Once again, dear doctors: A person can have anorexia at any size!

I’m going to share with you an email I got earlier this week.

Sadly, the things written here do not surprise me at all. I hear stories like this very often. Many doctors are ignorant to the truths around eating disorders, and often rely on the myths — such as that a person can only have anorexia if they are statistically underweight — to inform them. Of course, this is often damaging to patients.

Ignorance I can forgive. After all, the intricacies of anorexia are hardly common knowledge, and most doctors experience very few cases over a lifetime of practice. Size discrimination, on the other hand, I have no tolerance for.

Added to the ignorance, there is often an underlying contempt for any body that is not on the thin side. Doctors can be some of the most fat-phobic people, and can also be quite cruel. Given the position of authority that doctors have over us, and their supposed superior medical knowledge over us, their words can stay with us for long after they are spoken.

Weight discrimination does not lead to doctors being the best and most helpful versions of themselves. It is not fair to assume anything about a person based on their appearance. It is not right to allow those assumptions to invalidate what a person is actually saying. It is unprofessional to allow personal bias and fat phobia to affect the amount of personal respect you give to a patient.

Hi Tabitha,

Hope you’re doing well. I came across your blog and podcast a few months ago and they’ve been so helpful for me in my recovery so far.

I’m getting in touch for some advice/resources as I’m currently in a bit of a battle against my GP and a lot of friends about how I should be recovering. For a bit of background- I have a history of 12 years of binge-restrict cycle, a couple of years ago this turned to extreme restriction and I lost around 12 kg in the space of three months.. For the last year, I’ve been pulling myself out of restriction- initially going down the “I’ll eat more some calories but only if they’re healthy” route and, in the last couple of months, trying to embrace the fully unrestricted eating mantra, eating what I want when I want. I’m currently up to a BMI of 25 and still feeling really hungry every day- I’m pushing into the fear and trying to just keep eating nonetheless.

However, I went to a GP appointment yesterday to ask for help, as I feel I need a lot of emotional support at the moment (I’m finding the weight gain and fear around food exhausting to deal with) and it was a pretty crap experience. I told her my history, she weighed me and her advice was as follows:

“I think we both know you’re not hungry because” *gestures to my body* “you’re evidently not starving yourself”

“Why don’t you try not eating for a day and then you’ll know what real hunger feels like”

“Try smelling chocolate rather than eating it”

“If you keep overeating you’ll be like obese people- they have forgotten what it feels like to be full so they just eat and eat”

“If you’re hungry, eat an apple- just cut out the junk food, stop buying crisps”

“Get your friends to tell you when you’re eating too much to make you stop”

I was in shock- I cried in the appointment, cried for an hour on the phone to my mum after and then cried for most of the afternoon and evening. On one level, I know her advice comes from a place of ignorance. But I feel like I’ve taken about 10 steps back suddenly- I’ve lost trust in my ability to feed myself, I’m questioning every mouthful and my anxiety around food has increased dramatically. Phrases from what she said are ringing around my head and adding to the destructive things I’ve already been telling myself for years.

Sorry for the long explanation- I guess I’m just trying to find as much evidence as I can to convince myself that I’m doing the right thing right now, that I won’t just keep eating and eating forever. I wondered if you have any advice for dealing with GPs, any studies or articles I can arm myself with so that when my GP (and friends….and family) panic about my weight and food I feel like I have a bit of a defence against it.

Of course reading this email made me angry. I hope it made you angry also. But once the anger has passed, can we join together in productive action?

Doctors are incredibly busy people. They often don’t have time to research and educate themselves on things that do not affect the majority of the people they serve — like eating disorders. So here are a couple of short, sharp pointers you might want to pass onto your GP/PCP.

  1. A person can have an eating disorder at any size. This is because …
  2. A person can be in energy deficit at any size. If a person is suppressing their natural bodyweight via dietary restriction and/or exercise, then even if they are not statistically underweight for the population, they can be underweight for their body. If a person is in energy deficit and they have the genetic predisposition for an eating disorder, then they can have an active eating disorder regardless of whether you judge them as underweight or not.
  3. A person can still be in energy deficit, and therefore still have an active eating disorder, even after they have achieved some initial weight gain.
  4. Malnutrition is a huge physical insult to the body that leads to the slowing down of almost every system from digestive to endocrine. It also leads to the reduction in organ size of many vital organs including the heart. In the recovery phases the body often needs to store fat first in order to expend energy remedying damaged processes and organs. Do not assume that weight gain means a body is not still in a state of disrepair.
  5. If a person is in recovery from an eating disorder, they will likely still have poststarvation hyperphagia (extreme hunger) for a long while after initial weight gain whilst their body heals. Instructing a person to purposefully ignore their hunger is encouraging them to actively restrict food, and will likely lead to a worsening in eating disorder symptoms.
  6. Anorexia causes a hyper-awareness of weight gain, and a tendency towards negative mental state around one’s body. Your words will be remembered by your patient for a long time after you say them, so choose your words wisely.
  7. Eating disorders are deadly. They must be treated with respect.

And I might add:

8. It is never appropriate or productive to be judgmental about a person’s weight, whether they have an eating            disorder or not.

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