Eating Disorders in Larger Bodies
Just as common is the flip side of that misconception: the majority of people in larger bodies must by definition be big because they eat too much and hence are binge eaters. Again, this is untrue: bodies naturally come in a variety of shapes and sizes, and you cannot tell whether a person has an eating disorder—or what eating disorder they have—by their body size. Dieting and repeated cycles of weight loss may, over time, increase a person’s weight. Binge eating—which is almost always a response to undereating or a dieting mindset—can do this too. Everyone’s body responds differently to dietary restriction; some people will lose weight as a result of restriction while others who have a body that actively defends its set point weight may maintain or even gain weight. Patients who meet all criteria for anorexia nervosa except for the low weight criterion are said to have “atypical anorexia”. According to their Body Mass Index (BMI), they may still be labeled as “obese” despite severe caloric restriction. An individual with atypical anorexia doesn’t necessary need to be overweight either. Their body weight is within or above the normal range. They may be in any size body, as many patients with bulimia nervosa, binge eating disorder, avoidant/restrictive intake disorder, and other specified feeding or eating disorder.
Challenges Accessing Treatment
Recovering from an eating disorder in a world dominated by diet culture is hard enough. It is even harder if you are in a larger body or gain weight and develop a larger body as part of recovery, and must deal with the impact of weight stigma. People in larger bodies with eating disorders often meet delays in diagnosis and treatment due to providers’ weight biases and structural issues. Insurance guidelines often require a low body weight in order to cover treatment costs at higher levels of care. As a result, they may not be able to access any eating disorder treatment at all.
Patients Are Not Believed
People in larger bodies with eating disorders are often met with incredulity by family members and even providers who do not believe they have a problem or that the problem is serious. What’s worse, they may be congratulated when they lose weight due to symptoms of their illness. Professionals may even question whether they are telling the truth when they describe restrictive eating patterns. They are often assumed to be dishonest and eating more than they are reporting. These structural issues can further reinforce patients’ own inability to recognize they have a problem. A common symptom of many eating disorders is a lack of awareness that one is ill. People in larger bodies who have very significant eating disorders can easily convince themselves that because their body does not fit the stereotype of a person with an eating disorder, they do not have a problem. The reinforcement of their eating disorder behaviors by the praise from friends, family, and medical professionals can deepen this denial. How can they be expected to acknowledge their eating disorder is a problem when everyone around them is encouraging their behaviors?
Mixed Messages in Treatment Making Recovery Harder
Patients in larger bodies with eating disorders often receive mixed messages that can ultimately make it harder to recover. They may be encouraged to restrict their eating in ways that contradict behaviors required for recovery. Erin Harrop, a researcher recovered from an eating disorder writes: Shira Rosenbluth has similarly described how she was instructed to order a “kiddie” cup of ice cream while her thinner peers in treatment were instructed to order two scoops. The message to her was that her body was too large for her to eat regularly and that she needed to continue to restrict her eating to manage her body size. She also has noted that she was praised by a doctor for not eating during one of her inpatient treatment stays.
Being given such drastically different meals from my peers caused multiple harms: (a) it affirmed my disordered beliefs that my body was somehow ‘different’ or ‘broken,’ incapable of ‘handling’—or needing—food, (b) it affirmed my peers’ disordered beliefs that larger or fatter bodies should be starved or restricted, (c) it visibly separated me from my peers with similar diagnoses and behaviors, solely based on my physical appearance, and (d) my body continued in a state of caloric deprivation for two additional months during the inpatient process, which necessitated refeeding on an outpatient basis.“ Erin Harrop further describes her experience: “Today I understand this experience through a lens of weight bias; [my provider] was not able to see past my body size to the psychological and behavioral issues at hand. To her I did not look anorexic, and so I couldn’t possibly be anorexic.” “The degree to which my food marked me as ‘different’ and ‘problematic’ was obvious, dehumanizing, and confusing in a milieu espousing to destigmatize food and fat.” “Every meal was a visible, obvious reminder that my body was too fat and unacceptable—even to professionals trained in eating disorder treatment, body image, and ‘intuitive eating.’ This reinforced for me the faulty, disordered belief that my body could not “handle’ normal foods such as grilled cheese sandwiches or French toast and it harmed the therapeutic milieu in that it reinforced for my thinner peers that, if their bodies ever gained weight or (God forbid!) looked like mine, then they would not be able to handle foods such as a piece of cheese or slice of avocado, either.” “[Treatment rules she had to follow when she was thinner] helped to heal my body and mind by decreasing my engagement in disordered eating practices and sending a clear, consistent message that my body needed, and was worthy of, food. However, during inpatient care in a larger body, these important recovery messages were blurred, inconsistent, and at times blatantly negated.”
After Recovery
Once recovered, people in larger bodies may feel shame about their body size or that they’ve failed to recover appropriately as the typical image shown of someone recovered is a person who is slender but not too thin. The lack of support for recovery as a larger person may leave them vulnerable to pressures to diet and relapse.
What You Can Do
If you are in a larger body and have an eating disorder, please keep in mind that there is nothing wrong with your body. You are every bit as worthy of treatment for your eating disorder as anyone else. We live in an incredibly fat phobic society, and this will mean additional challenges for your recovery. Be prepared to advocate for your needs. Find a cognitive-behavioral therapist who specializes in disordered eating behaviors. Search for providers who espouse a Health at Every Size® approach. This approach acknowledges that bodies naturally come in all sizes and focuses on behaviors versus weight outcomes. But don’t stop there. Interview them to make sure they do not encourage restriction ever for people in larger bodies. Do not fall for someone who promises to help you shrink your body by, as eloquently described by Deb Burgard, PhD, prescribing the same behaviors that would be symptoms of an eating disorder in a thinner person. Make sure you find providers who will listen to your symptoms and not base a diagnosis on your appearance. Be prepared to fight with your insurance for coverage based on your symptoms and not your body size. Even within treatment settings be prepared to assert your need to being given adequate amounts of food. Food restriction should play no part in recovery from an eating disorder of any type or in any size person. Adequately nourishing your body is a requirement of recovery. Being given permission to eat without condition will allow for a full recovery. Be prepared to discuss your body image concerns and learn about weight-based oppression. It can be very helpful to seek out communities that address fat activism and body positivity.
