All the horses in this picture are different sizes. All the horses in this picture are respected and thought of as beautiful.
On Sunday I published a podcast I recorded with the wonderful Rachel Millner on the topic of Anorexia and people in larger bodies. I was written a note by the mother of a teenager with Anorexia and this inspired the conversation. The main frustration being, that her daughter has Anorexia and is in a larger body, therefore because this is unrecognized by the majority of medical professionals the young lady is not being offered responsible and appropriate treatment.
It is both irresponsible and inappropriate to tell a person who has Anorexia that they should diet, lose weight, and do more exercise. I am sure that everyone agrees on this — or at least gives it lip service —, but in practice this is the reality of what is happening all the time. The problem is that doctors, therapists, dietitians, often don’t comprehend that a person can have Anorexia and not be thin. The DSM-5 may be partly responsible for the lack of understanding here. It’s rather vague explanation on body weight presentation for Anorexia criteria is thus:
Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .
“Significantly low bodyweight” doesn’t have to mean “thin.”
Underweight doesn’t have to mean thin
A person who is underweight can be underweight at any size if the weight that they are is less than the weight that they would be without restrictive eating. A person doesn’t have to be in a thin body in order to be underweight. If I restricted what I ate today and lost weight due to that restriction, I would be underweight — even if I was still statistically in the “healthy” weight range.
Likewise if my natural weight is around 200lbs and this is the weight that I am at when I eat unrestricted, then if I should restrict food and settle at 190lbs, I am underweight. Like it or not, body diversity is a real thing. Some people are in small bodies, some people are in larger bodies. Whatever size body you are in, if you restrict food and lose weight as a result of that restriction you are underweight. And I don’t care what height you are either. Two people can both be 5’6″ tall and one might weigh 140lbs, the other might weigh 200lbs. Both are right. Both are healthy cet par.
To make this easier, let’s talk about horses for a moment. A 16hh thoroughbred is the same height as a 16hh Friesian. However, I will expect the Friesian to weigh more than the thoroughbred of the same height. If fact if the Friesian doesn’t weigh more then the thoroughbred it might be a case of neglect. You’d have people calling the Humane Society and all sorts of fuss about it.
Friesian horses are naturally larger set than thoroughbreds, and this is the way that they are designed to be. Nobody tells a Friesian horse owner that they are feeding too much or that they need to exercise the horse more, it is accepted that type or horse is supposed to be that way. Shame the same sort of respect isn’t applied to people.
Horses come in all different shapes and sizes. People come in all different shapes and sizes. Deal with it. Or don’t, and be forever fighting an imaginary battle with fat.
Energy deficit can happen at any weight
Let’s get down to the nuts and bolts of Anorexia. It is genetic code that gets turned on when a person with that genetic code variation go into a state of energy deficit.
Energy deficit means that you are not eating enough to meet your nutritional needs. There is less energy coming in than there is going out. You are in the red, so to speak. Therefore, energy deficit can happen at any weight, as a person can be not meeting their nutritional needs at any weight. Therefore, Anorexia can happen at any weight if a person has the genetic predisposition for Anorexia.
Is Anorexia less dangerous if a person is not low weight?
In fact it is arguably more dangerous as the energy deficit and the malnutrition caused by it can go on for years and years and not be addressed. When I was emaciated, people told me to eat. It was bloody obvious I was unwell. If a person in a larger body has Anorexia and is underweight, then the following tends to happen: they are congratulated and told to keep going. If they do express concern over the fact that they don’t eat very much, have obsessive food and exercise thoughts, are experiencing symptoms of malnutrition, then they are outright disbelieved, or told that they are imagining it.
Due to this, in a sense Anorexia is more dangerous for people in larger bodies as they are told to diet and exercise and thus increase the energy deficit and the malnutrition further. They are patronized and not given appropriate treatment. In short, they are treated with gross misconduct and outright cruelty.
Therapists, RDs, PCPs, and other healthcare professionals need
to change their fat-phobic thinking not their patient’s weight
Medical and mental health professionals need to stop validating eating disordered behaviors for a start.
- You do not help a person with an eating disorder by suggesting that they try to lose weight.
- You do not help a person with an eating disorder by suggesting they exercise more.
- You do not help a person with an eating disorder by telling them that they will be happier at a lower weight.
In fact, scrap the “with an eating disorder part” you do not help anyone, eating disorder or not by telling them that their mental and physical issues will be blanket solved by losing weight. A person’s weight doesn’t indicate either health.
If you are a professional in the eating disorder field and not focusing on weight loss is a problem for you; do not work with people with eating disorders. Go do something else — you are going to do harm if you continue to work or aspire to work in this field.
Patients in larger bodies are often outright disrespected
“Look, you don’t have Anorexia … you have to be underweight for that to happen.”
These words were said to one of my clients by her GP when she went to him with her suspicions that she has an eating disorder. She explained to him that she didn’t eat at all on some days and usually only ate one meal a day in the evening. Also that she had obsessive thoughts about food but had fear of eating more.
Had the same woman presented to her Dr with a BMI of 16 or lower he would have been all over that! But no, because she is not statistically underweight, he told her she cannot have Anorexia. She suspected that he didn’t believe her about how little she was eating, and came out feeling ashamed and misunderstood. Oh, and he told her to do more exercise. Thanks doc!
The contempt for eating disorder patients is infuriating. We are talking people who are at risk from chronic malnutrition being told to eat less food. How is this possible?
Symptoms and mental state not body weight
Anorexia is not a weight condition. It is a mental and physical state. If a person is showing physical signs and symptoms associated with malnutrition, and if a person is showing the mental signs and symptoms of Anorexia, they have Anorexia. They are in energy deficit and this has to be amended by achieving a state of energy surplus. Energy surplus is achieved by resting and eating. The rules here are the same regardless of a person’s weight. If a person is in energy deficit, they have to eat and rest.
This is the same reason that I argue that target weight ranges for people in recovery are bullshit. Many of us reach said target weight and are still having symptoms of energy deficit. Hence, we have to eat more and rest more and likely gain more weight until our mental state resolves. No amount of judgement about what a person’s weight should be is going to change what their body wants to be. The body doesn’t care about fashion. The body doesn’t care about the latest fat-phobic research that just came out telling us why we all need to weigh less. The body is programmed to be within a certain weight range and you can try and alter that all you like but the results will never be good.
Doctors: Stop allowing fashion to dictate what a healthy body looks like. Use your ears more than you use your eyes when you assess a patient for mental health. Leave your weight bias at home when you assess for physical health.
- Energy deficit – a state when the amount an individual consumes is less than their nutritional needs. A person doesn’t have to be in a thin body in order to be in energy deficit.
- Underweight – a person who is underweight can be underweight at any size if the weight that they are is less than the weight that they would be without restrictive eating. A person doesn’t have to be in a thin body in order to be underweight.
- Anorexia is not a weight condition, it is a mental and physical state condition.
Thank you for your insights and no shit honestly! The world needs you!
I think that this is misleading towards anorexia. I mean at any weight you can have an eating disorder but not anorexia, the way it is classifie . It would be ednos. So this article isn’t worth a crap.
thank you again for this thought-provoking post! I take this opportunity to ask you a semi-related question. I had my anorexia onset when I was already adult and I had maintained my adult set point weight for years without ever dieting in any way.
Now, in recovery, I’ve gone back to that weight. It’s just what I have always weighed, what I have always “been”. Except for the months of active anorexia I’ve never weighed significantly less or significantly more than this. Yet right now I can’t seem able to maintain this weight without restricting; it’s not that I starve, I eat proper meals and don’t exercise, but I still don’t eat really what I want how much I want. Before my ED I was able to maintain this exact weight without ever restricting; now I can’t – again, I was already an adult before. How does this happen? I just can’t wrap my mind around it.
In the same way that the body responds to dieting by raising the set point weight … your body wants to be at a higher weight now. In a sense when we restrict food we teach our bodies that it is prudent to be a heavier weight in case “famine” comes again.
Thank you Tabitha. Do you think things will go back to normal once I’ve been feeding my body properly for a sustained amount of time? I certainly don’t plan to starve again.
Thank you again, your blog is amazing!
Trusting your body is honestly the only option you have. Feed it, allow it to heal and do what it needs to do xx
Hello ! This is so enlightening and powerful. It really made me think about how we judge weight all the time. The medical violence that happens as soon as you have a few kilos more than what is deemed healthy is unbelievable. It really is a subject that is worthy to fight against.
Thank you very much.
There are no statistics that support atypical anorexia (which is what a person with a normal or higher bmi will be diagnosed with) being more dangerous than anorexia. Most morbitities due to anorexia are caused by heart or other organ failure because once your body has burned through all your body fat it begins breaking down your muscle tissue to fuel itself. This isn’t going to happen if you still have plenty of body fat. Yes, it is damaging in the long run to be malnourished but that’s certainly not on par with being at risk of dropping dead any second.
It is no less dangerous for someone with a higher weight and higher set point to have anorexia than someone who started out naturally thin. You could have two anorexic people, one could have started off naturally thin and the other naturally heavier. Let’s say they both lost 40 pounds. The naturally skinny person would look probably like a skeleton, but the heavier person would probably look like the naturally thin person to begin with. Is the naturally thin person any more sick, mentally or physically? No
you, lady, are a danger to those around you. jesus fucking christ. you are criminally stupid.
You’re right. She’s promoting obesity.
no, shes simply saying that you can develop anorexia at any wight and that just because you are heavier doesn’t mean that you can’t have the same mental disorder as a thinner person.
Thanks for your helpful and incredibly smart post, Tabitha. This was one of the things I hated most, I have always been large and heavy for my age, and even when I was sick, fainting, having palpitations and couldn’t sit down without my bones rubbing on the chair, I couldn’t get much professions help because my bmi was ‘too high’. Heck, my friend (who was healthy) was skinnier than me! It has made me so angry since I have gained weight to know that I was denied help from all but my mother because I didn’t look like the typical walking skeleton who weighs 60 pounds that most people think of when they think ‘anorexia’. I really wish more people knew that you don’t have to be very obviously underweight to be sick. Again, thank you
Hiya tabitha, I have a doctors appointment next week and am terrified to tell her I feel I have anorexia, because my bmi is above 17.5 and I am only just considered underweight for height. And I don’t look extremely thin. When I told my partner and family, even they said no you don’t have that ect. So if they don’t believe me because I’m not thin enough, how do I convince the doctor and get help? I’ve struggled with this for 8 years now and the last couple of years I’ve felt more and more ill, have headaches daily and can barely think straight. I’m trying to do it myself but as soon as I eat more I go into senile saying see I’m fine, then I start restricting again until I’m back to eating just one meal or less a day. It’s ruining my life, and if my doctor fobs me off I don’t know what to do. I feel like I need to restrict more until I’m sick enough and thin enough for them to help me. I’ve already told my doctor several times that I find it hard to eat more, and she’s just said some people don’t have a big apetite, so I’m scared she won’t have a clue about eating disorders and will just say my weight isn’t anorexic. Do you have any advice on what I can say to her at my appointment? X
You have to be very strong and explain to her that a person can have AN in any size bodies. Don’t expect her to be educated in this, as she likely will not be. You will have to explain to her. If you want you could point her in the direction of some of the resources on this website as I do have a number of blogs and podcasts explaining this.
Thank you so much for replying. I am trying to write everything down now that I want to say, would it be worth explaining to her about the migration and famine instincts or would I be better not even going into that with her do you think? X
I mean, I would personally. But The trouble is that most GPs only have very limited knowledge of AN, and what they have is based in psychotherapy so it is a lot for them to comprehend. I think most important is to have an idea of what you want and need out of your doctor and being very specific
I get the body diversity, but what about a woman with high blood pressure who’s asked to lose 20 pounds so she can be healthy, even though here present weight is what she tends to? Wouldn’t it be a bad idea to suggest she should stay at that weight?
I’d ask, what advice would be given to a thin person to address their high blood pressure, and then let’s give the same standard of care to all patients. Probably stress reduction and exercise, or something like that, right? Then perhaps medication if those didn’t work.
Anorexia Nerovsa is actually diagnosed based on a person’s weight. you have to be classified as underweight for your height and age to be diagnosed with this type of eating disorder. people can recover from anorexia but then once you reach the point where your body is no longer physically underweight, you would not be classified as having anorexia nervosa. people with larger bodies cannot be anorexic. there is no such thing….they would have to be diagnosed with ednos ( eating disorder not otherwise specified) or binge eating disorder or bulimia. anorexia nervosa is the only eating disorder with an underweight criteria and it’s there for a reason. not to discriminate against people who don’t fit into this diagnosis. its there for doctors to diagnose and determine the proper treatment. an underweight person with anorexia has different energy requirements than a heavy set or normal weight person who may be excessively dieting. major difference, anorexia nervosa is a mental condition that affects body weight and people who have it have an inability or fear to gain weight, it is not a simply someone’s state of mind, when they do not fit into the underweight category. if that were true, every crash dieter or person who restricts and then eats normally, and is never happy with the results, could claim they are “anorexic”…..and being energy deficient while still remaining within a normal or heavier frame is not anorexia. you would still have to be deemed underweight even if you are taller. i have anorexia. i think the way this article is written is very informative. the fact that you say people in larger bodies can have anorexia shows you don’t understand this disease. wanting to be thin is not the same as suffering from anorexia nervosa.
Lacey, as this is a new concept and the medical understanding of it (endocrinolgy, metabolism etc) is still in its infancy, I think that a new term will emerge in time to distinguish between underweight anorexics and those who are not underweight but starve/exercise just as much. I think it’s a worthwhile distinction also because often the mental motivation is different- atypical anorexia may have no roots at all in body dysmorphia or control issues, but simply be the result of someone not made for it wanting to be just normaly slim in a society that incorrectly believes that this can be achieved by everyone in a healthy way, and remaining bewildered by their ‘failure’.
However, this is not to say, as you suggest, that just anyone who has ever crash dieted and not got results is an atypical anorexic (to use the current term for now), but people who have severely restricted themselves for decades, fasting and overexercising and maintaining on very low calories, endangering their physical health and ruining their mental health in the process, well yes, they are anorexic. The agonising hunger, self recriminations, malnutrition, and absorbing obsession are the same.
The terms (or the criteria) need to be changed, as is normal in any field when knowledge has grown.
Michelle, I couldn’t agree with you more on your assessment here. Genetics also factor into a person’s stabilized BMI at a given weight range which could be their healthy weight range even if the BMI were slightly higher than what’s currently medically deemed as “healthy”. Their eating and exercise restrictive behavior, even if they appear “normal” weight range or slightly overweight, metabolic rate/speed status and nutritional status (malnourished), obsessive/compulsiveness in order to stay at the weight range they’re currently at needs to be factored in since they’re obviously ruining their physical and mental health by starving and exercising in order to even stay at the weight range they’re at even if it appears slightly overweight to observers who rely on first visual impression and judge others accordingly. Basically, people who treat their bodies this way are going through a living hell even if they don’t appear Anorexic to others. I speak from deep personal experience on this. Since 1992, I’ve had nearly 60 lbs. removed from my body involuntarily with no change in appetite, eating habits or exercise routine. I’d not become eating disordered until recently, when 18 lbs. fell off of my body in 7 days in Dec. 2016. I’ve been afraid of regaining those 57 unintentionally lost lbs. for 25 years already. Now I’m working with chronic metabolic damage trying to gradually restore weight to an agreed-upon weight target without winding up slightly heavier than what’s societally/culturally approved nowadays. All I have to do is look at food and gain weight thanks to my metabolism having become ultra slow once my body went into starvation mode in 12-2016 following my 18 lbs. lost involuntarily in 7 days with no change in appetite or eating habits. No specialist has been able to diagnose the causative of this. You have no idea how miserable and anxious I am over this right now. Michelle, I believe that you’d identified it well here. Even though I appear slightly thinner than I should be, right now, my weight had overshot in 1988 by 35 lbs. during an eating disorder recovery with no over-eating involved whatsoever. Then 37 lbs. dropped off me in 7 days in 1992 and I felt better without the extra pounds weight overshoot. I’d managed to maintain that involuntary weight loss for 25 years up until December 2016 when 18 lbs. came off of me involuntarily in 7 days making me sick. I’d wound up having a near fatal stroke, total hip replacement surgery and central nervous system damage. Weight stigmatization needs to come to a halt. More need to learn relevant alternative knowledge as to why others look the way that they do physically instead of automatically judging them relying on first visual impression. Many thanks for having borrowed time to read this. My weight story is weight loss that’s been involuntary over the past 25 years; yet I’m now eating-disordered due to fear of rapid weight gain rebound.
Respectfully, anorexia is not solely due to the fear to gain weight. You’re right about a lot of things, viz. the diagnostician criteria; however you mislead several times. You underrepresent the myriad of variables associated with AN; not simply “the fear of gaining weight”. Often it manifests due to compulsive behaviors & it’s used to maintain control, therefore providing instant gratification. Your failure to delineate the dynamic nature of eating disorders not only directly contradicts your “not to discriminate against those who don’t fit the diagnosis” but does a disservice to highly variable presentations of serious, life threatening, illnesses. If you don’t see the contradiction, I will explain. You reference the exclusivity in diagnosis to be justified by not fitting the criteria, which is true but your description of AN is not inclusive enough which undermines a lot of your intro to nutrition college course knowledge.
Thank you so much for this. I’ve worked as a professional horse trainer and rider for over a decade, and the weight stigma in the industry has fueled my eating disorder and made me resent my body type since I was a teen. Your metaphor using horses was so obvious to me when you explain it that way. I don’t expect my warmbloods to have to same body type as a racehorse, so why do I hold my own body to a different standard?
Thank you so much for this. I’ve worked as a professional horse trainer and rider for over a decade, and the weight stigma in the industry has fueled my eating disorder since I was a teen. Your metaphor using horses was so obvious to me when you explain it that way. I don’t expect my warmbloods to have to same body type as a racehorse, so why do I hold my own body to a different standard?
Ughh. Although I’d read this way before going in, I finally got setup on some government funding for local citizens of a certain place. It’s all the help I can get right now, so I’m literally on my own it seems, until I can afford to at least hire a nutritionist. It’s so annoying. Texas is apparently shit with mental health treatment in general.
The psychiatrist not only DOESN’T understand eating disorders, but thrice he told me that while self-starvation and obsessive exercise = anorexia, “People who have anorexia are usually…you know…more lean, and you look fine. You don’t look like you have anorexia.” He never gave me a chance to explain that I look the exact same as I did in sixth grade, just very slightly different, in height and style; my weight has remained the same since eighth grade; and that I present the less at-a-glance symptoms of anorexia, including malnutrition, anemia, lanugo, brittle hair.
HOW can you freaking determine whether or how anorexic someone is based on stigmatic opinion and how they look? It makes zero sense whatsoever.
Thrice, he told me that I need to make sure I exercise despite being unable to due to my body feeling like it’s breaking apart. Like, it’s the whole reason I can’t anymore. He also said not to sleep/eat too much and just seemed interested in prescribing medication, and told me that if dieting makes me happy, then to diet…
He got frustrated when he asked me if I “believed” I had an eating disorder, regardless of being treated for EDNOS in the past and a recent hospitalization for malnutrition and dehydration…because apparently using medical factors as proof is not acceptable and it’s got to be all in my head? I DON’T UNDERSTAND THE LOGIC, AGH.
When I was insured under better insurance, I was in denial. My family’s too into fad diets to notice anything out of the ordinary, partaking in diets that glorify anorexia itself. I didn’t want to recover because it felt futile. If I were still in that mindset of not wanting to recover, my ED would have an excuse to sweep in and be like, “See? You’re the only one who’s crazy for thinking you have a problem.”
If I were so depressed but not yet to the point of suicidal thoughts, that would have been enough for me to wonder what is even the point and to reconsider suicide.
Like, I haven’t the privilege to find a doctor who specializes in this ish because the insurance doesn’t cover that, and Texas is sooo limited. It’s ridiculous. The hospital was only equipped to rehydrate me; they had no idea where to even start with treating malnutrition or helping ED patients.
Yet still, I’ve never wanted something so bad in my life, so I’m determined. I know there are medical risks and that people should have medical assistance, but sheesh…if eating disorders are so deadly, and especially anorexia, WHY do the medical and mental health fields fail to understand it so much? And how can we make a difference? Do I just keep sharing my story (I’m a blogger)? Although it doesn’t feel like it’s really enough. Doctors seem to get upset at that, at least here. They look back to their DSM and/or stereotypes and say, “Hmm, so I’m going to prescribe you ___. And by the way, do YOU believe you have a problem?”
Hi. I have never been a big eater and at 12 years old I didn’t want my toast I was getting for breakfast. My mum rubbed the 2 slices on my face. I couldn’t see any skin just cuts. Now I’m 41 and I don’t eat much. I would eat when with people maybe one meal a day. I usually go a couple of days a week without food. Past 5 weeks or so iv been on my own and only been eating a pot noodle or a sandwich every other day. I can’t hold relationships and I fall out with everyone.i just keep hurting my family with my moods and I lash out. I don’t cry but this past 5 weeks or so I can’t stop balling my eyes out for nothing. I thing I’m losing the plot. I don’t want to be here anymore. I’m not dead yet because my kids mum has health problems and I’m afraid she will die and I don’t want my kids to have no one if she does die. This the only thing keeping me from killing myself. Is there any hope
Striker… Im sorry no one replied to you. I hope you’re OK and that you see this. Yes, there is hope for you… There’s always hope. Firstly, you’re not eating anywhere near enough… Please make that your focus to start with. I promise you will start to feel a little better emotionally if you at least start to eat more. I know it’s hard but it’s really important. I’m sorry about the abuse you’ve suffered. Please try and get some help if you can and talk to someone you trust. Be kind to yourself and please, make sure you eat. We need you to be here… Please don’t leave us xx Sending love and well wishes xxx