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.