weight stigma atypical anorexia nervosa

Atypical Anorexia Nervosa (AAN), although only added to the Diagnostic and Statistical Manual for Mental Disorders in 2013, is up to 3 times more common than anorexia nervosa (AN; Harrop et al., 2021).

What differentiates AAN from AN is the individual’s weight; AAN encapsulates individuals with “normal” or higher body mass index (BMI; Abbate-Daga et al. 2013). Some consider them as two separate diagnoses, while others view them as the same condition on the weight spectrum. Either way, their psychopathology is strikingly similar (Moskowitz & Weiselberg, 2017; Walsh et al. 2022). In both conditions, individuals struggle with overvalued ideas of weight and shape, body image distortions, and intense fear of gaining weight leading to restricted food intake.

Weight stigma describes the devaluation and discrimination of people of higher weight in societies that idealise being thin. Research shows that such stigma also undermines health behaviours and preventive care, contributing to disordered eating, psychological difficulties, and health care avoidance (Puhl, 2020; Tomiyama, 2014). Weight stigma in healthcare may be particularly risky in paediatric settings when children are forming foundational beliefs about their growing bodies (Harrop et al. 2023). Because individuals with AAN present at higher weights compared to patients with AN, individuals with AAN are more likely to experience weight stigma. In the absence of intentional efforts to address weight bias, healthcare professionals may over-rely on weight presentation, missing anorexia symptoms in higher weight individuals (McEntee et al., 2023).

This research study aimed to investigate the lived experiences of individuals with AAN in medical care exploring the impact of weight stigma in their care journeys (Harrop et al, 2023).

Weight stigma undermines health behaviours, causing disordered eating, psychological difficulties, and avoidance of support through healthcare.

Methods

The study is based on data from 38 individuals who completed a 6-month interview about their healthcare experiences as part of a larger longitudinal, mixed methods study. Participants were recruited through multiple sources (e.g., eating disorder treatment centres, social media) and had to:

• Be 18+ years old
• Have a history of Atypical Anorexia Nervosa (AAN)
• Live in the US
• Speak English

Participants were between the ages of 18 and 74. Thirty identified as cisgender women and eight as transgender or non-binary. Almost three quarters (74%) were of white racial background with the rest being of Latinx, Black, Alaska Native, Asian and Pacific Islander, and Middle Eastern backgrounds.

The study used a combination of interviews and artistic expression. Participants were asked to create images representing their interactions with healthcare systems before the interview, which were then used as prompts to facilitate discussions. The researchers also collected demographic information from the participants and considered their own diverse identities and experiences while conducting the study.

Data were analysed from an interpretive hermeneutic and critical feminist perspective. A coding guide was developed to categorise the data from the interviews. The coding process involved multiple researchers, and themes were identified through discussions and comparisons.

Results

Multiple themes relating to weight stigma were identified across the illness trajectory, ranging from the initial development of an eating disorder  to post-treatment.

Eating disorder development

Starting from childhood, participants shared that healthcare providers often pathologised their weight and bodies. For participants who were heavier as children, they recalled receiving messages from providers about the health risks associated with their weight. This early exposure to weight-related comments from doctors contributed to feelings of shame and the perception that their bodies were problematic. Some participants reported that their eating disorder behaviours were triggered by conversations with healthcare providers.

Some of the worst damage that I have done to myself has been through dieting and has been supported by my doctors. Doctors… helped me find better ways to starve myself for 30 years.

Pre-treatment and in treatment

Despite displaying symptoms like caloric restriction and weight loss, participants reported that providers frequently praised their behaviours, reinforcing harmful patterns. Healthcare providers commonly failed to recognise the presence of an eating disorder, even as participants’ bodies were visibly changing. Participants felt unheard and unsupported when discussing physical symptoms with providers. They described initially being misdiagnosed with other disorders instead of atypical anorexia nervosa despite typical restricting behaviours and significant weight loss.

Participants also reported providers assumed binge or purge behaviours, while failing to screen for restriction. Within inpatient care settings, participants believed their experiences differed from their peers, and witnessed fatphobic comments from other patients or staff members, which hindered progress.

Even when I was diagnosed with bulimia… that wasn’t really accurate, because I wasn’t really bingeing but they assumed that “this fat person must binge”.

Post-treatment

During periods of remission following efforts for some body weight restoration and healthier eating, professionals questioned the anorexia nervosa diagnosis and reverted to weight-loss focused advice, often triggering relapses in restricting behaviours and then cycles of deterioration. The comments also fuelled poor body image cognitions of participants and led to healthcare avoidance due to anticipatory stigma.

I’m terrified of a full-blown relapse, because I’m avoiding going to the doctor, because of the immediate uncomfortableness in the room…

Despite reporting excessive calorie restriction, compulsive exercising and rapid weight loss, providers frequently praised participants’ behaviours, thereby reinforcing harmful patterns.

Conclusions

The authors concluded that weight stigma was present for many individuals with Atypical Anorexia Nervosa (AAN) across different stages of their illness, from childhood through treatment and into recovery.

Reports from patients revealed that weight stigma contributes to the extension of eating disorder (ED) behaviours, delays in accessing necessary care, suboptimal treatment environments, reduced motivation to seek help, and decreased utilisation of healthcare services. This study also highlighted the inadvertent reinforcement of EDs by many healthcare providers, who adopt weight-focused rather than patient-centred approaches in healthcare settings.

This research highlights the urgent need for a more empathetic, informed, and patient-centred approach to anorexia nervosa treatment across all body types.

Strengths and limitations

This study has several strengths:

• It is the first qualitative research study with a well-thought out design that allowed for in-depth investigations of people with lived experience of Atypical Anorexia Nervosa (AAN).
• Open, reflective practice by the researchers and involvement of multiple individuals in their methodology was used to reduce individual biases.
• The researchers also sought feed back from the participants and a community partner who contributed to theme development. Involvement of people with lived experience in all stages of research work, including the thematic analysis, ensures conclusions drawn are representative and relevant to their ideas and needs, maintaining patient centred focus.
• Overall, the methods were well explained and the mixture of techniques used (including art-based methods) allowed for inclusion of diverse viewpoints, which improved the study’s credibility.

Yet, potential limitations should be recognised for a balanced view of the results:

• Purposive sampling means that the included group of participants sharing their views is unlikely to be representative of the general population with AAN. There was also limited diversity in the interviewed individuals, especially related to racial background.
• The retrospective design was subject to recall bias from the participants as they may have found it difficult to accurately recall their interactions with healthcare providers starting from childhood. They may also be prone to self-report biases, recalling and interpreting past experiences influenced by later ones or limit information shared due to feelings of embarrassment or other factors.
• Lastly, views of healthcare providers of different backgrounds were all studied together as a uniform group, with limited effort made to unpick differences in attitudes of different providers or different settings. The viewpoint of providers was not studied, to explore their awareness of this phenomenon and its impact, their challenges in diagnosis or communication and reflective awareness of weight biases. This could be an interesting area for future research, as suggested by the authors.

The methodology allowed for an in-depth exploration of people with atypical anorexia nervosa and lived experience of weight stigma, utilising a mix of techniques including art-based methods.

Implications for practice

The study highlights the necessity for healthcare providers to better understand the diverse manifestations of eating disorders (EDs), irrespective of body weight, and to approach patient care with sensitivity and awareness. Treatment for EDs is naturally influenced by larger societal ideas that may be slower to change (McEntee et al., 2023). However, there is a clear need to address provider weight bias due to healthcare-induced marginalisation and harm for people with normal or higher BMIs and EDs.

Even outside the world of EDs, healthcare professionals are found to overly attribute problems to obesity and fail to investigate symptoms further beyond advising on weight loss. Clinicians may feel uncomfortable discussing weight and eating habits often due to stigma, lack of training, fear of causing offence, time constraints, personal biases, and complexity in assessing eating habits leading to missed opportunities to identify people with ED symptoms in this patient group (Phelan et al., 2015).

New guidelines for treatment should prioritise health behaviour change over strict weight-related outcomes and incorporate this paradigm of clinical practice in new training materials for health professionals across all specialties (McEntee et al., 2023; Ralph et al., 2022). Efforts to enhance ED care should transcend the confines of the ED field. It is important that future training of healthcare professionals in specialist ED teams focuses on weight-inclusive approaches to diagnosis and treatment, as an alternative to the prevailing weight-centric model (Clifford et al., 2015; Ralph et al., 2022).

It would also be important to consider developing screening tools for malnutrition symptoms and restrictive behaviours associated with distorted cognitions, in people with higher BMIs (Harrop et al., 2023). This would improve earlier identification of atypical ED cases and avoid dismissal of specific patient or family concerns from services.

This paper is a call for health providers to become more aware of their own biases and reflect on the impact of current models of care and communication about the mental health of patients across the weight spectrum. A continuation of the current model of caring for patients who do not fit the emaciated archetype of ED will only perpetuate the difficulties of affected individuals and contribute to increasing health disparities based on weight.

New guidelines for treatment of eating disorders should prioritise health behaviour change over strict weight-related outcomes and move to a weight-inclusive approach.

Statement of interests

The author of this blog has no conflicts of interest.

Links

Primary paper

Harrop, E. N., Hutcheson, R., Harner, V., Mensinger, J. L., & Lindhorst, T. (2023). “You Don’t Look Anorexic”: Atypical anorexia patient experiences of weight stigma in medical care. Body Image, 46, 48-61.

Other references

Abbate-Daga, G., Amianto, F., Delsedime, N., De-Bacco, C., & Fassino, S. (2013). Resistance to treatment and change in anorexia nervosa: a clinical overview. BMC Psychiatry, 13(1), 1-18.

Clifford, D., Ozier, A., Bundros, J., Moore, J., Kreiser, A., & Morris, M. N. (2015). Impact of non-diet approaches on attitudes, behaviors, and health outcomes: A systematic review. Journal of Nutrition Education and Behavior, 47(2), 143-155.

Harrop, E. N., Mensinger, J. L., Moore, M., & Lindhorst, T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. International Journal of Eating Disorders, 54(8), 1328-1357.

Mishra, K., & Harrop, E. (2023). Teaching How to Avoid Overreliance on BMI in Diagnosing and Caring for Patients With Eating Disorders. AMA Journal of Ethics, 25(7), 507-513.

McEntee, M. L., Philip, S. R., & Phelan, S. M. (2023). Dismantling weight stigma in eating disorder treatment: Next steps for the field. Frontiers in Psychiatry, 14, 1157594.

Moskowitz, L., & Weiselberg, E. (2017). Anorexia nervosa/atypical anorexia nervosa. Current Problems in Pediatric and Adolescent Health Care, 47(4), 70-84.

Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews, 16(4), 319-326.

Puhl, R. M., Himmelstein, M. S., & Pearl, R. L. (2020). Weight stigma as a psychosocial contributor to obesity. American Psychologist, 75(2), 274.

Puhl, R. M., Latner, J. D., King, K. M., & Luedicke, J. (2014). Weight bias among professionals treating eating disorders: attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders, 47(1), 65-75.

Ralph, A. F., Brennan, L., Byrne, S., Caldwell, B., Farmer, J., Hart, L. M., … & Hay, P. (2022). Management of eating disorders for people with higher weight: clinical practice guideline. Journal of Eating Disorders, 10(1), 1-42.

Tomiyama, A. J. (2014). Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model. Appetite, 82, 8-15.

Walsh, B. T., Hagan, K. E., & Lockwood, C. (2023). A systematic review comparing atypical anorexia nervosa and anorexia nervosa. International Journal of Eating Disorders, 56(4), 798-820.

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