Thin Bias in Eating Disorder Treatment

When you picture someone with anorexia nervosa, what comes to mind? For many people, it may be an emaciated white female whose in her early 20’s. She appears pale and disheveled, and may have a feeding tube in her nose. Not a lot of lay persons will say otherwise. More times than I care to count, I’ve had eating disorder clients tell me that they are not sick enough. Where the majority of this disillusionment stems from is the typical body type thought to be associated with anorexia nervosa. The aforementioned example is the traditional anorexia that many of us are familiar with. However, I’m here to say that anorexia (or any eating disorder for that matter) does not have a look. You cannot look at a person and determine whether or not they have a restrictive eating disorder. It takes some hard digging into their daily patterns and thoughts around food and exercise to diagnose that stuff.

Eating disorders pop up across the board. I’ve seen men with eating disorders. I’ve seen black females with eating disorders. I’ve seen gay men with eating disorders. I’ve seen women in higher weight bodies with anorexia, which is the ED I’m discussing today. I’ve also seen (for another podcast) women and men in higher weight bodies who think they have binge eating disorder, when really they have a restrictive eating disorder that forces them to binge eat (as a response to restriction). More often than not, these are the patients that are falling through the cracks. These are the patients who aren’t getting diagnosed and aren’t getting sent to treatment until it’s too late. Even if they are sent to treatment, insurance companies will frequently cut their days short because they either weight restore or they were in a normative weight category to start with.
For those of you out there who are reading this and have an active eating disorder and can identify with one of these groups I’ve mentioned, you ARE “sick enough”. Oftentimes, you are more sick and treatment resistant than those with the stereotypical body shape that anorexia is known for because of the constant battle in your head and the resistance to seek help. Please do not let this be a barrier for you. Find a clinician that “gets it” and is willing to work with you and your struggles around weight and food. Everyone deserves eating disorder care, regardless of their body size, gender, sexual orientation, or race. Eating disorders show up in a variety of marginalized populations. The reason we do not “see” them is because we aren’t looking for it. Doctors aren’t always looking for it. Dietitians aren’t always looking for it. Therapists don’t always see it. If you need help, be sure to reach out.

Let’s get into eating disorder treatment as it exists today. Some of the above situations can be classified by the DSM-5 as “other specified feeding or eating disorder, OSFED”, previously known as atypical anorexia. Right now, there are few treatment programs and insurance agencies who sympathize with this diagnosis. In essence, they are colluding with the notion that you are, in fact, not sick enough. This is rubbish. BMI is rubbish. Anyone who is suppressing their natural body weight by restricting, overexercising, engaging in substance abuse or otherwise to suppress their appetite (regardless of BMI) is “sick enough”. This is what keeps many people from treatment that they need, or keeps them from going back to treatment. They are either told by their medical provider that they aren’t at a dangerously low weight, or they go to treatment and see others who are in fact at a dangerously low weight. And this further drives their “not sick enough” mentality! They believe that their weight holds value, and if it is higher, that they must diet harder. Wrong! They simply need a treatment paradigm that accounts for this. Unfortunately, many insurance reimbursements are driven by weight, NOT behaviors. If their weight is stable or restored, they’re typically discharged to a lower level of care despite their readiness to do so. This very fact is the reason why I see so many patients with anorexia on an outpatient basis who cannot completely buy into the fact that they have anorexia and that they are, IN FACT, very sick indeed. If you skip meals, feel dizzy, and/or have organ dysfunction that stem from an eating disorder (bradycardia/tachycardia, arrhythmia, low BP, slowed digestion, kidney failure, and others), then you ARE sick enough. F the labels. Get help today.

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