I’m tired of hearing people talk about eating disorders as if losing weight was the only significant criteria.
In part, I think this hyper-focus on weight stems from the fact that our diagnostic criteria reflect our attempts to define mental illness in similar ways to physical ones. However, these labels are really only useful for streamlining professional communication and suggesting what treatments might be helpful for patients.
The primary diagnostic distinction for anorexia nervosa is severe restriction of food intake such that the patient has reached a “significantly low body weight … less than minimally normal” [DSM-5]. No where in this definition do they explain what “significant” means nor what “normal” actually is and not only is this vague, but it only reflects ONE specific eating disorder.
Being subjectively “underweight” might be a contingency for diagnosis with anorexia nervosa but it certainly isn’t necessary for being greatly at risk.
The majority of people with eating disorders are NOT underweight and still one in five suffers will die.
Fortunately, the DSM 5 is trying to evolve to capture the severity of eating disorders regardless of body weight by introducing the category “atypical anorexia nervosa” without BMI constraints. Frighteningly, the broadening of this classification encapsulated FIVE TIMES more people than anorexia nervosa alone [Stice, Marti, and Rohde, 2012]. The elementary measure that distinguishes a mental illness in the DSM is whether or not the patient experiences distress and/or impairment in their daily lives as a result of their symptoms. Beyond this, I believe that ideally there would be no additional contingencies (especially not physical ones) for someone to be deemed worthy of help. However, the unfortunate reality is that diagnoses are often treated very stringently in a health care system that’s wearing thin.
Given our society bombards us with alarming information from diet culture, it’s no coincidence that we have become equally as fearful (if not more so) of the “obesity epidemic” as we are of the rise in the incidence of eating disorders. Looking at the way we live and the biases present in our lives, it sadly makes sense that so many people meet the mark for distress and impairment surrounding weight, shape, and food.
Life-threatening stigma is propagated by overvaluation of the relevance of body weight in eating disorders and healthcare in general, and leads to the perpetuation of the belief that outward physical symptoms are a reliable metric for mental illnesses.
Eating disorder presentation dances a dangerous line between physical illness and more at archetypal diseases of the mind because they often do present with physical symptoms, causing people to make unfounded assumptions about symptomatology and potential treatments based on appearances.
While a patient appearing emaciated might signal that yes, physical intervention is urgently necessary, this doesn’t meant that patients in bigger bodies are any less at risk. In fact, people with restrictive eating disorders who are not underweight can be just as physically compromised as those who are [Sawyer et. al, 2016]. The consequences of malnutrition, including low blood pressure and low heart rate, can occur at all body sizes. One of these complications, loss of brain matter and the resulting cognitive impairments, appears to occur with weight loss no matter what weight you started at [Roberto et al. 2011]. Meaning that, weight gain is a necessary part of recovery (if weight loss was associated with your illness) but not only for patients who were underweight.
Physiological complications of poor nutrition and restricting food intake cannot be assumed by someone’s appearance. Necessarily, this means that therapeutic intervention should coincide with proper treatment of the physical concerns independent of someone’s weight. Like many biases inherent in society, allowing outdated beliefs to influence our treatment of patients with disordered eating is life-threatening, which is why promoting proper information and awareness is as important now as ever.
Eating disorders of all types can negatively impact physical health regardless of BMI but we know that not all cases are taken equally seriously. Consequently, both the physical and psychological impact of the manifestation of weight-stigma may be disproportionate in sufferer’s in larger bodies. Effects of weight loss can be amplified in patients who started at higher weights despite appearing like they are less at risk given that they have the dangerous potential to lose more weight to begin with. [Virginia Smith, 2019]
While physical symptoms may be differentially judged in patients with different outward appearances, so too can psychological symptoms, that may often even be worsened as a consequence of weight-stigma and discrimination. Putting too much emphasis on weight as the central component of eating disorders ignores the fact that they are first and foremost mental illnesses. Not only does this contribute grounds to the “sick enough” dilemma many people experience, but it also limits proper therapeutic intervention and worsens treatment thoroughness.
There is often so much focus on weight-restoration in patients who may be under-weight that the other aspects of treatment are overlooked, at a cost to everyone. Rehabilitation from a disordered relationship with food should focus on restoration of what was lost beyond just physical weight. No matter your weight, muscle, bone, and brain matter can be lost when the body has been starved.
Eating disorders are more than about the weight you do or do not lose. You risk loss of peace with food and your body. Your self-acceptance and autonomy are threatened. Many patients lose the ability to live spontaneously and without impairment or distress. Happiness, health, and freedom are far more severe consequences than the pounds that are shed and it’s time we started acting like it. Misery is misery and no one in any body deserves to suffer in the clutches of disease.