Dismantling weight stigma in eating disorder treatment: Next steps for the field

Abstract

The authors posit current guidelines and treatment for eating disorders (EDs) fail to adequately address, and often perpetuate, weight stigma. The social devaluation and denigration of higher-weight individuals cuts across nearly every life domain and is associated with negative physiological and psychosocial outcomes, mirroring the harms attributed to weight itself. Maintaining focus on weight in ED treatment can intensify weight stigma among patients and providers, leading to increased internalization, shame, and poorer health outcomes. Stigma has been recognized as a fundamental cause of health inequities. With no clear evidence that the proposed mechanisms of ED treatment effectively address internalized weight bias and its association with disordered eating behavior, it is not hard to imagine that providers’ perpetuation of weight bias, however unintentional, may be a key contributor to the suboptimal response to ED treatment. Several reported examples of weight stigma in ED treatment are discussed to illustrate the pervasiveness and insidiousness of this problem. The authors contend weight management inherently perpetuates weight stigma and outline steps for researchers and providers to promote weight-inclusive care (targeting health behavior change rather than weight itself) as an alternative approach capable of addressing some of the many social injustices in the history of this field.

Medical Nutrition Education for Health, Not Harm: BMI, Weight Stigma, Eating Disorders, and Social Determinants of Health

“…Medical education should seek to end weight stigma in healthcare [ 48 , 50 , 65 , 69 , 77 , 96 – 98 ]. Medical education and communication with patients should be centered on behaviors and objective measures that are clearly linked to health outcomes, as this models a healthy approach to nutrition, weight, and physical activity (Table 1 ).…”

“…Overweight individuals are often told to lose weight without assessment for eating disorder risk, making it more likely that at-risk health behaviors (e.g., restriction, purging, over-exercise) will go unrecognized. This impairs their ability to access and receive appropriate treatment [ 98 ]. Learners should be taught that patients of all weights may suffer the negative physical and mental health outcomes of eating disorder behaviors and cognitions [ 105 ].…”

“…Nutrition counseling must always be done with an awareness and consideration of eating disorders, regardless of BMI. Trainees need to learn how to provide nutrition counseling that does not encourage risky eating behaviors or impair eating disorder treatment [ 92 , 98 ].…”

“…When nutrition education contains anti-obesity messaging, it can cause harm by contributing to the onset or perpetuation of eating disorder behavior among patients and students [ 98 , 106 – 108 ]. In one treatment center, 18% of patients affirmed that anti-obesity messaging contributed to the onset of their disorder, and these patients presented with more severe symptoms [ 107 ].…”

One Sheet Does Not Fit All: The Dietetic Treatment Experiences of Individuals with High Eating Disorder Symptomatology Attending a Metabolic and Bariatric Clinic; an Exploratory Mixed-Methods Study

“…Despite the increasing prevalence of EDs in this population, data suggest that individuals with higher body weights are less likely to be diagnosed with an ED and experience significant delays in accessing specialist ED treatment [6]. Several factors that may explain these treatment delays have been identified.…”