Thin Bias in Eating Disorder Treatment

When you picture someone with anorexia nervosa, what comes to mind? For many people, it may be an emaciated white female whose in her early 20’s. She appears pale and disheveled, and may have a feeding tube in her nose. Not a lot of lay persons will say otherwise. More times than I care to count, I’ve had eating disorder clients tell me that they are not sick enough. Where the majority of this disillusionment stems from is the typical body type thought to be associated with anorexia nervosa. The aforementioned example is the traditional anorexia that many of us are familiar with. However, I’m here to say that anorexia (or any eating disorder for that matter) does not have a look. You cannot look at a person and determine whether or not they have a restrictive eating disorder. It takes some hard digging into their daily patterns and thoughts around food and exercise to diagnose that stuff.

Eating disorders pop up across the board. I’ve seen men with eating disorders. I’ve seen black females with eating disorders. I’ve seen gay men with eating disorders. I’ve seen women in higher weight bodies with anorexia, which is the ED I’m discussing today. I’ve also seen (for another podcast) women and men in higher weight bodies who think they have binge eating disorder, when really they have a restrictive eating disorder that forces them to binge eat (as a response to restriction). More often than not, these are the patients that are falling through the cracks. These are the patients who aren’t getting diagnosed and aren’t getting sent to treatment until it’s too late. Even if they are sent to treatment, insurance companies will frequently cut their days short because they either weight restore or they were in a normative weight category to start with.
For those of you out there who are reading this and have an active eating disorder and can identify with one of these groups I’ve mentioned, you ARE “sick enough”. Oftentimes, you are more sick and treatment resistant than those with the stereotypical body shape that anorexia is known for because of the constant battle in your head and the resistance to seek help. Please do not let this be a barrier for you. Find a clinician that “gets it” and is willing to work with you and your struggles around weight and food. Everyone deserves eating disorder care, regardless of their body size, gender, sexual orientation, or race. Eating disorders show up in a variety of marginalized populations. The reason we do not “see” them is because we aren’t looking for it. Doctors aren’t always looking for it. Dietitians aren’t always looking for it. Therapists don’t always see it. If you need help, be sure to reach out.

Let’s get into eating disorder treatment as it exists today. Some of the above situations can be classified by the DSM-5 as “other specified feeding or eating disorder, OSFED”, previously known as atypical anorexia. Right now, there are few treatment programs and insurance agencies who sympathize with this diagnosis. In essence, they are colluding with the notion that you are, in fact, not sick enough. This is rubbish. BMI is rubbish. Anyone who is suppressing their natural body weight by restricting, overexercising, engaging in substance abuse or otherwise to suppress their appetite (regardless of BMI) is “sick enough”. This is what keeps many people from treatment that they need, or keeps them from going back to treatment. They are either told by their medical provider that they aren’t at a dangerously low weight, or they go to treatment and see others who are in fact at a dangerously low weight. And this further drives their “not sick enough” mentality! They believe that their weight holds value, and if it is higher, that they must diet harder. Wrong! They simply need a treatment paradigm that accounts for this. Unfortunately, many insurance reimbursements are driven by weight, NOT behaviors. If their weight is stable or restored, they’re typically discharged to a lower level of care despite their readiness to do so. This very fact is the reason why I see so many patients with anorexia on an outpatient basis who cannot completely buy into the fact that they have anorexia and that they are, IN FACT, very sick indeed. If you skip meals, feel dizzy, and/or have organ dysfunction that stem from an eating disorder (bradycardia/tachycardia, arrhythmia, low BP, slowed digestion, kidney failure, and others), then you ARE sick enough. F the labels. Get help today.

Thin Bias

Hello from Oklahoma! I’m sorry it’s been so long since I made a blog post. Starting up my private practice while continuing to work elsewhere has proven to be a challenge. Anyway, I wanted to touch on the subject of thin bias, what we commonly refer to in the HAES literature as “weight bias”. Society has put into our heads that thin is the preferred body shape (especially for females), and that fat bodies somehow represent less value. Let’s delve into the psychology of this today, as I’ve been dealing with it a lot recently in the patients I see, as well as in the world around me.

Have you ever had someone tell you, “Wow, you look so great! Have you lost weight?”. Your knee jerk (emotional) response is usually flattered, with an instinctive thank you, or also finding something about your admirer that you may comment on in a positive light as well. But, deep down, a lot of us feel a bit of CONFUSION around… “did they not think I looked good before?” Another example might be, you are clothes shopping with a friend. You come out of the dressing room reluctantly because you don’t like the way it makes you look or feel. Your verbalization of this phenomenon is, “Gosh, I look so fat in this shirt”. What does the friend usually say in response? You probably guessed it. “No it doesn’t! You’re not fat”. This pathologizes the inclination that we feel when we ask people how we look in something. They never dare say that we look fat, EVEN IF we are living in a higher weight body. The word “fat” is taboo, and shouldn’t be discussed (as per society). Wrong. Next time when you’re presented with a similar situation, perhaps as the friend on the receiving end, instead of trying to pacify the fat comment, simply say, “Let’s find a shirt that you may like better”. This is a weight neutral comment that completely leaves weight out of the equation. And, any of you men and women who have a favorite store or embody a favorite style know, there are PLENTY of clothes that can compliment your body and make you feel good in your own skin.

So this right here is one example of how society, and really fat shaming if we’re being honest, seems to work. You lose weight, which is valued, you get more attention, therefore you think it is the right thing to do. For those of us with a predisposition to an eating disorder, be it genetics, environmental, trauma-related, or otherwise, we latch onto that verbal praise as we begin to lose weight, and it drives our eating behavior for years and years to come. We’re constantly seeking that verbal validation of “you are enough. You are valuable because you are thin”. And when that verbal praise goes away if you were not able to keep the weight off, that cycle is further perpetuated by the comments ending. Restring and/or overexercising, or whatever disordered behavior to keep weight from creeping back on, begins again. It can be very damaging to people. So try to keep your weight comments and criticisms to yourself, as it can seriously harm someone, especially if their trajectory is toward eating disordered behavior.

Now. This information may be new to you. That is why I tend to stop and make myself clear for those people who think I’m bashing their beliefs about weight.. about counting calories.. etc etc. I’m only offering you a different perspective. I am not shaming you for not pondering this information before, because, as of two years ago, I did not even realize it. But I’ve done a lot of growing in my career and my thoughts around dietetics, nutrition, and how I can help others. And this information right here tends to be the meat of it. It’s raw. It’s truthful. And, until you can look at your own internal biases about weight and body size, you will never be able to understand what I, and the patients I treat, are feeling when they are faced with fatist comments, or even are turned away from admission into an eating disorder program because they don’t meet “weight criteria”.

My next blog will discuss in depth how weight centric eating disorder programs and insurance reimbursement guidelines can be damaging to those with an eating disorder who do not portray the “underweight sick body type” of anorexia.

It’s NOT One Size Fits All

You’ve all heard or experienced the personal trainers and “nutritionists” at your local gym or in your favorite health magazine who dole out meal plans with the promise of weight loss or even improved athletic performance.  What most people don’t understand is that, if you know anything about nutrition, you cannot prescribe a cookie cutter approach to nutrition.  Most of the above-mentioned meal plans are exact replicas sold to the masses that offer no individuation or thought to daily routine and eating schedule, preferences, past and present behaviors, or medical history.  What these plans are typically based upon are those who have followed it in the past who have achieved results.  Remember, what works for one person does not mean it will work for you.  Not to mention, “results” (e.g. weight loss, lowered cholesterol or glucose levels) are frequently short-lived and often become worse when the diet is stopped or, more accurately, can no longer be maintained, after which a surplus of weight is regained.

Diets can rarely be maintained any longer than 6 months, as most diets are not conducive to all of life’s situations.  People are always prone to “falling off the band wagon”.  Failing at dieting further promotes the weight loss industry’s bottom line, as society doesn’t blame the diet, it blames the person…. So said person enrolls in the next diet fad endorsed by those who claim to be experts in nutrition and health.  What most people don’t realize is that, within 4-5 years, most of the weight that was lost from dieting is regained, plus about 5 pounds more.  In this process, metabolism decreases, muscle is lost, and each subsequent attempt at dieting becomes more difficult.

In contrast to personal trainers and nutritionists without a degree in dietetics (or any medical knowledge at all), registered dietitians are qualified health professionals with years of training who can help you on your journey to improving your relationship with food and your body.  As a dietitian, I am afforded the unique opportunity to help clients with the one thing that keeps them alive and going – FOOD!  And not just alive – but with more zest and passion for life BECAUSE they are enjoying the foods and experiences that come with living a full life.  Food and myths about its effects are a personal passion of mine.  There is so much diet fear-mongering out there that is complete bullshit.  But this same bullshit is fed to you (no pun intended) with the promise that it will make you happier, healthier, and slimmer.  Let’s face it: diet don’t work.  If they did, we’d all be skinny already.  For the vast majority of people, they only bring pain and suffering and a horrible relationship to food and their bodies.  For the small percentage of people who it DOES work for, they go on to develop disordered eating or full-blown eating disorders that they may die from.  Let me be clear when I say that the word “diet” means anything that focuses on numbers, macronutrients, weight on a scale, or body size.

Diet culture has its clutches on society, and I would be powerless to stop it.  I will, however, continue to endorse a non-diet approach which includes principles from intuitive eating and health at every size because I have seen the life transformations that come about as a result.  Don’t get sucked into the common line of, “If it worked for me, it will work for you”.  Nutrition is not one size fits all!  There are so many other factors you must consider.  Working with a Registered Dietitian who uses the non-diet approach is my best advice to you if you are tired of being caught up in cyclic dieting.  You can reclaim your thoughts around food and weight and be free to live your life with more substance, more energy, and more compassion for those around you.

The Journey Begins

My friend said to me today as she was eating a sandwich and chips, “I always feel weird eating around you.. like you’re going to judge me”. I retorted by explaining that I am not the food police and that I don’t pay attention to “eating healthfully” on most days. I eat what my body tells me to eat. I told her that I definitely ate healthy almost always when I was in my disorder. What struck me about her comment was that she automatically thought that my profession as a dietitian meant that I eat healthfully all the time and that I look down on people that do not. Her comment had a lot to do with what diet culture has put into our head; that there is a right and a wrong way to eat and also the notion that dietitians are here to tell us what to eat and what not to eat.

Traditionally, dietitians in the field were there because they helped people lose weight. Times are changing though. There are more and more dietitians who follow the non-diet approach because they know that diets do not work. I am fortunate enough to work with people who have shown me the way, as I was skeptical about sidelining dieting and calorie restriction, as it’s what I was taught in my professional training. Calories in, calories out right? If you don’t eat or burn 3500 calories, you’ll lose a pound right? Cut calories and exercise more and you’ll lose weight right? Not necessarily.

Metabolic suppression is a very real thing and happens to most people who engage in dieting throughout their lives. Each time you diet, your metabolism decreases by as much as 40%. We all know that dieting makes us crazy. Also, when you cut your favorite foods out of your diet, you’ll only crave them more. Most people eventually give into these cravings. When they do, they tend to overindulge if they have been restricting for any length of time. At that point, their metabolism is low enough that it doesn’t protect them against the large influx of calories and they tend to regain weight with each “slip up”.
This is especially true when you are too tired to move your body due to low energy levels associated with dieting. If you are decreasing your energy expenditure, you’re unable to maintain your muscle mass during dieting, so your metabolism decreases even further. Muscle is lost when you diet through a variety of mechanisms (that I’ll probably blog about in the future). Therefore, each subsequent attempt at dieting becomes more difficult. A sounder approach is to feed your body what you need to have the energy to move joyfully, and to maintain your mental wellness and relationship surrounding food all the while.

I am an anti-diet dietitian and I’d like to help you on your journey to your version of health. Health doesn’t look the same for everyone. Health doesn’t have to look like extreme weight loss and long, arduous workouts. Health is what works for you. Health should be sustainable BECAUSE it works for you. Nutritional advice should be very personalized, as you are a unique individual with unique wants and needs. Please feel free to contact me for a free 15-minute phone consultation that will start your journey to true wellness and body liberation.