an eating disorder, and if you are normal weight, you must not have an eating disorder.
“Underweight” or “obese” and “eating disorder” are not mutually inclusive terms. And “normal weight” and “eating disorder” are not mutually exclusive terms.
Yes, weight can be an important piece of clinical data; however, it should be used in conjunction with other clinical data (like eating and exercise behaviors, purging behaviors, body and food preoccupation) when making an eating disorder diagnosis. One cannot assume from a single piece of data, like weight, that an individual has, or does not have, an eating disorder.
For example, one cannot assume that someone with an underweight appearance has anorexia – they may have a physical illness or medical condition, are under stress, or are underweight because that is simply their body type and genetic predisposition. Similarly, one cannot assume that someone with an overweight or obese appearance suffers with binge eating disorder – they may have a medical condition or that may simply be their body type and genetic predisposition. One can also not assume that because an individual has a normal weight appearance, that they do not have an eating disorder. In fact, individuals struggling with binge eating disorder can be of normal weight and those who struggle with bulimia are typically of normal weight.
The Danger of the Stigma
The idea that you can determine whether or not someone has an eating disorder (and the severity of that disorder) based on weight alone is a dangerous misconception. For instance, like underweight or obese individuals with an eating disorder, normal weight individuals with an eating disorder can die. Despite an outward appearance of health, what happens inside the body as a result of eating disorder behaviors can be deadly. For example, electrolyte imbalances that can occur as a result of frequent purging can cause one’s heart to stop beating – electrolytes help send electrical impulses to our muscles to allow them to contract, so when electrolytes are imbalanced, one’s heart muscles can stop contracting.
A 2009 longitudinal study that tracked mortality rates of patients with anorexia who were underweight and patients with bulimia and eating disorders not otherwise specified (EDNOS; the most prevalent eating disorder diagnosis in which full-criteria for anorexia, bulimia, or binge eating disorder are not met) who were normal weight further supports the dangers of this stigma. Mortality rates were similar across eating disorder diagnoses (5.2% of patients with EDNOS died, 4.0% of patients with anorexia died, and 3.9% of patients with bulimia died). Furthermore, research has shown that EDNOS has eating pathology, comorbidities, and physical health problems just as severe as anorexia, bulimia, and binge eating disorders (Thomas, Vartanian, and Brownell; 2009).
The Source of the Stigma
Like other forms of weight stigma, weight stigma in the world of eating disorders likely stems from many origins, including the following:
- Celebrity magazines that pronounce an actress as having an eating disorder simply because of an ultra-thin appearance.
- Popular reality shows that encourage rapid weight-loss amongst overweight or obese contestants by engaging in restrictive diets and over-exercising. These shows tend to operate under the guise that the contestants are making healthy life changes and promote the thought that these dangerous behaviors are okay if you need to lose weight.
- Having a stereotypical ideal that individuals with eating disorders fall at either extreme of the weight continuum.
- The thought that overweight or obese individuals cannot suffer from restrictive dieting behaviors. The meant-to-be humorous “I beat anorexia” t-shirts that are often seen worn by overweight or obese men plays on the stereotype that those struggling with restrictive dieting behavior must be thin and must be women.
- The thought that normal weight individuals must not binge eat, because if they did, they would be overweight or obese.
- The thought that only severely underweight individuals with eating disorders are at risk of dying.
- Our culture has become increasingly insensitive toward overweight and obese individuals, with automatic assumptions that issues with overeating or binge eating are to blame for their weight.
- Our culture has also greeted the diet and weight-loss industry with open arms. The popularity of fad diets seems to be positively correlated to the “war on obesity.” This fuels the idea that disordered-eating thoughts and behaviors are okay if you need to lose weight, despite the dangers that surround them. Ironically, diets don’t work in the long-term – as they can lead to weight gain.
Furthermore, as a clinician, I question whether or not the, now outdated, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) has helped fuel some of the weight stigma experienced in the world of eating disorders. Take for example the DSM-IV’s criterion A for determining “underweight” for anorexia; it suggests that in order to be considered underweight, the individual must weigh less than 85% of the weight considered normal for that person’s age and height based on group charts or a body mass index (BMI) calculation equal or below 17.5 kg/m2. In other words, someone could lose 100 pounds or more in a short amount of time due to extreme restriction of calories, yet not meet the full criteria of anorexia simply because their current weight falls within the “normal” range. This is in despite the fact that their current weight is not their normal.
While it may not have been intentional, this criterion has led many individuals, including clinicians, to strictly interpret the suggested guideline for “underweight,” rather than taking into account that individual’s personal weight history. In my experience, I’ve found that this has mistakenly resulted in a “You must meet this numerical guideline in order to suffer with anorexia” rationale. Unfortunately, this numerical guideline has also invalidated many individuals who are struggling with an eating disorder. By not receiving an anorexia diagnosis due to not meeting this “underweight” criterion, it is as if their struggles are not legitimate or severe enough to be of real issue. This invalidation results in many striving to meet this strict underweight guideline or deeming their disorder as not severe enough to seek treatment.
Fortunately, the DSM-5, which was released in May 2013, has attempted to clarify this criterion for anorexia. The new criterion A highlights the individual differences in weight, as it states, “Weight assessment can be challenging because normal weight range differs among individuals, and different thresholds have been published defining thinness or underweight status” (p. 340). While BMI guidelines are still provided, this new criterion A for anorexia clarifies that weight is more individualized and should take into consideration age, sex, body build, developmental trajectory, weight history, and physical health. My hope is that this clarification will place more emphasis on the individualized nature of weight and less emphasis on norm-based or BMI comparisons, thus helping lift some of the weight stigma around eating disorders.
The bottom line is this: Eating disorders do not discriminate. Eating disorder attitudes and behaviors can affect individuals of all weight, sizes, and shapes. Not only does weight stigma prematurely and, perhaps, erroneously determine whether or not someone struggles with an eating disorder, it also prevents those who are struggling from seeking the help they need. This stigma perpetuates a false belief that treatment is only necessary if one’s weight falls at either extreme of the weight spectrum. This is simply not true. A number on the scale is not enough to validate or invalidate an eating disorder diagnosis. Individuals of all weights who are suffering from all types and severities of eating disorders equally deserve treatment. Likewise, full-recovery is possible for all eating disorder sufferers.