How We Set Recovery Weights

Recovery Weight [Image description: doctor scale]
Photo by Samuel Ramos on Unsplash
If you have an eating disorder, or your child has one, there is a good chance that weight gain will be an essential part of the recovery process. This is true not just for people in objectively small bodies, but also for people in larger bodies who are diagnosed with Atypical Anorexia, a weight-biased diagnostic category included in the DSM-5. It is even true for people recovering from bulimia nervosa and binge eating disorder.

The eating disorders field lacks consensus on how to set recovery weights. I know a respected professional who argues adolescents should be routinely restored only up to the 25th percentile weight for age. They argue that this reduces their potential for experiencing weight stigma and reduces their anxiety. However, I see a problem with this, as do many of my colleagues and many families and recovered people.

This article discusses why weight recovery is a priority; what the research on weight suppression says; how we use growth curves in setting recovery weights; what evidence suggests that many providers set recovery weights too low; and how this applies to people in larger bodies.

Why Prioritize Weight Recovery

We know that while weight recovery in anorexia is not sufficient for recovery in and of itself, it appears to be a prerequisite for full psychological recovery. Eating disorder cognitions as well as most of the physical symptoms appear to recede only with full weight restoration. Food is medicine not just for the body, but for the brain as well. That is why we often say, “Food is medicine.”

The research on timelines for eating disorder recovery show that remission of eating disorder behaviors such as binge eating and purging takes an average of eight or nine months, and weight recovery takes on average 12 months. But it takes even longer to end eating disorder thoughts, including the preoccupation with shape and weight and urges to restrict, purge, or exercise. These thoughts can persist for nearly a year after a person has reached a normal weight, has stopped engaging in behaviors, or both.

Weight Suppression and Negative Energy Balance

We also know that weight suppression—defined in adults as the difference between a person’s current weight and their previous higher adult weight—predicts continuation of eating disorder symptoms including binge eating. In children and adolescents, weight suppression would be defined as a negative deviation from one’s expected weight curve. Therefore, at EDTLA we prioritize full weight restoration for all patients in all body sizes and with all eating disorders. Failing to fully restore a person to their recovery weight for body and brain could prevent them from a full recovery.

A negative energy balance—taking in less energy than one’s body needs—may be a primary contributor to the development of an eating disorder in someone who has the innate susceptibility. Cindy Bulik, Ph.D. describes how a negative energy balance lowers anxiety for a person with this vulnerability, creating a trap. Restriction becomes seductive under these conditions. Couple this with the evidence that the weight loss leading to the development of anorexia nervosa could be unintentional—such as a side effect of an illness or an overexpenditure of energy for sports combined with undereating.  Together these suggest the best defense against relapse is maintaining an adequate energy balance and a healthy weight where the brain is functioning well enough to not act on residual thoughts.

Using Growth Curves to Estimate Recovery Weights

In this section, I will discuss why using individual growth records is so important. We have received guidance from our colleagues specializing in adolescent medicine and eating disorders. Like many eating disorder dietitians, one of the things we do is look at childhood growth records when they are available. This method is more tailored than using population averages such as BMI to set recovery goals.

In the US, most pediatricians document children’s growth on the CDC growth chart, which plots height, weight, and body mass index (BMI) against age-based averages.  In healthy children and teens, height and weight each increase along a consistent growth curve. Some children and teens grow steadily along the 95th percentile, some along the 75th percentile, some along the 50th percentile, and still others along the 25thh percentile.

But not every body is the same, and it’s normal for individuals’ height and weight to follow different growth curves. For some children and teens, a weight along the 75th percentile and height on the 25th percentile is normal. This defines the growth curves for that individual. Just as not every woman of average height wears a size 8 shoe, not everyone of average height is meant to be at the 50th percentile for weight. There is always a normal distribution in a population. These growth percentages appear to be largely genetically determined.

A deviation on an individual’s growth curve for weight, height, or BMI—even in the absence of actual weight loss—may indicate there is a problem such as an eating disorder. A child should be growing and gaining weight during this time, so the failure of a child or teen to gain the appropriate weight can be equivalent to weight loss. This means that when there is actual weight loss, the amount of suppression—the difference between current weight and where one should be on a growth trajectory—is usually even greater than the actual pounds lost.

Thus, a parent may come to us and say, “My child has only lost 10 pounds.” However, when that weight is plotted and we notice that the child also failed to gain any weight in the months before they lost weight, we might now look at their curve and see that in fact, the child should gain 20 pounds (or more!) to catch up to where they should be on their own unique growth curve. Some kids may not have lost any weight at all—but have fallen short of their appropriate gain for so long that they now should gain at least 10 pounds.

This is why we also often say that weight is a moving target. To remain in recovery, a year from now an individual’s goal weight must be higher than the weight that would be healthy at their age today. And this is true even for children who are no longer getting taller, as it is normal for weight to continue to be gained through about age 20.

This is why we will ask to see your child’s (or your) growth records. We will estimate what their weight should be for their current age based on their growth history. Returning to their own growth curve is usually a minimum estimate because we cannot know for certain where some one’s body will end up. We will consult with your child’s pediatrician. You may also want to consult with a specialist in eating disorders and adolescent medicine.

Please be aware that some non-ED specialist pediatricians may not be well-informed about this individualized process of setting goal weights. I once had a pediatrician who told a teen’s parents she would be happy if my patient got to a certain weight because that was the weight that the pediatrician—who was herself quite petite—had weighed at the patient’s age.

What? A pediatrician setting a goal weight for a patient based on her own unique growth history!?? When you take your clothes in for alterations, does the tailor cut the clothes to fit the tailor?  Do you see the problem here?

Speaking of growth curves, the use of growth curves to spot early eating disorders is an underutilized practice. In a recent study on pediatric patients hospitalized with an eating disorder, 48% of patients experienced a deviation in the growth curve a median of almost 10 months prior to the first eating disorder symptoms being reported by parents.

We will also show you how your teen’s weight should be tracking on the weight curve. Teens generally gain 30 to 40 pounds in the course of puberty. While many children gain weight and grow naturally during this period, we find that children who have had an eating disorder may need continuing guidance to help their weight keep pace with their age and height. We encourage parents to keep an eye on their teen’s weight to make sure weight continues to track along the expected curve. We respect parents and educate them on this.

The Field Tends to Set Recovery Weights Too Low

Looking at historical growth curves is especially important because parents have shared that in their experience, health professionals often set their teens’ recovery weights too low. This is not surprising; even providers are susceptible to weight stigma. It is challenging for providers to take on a whole cultural system that reinforces the false virtue of thinness.

At EDTLA, we do our best to challenge our own weight biases and that of our patients and their families. We believe that facing the anxiety of a patient or a child restoring to a slightly higher weight has benefits that outweigh the costs. We help the family challenge the belief that being fat is worse than remaining ill. I never want to be the provider who set a goal weight so low that it contributed to prolonging a mental illness from which it may take a patient 9 to 22 years to recover.

Challenging weight bias and setting higher weights goals does not always make us popular. Teens with eating disorders are by definition, terrified of gaining weight. In her blog, eating disorder specialist pediatrician Julie O’Toole discusses the setting of goal weights and how parents fear that too much weight gain will make their teen more depressed and anxious. Dr. O’Toole emphasizes the importance of basing treatment goals on data rather than placating the eating disorder.

Remember that an irrational fear of weight gain is often a symptom of the disorder. The anxiety over one’s body size often improves significantly with recovery, which requires more regular eating patterns and—ironically—weight gain. Please note this is rarely immediate. It may take up to a year of being at one’s healthy weight and learning to tolerate a changed body before the eating disorder thoughts fully subside. On the other hand, appeasing the fear of gaining more weight can maintain the fear and potentially the disorder.

How Does This Apply to People in Bigger Bodies?

We are often asked why a person who has historically been at a higher-than-average body weight must be returned to a weight that is higher than average. We recognize that bodies naturally come in a variety of shapes and sizes.  Some people are meant to be larger. We often encounter patients and families who say “but they looked better when they were a few pounds less” and want to use the eating disorder as an opportunity to keep a person’s weight suppressed. We believe that using an eating disorder as an opportunity to avoid returning to a previous higher weight could hinder the individual from reaching full recovery. And the research on weight suppression supports this. In the words of Julie O’Toole, “Rarely can a child who is genetically programmed to be larger than average be safely held at a ‘thin’ body weight. Size acceptance may be a part of the family’s treatment challenge.”

Of Course, Recovery is About More Than Weight

Remember, though, that an estimated recovery weight is just that—the best estimate of where recovery will occur. I think it is important for parents to have a roadmap and to know generally whether they might be needing to add (at least) 10 pounds or 20 pounds or 40 pounds because it gives you a realistic expectation of how long the weight recovery phase may take. Again, this may change over time and our estimates are usually a minimum weight and bodies may go higher.

Ultimately, recovery is about state, not weight. And recovery means more than just weight recovery. We are looking for recovery of physical health—normalization of heart rate, blood pressure, and body temperature and resumption of menses when appropriate—as well as psychological recovery which includes improved mood, decreased eating disorder thoughts, return of normal hunger cues, and more regular eating, a less fraught relationship with food, improved social functioning, and a return of interest in other age-appropriate activities.

In one informal survey of 29 parents whose teens were given a recovery goal of 19 BMI, most reported recovery actually occurred at a BMI of 23 or greater and none achieved recovery at a BMI lower than 21. Parents will report that often, with an additional ten extra pounds, their teens were more likely to attain state recovery. If someone is not doing well at what we initially estimated to be a recovery weight, we will review that and may suggest after a few months that we raise the goal weight a little.

This post has described our thinking, which is informed by research, parent feedback, and expert opinions by leaders in the intersection of adolescent eating disorders, FBT, and Health at Every Size ®. We hope it helps you understand our recommendations.

But you don’t have to take our word for it. We invite you to do your own research. Below we’ve compiled some resources from leaders and colleagues in the field. And we strongly suggest you watch this video by Eva Musby.

Sources and Further Reading

Bulik, Cynthia, UNC Exchanges Blog: Negative Energy Balance: A Biological Trap for People Prone to Anorexia Nervosa

Butryn, M. L., Juarascio, A., & Lowe, M. R. (2011). The relation of weight suppression and BMI to bulimic symptoms. The International journal of eating disorders44(7), 612–617.

Eddy KT, Tabri N, Thomas JJ, et al. Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. J Clin Psychiatry. 2017;78(2):184-189. doi:10.4088/JCP.15m10393

EDTLA Blog: Are We Setting Recovery Weights Too Low

EDTLA Blog: Unintentional Onset of Anorexia Nervosa

FEAST of Knowledge 2020 – 08 Health At Every Size (HAES) by Rebecka Peebles, MD

Full Bloom Podcast: Why do my child’s caregivers need to present a united front around body positivity? with Lauren Muhlheim, Psy.D., FAED, CEDS

Gaudiani, Jennifer, Weight Goals in Anorexia Nervosa Treatment

Kartini Clinic Blog, April 12, 2013 Determining Ideal Body Weight 

Kartini Clinic Blog Sept 1, 2016 Setting Goal Weights

Lebow, Jocelyn, Leslie A. Sim & Erin C. Accurso (2017): Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa?, Eating Disorders 2018 May-Jun;26(3):270-277. 

Marion, M., Lacroix, S., Caquard, M. et al. Earlier diagnosis in anorexia nervosa: better watch growth charts!. J Eat Disord 8, 42 (2020).

Musby, Eva Weight-Restoration: Why and How Much Weight Gain?

Musby, Eva: Growth Charts and Weight Gain Made Simple

New Plates Podcast Episode 21: State Not Weight with Dr. Rebecka Peebles

When You Have Adapted a Health At Every Size Approach and Your Family is Still Stuck in Diet Culture

When You Have Adapted a Health At Every Size Approach and Your Family is Still Stuck in Diet Culture [image description: a crack running through pavement]
Pixabay
For many of my patients who have firmly joined the anti-diet camp and embraced a Health at Every Size approach® (HAES) to health, dealing with family members entrenched in diet culture can be a minefield that is tough to navigate. Let me say that I get it! I also have friends and family members who remain focused on thinness and weight loss. It’s hard!

I notice that for many of my patients, it feels like HAES opens a huge chasm between their beliefs and the beliefs of their family members. It’s an entirely different world view. In fact, the only parallel situation I have observed is the divide between patients who are liberal in their political beliefs and their conservative family members. There is almost no bridging the gap. They cannot see eye to eye and they feel no political discussion with these family members is safe.

If you feel the HAES paradigm has been personally helpful, you grow eager to share your knowledge with family members. You may want to help release them from their own diet prisons as well as transform them into HAES advocates and supporters for your health.

However, I recommend setting modest expectations. You have probably worked hard at recovery, meeting with a HAES treatment professional, reading, studying, and doing the work. You have spent countless hours on your personal journey breakup with diet culture. This has been a long and involved personal process.

Consider your family member: they have not invested the time or energy in this project that you have. They are probably still wedded to diet culture. They are not likely to be swayed merely by your testimonial that HAES has been helpful for you. After all, they still get diet messages everywhere they turn. They have been absorbing these messages for many years.

People rarely disavow diet culture immediately upon learning about HAES. I know this because I know the process you have been through. Even as a professional immersed in the eating disorder world, my own evolution to a firm HAES stance developed over a period of about 5 years. I see with my patients too that it is a process. Some aren’t ready to let go of diet culture and don’t return after a first session when I convey that I do not support the pursuit of weight loss. For those who stick with treatment, it can take many months to evolve into a HAES adherent.

Your exuberance about HAES may fall on flat ears. Remember this chasm between HAES and diet culture is just as vast as that been liberals and conservatives. So, I recommend taking a page from the people I’ve worked with who have a political divide in their family: set your expectations and Agree to Disagree. Use radical acceptance. Do not focus on proselytizing your family members. This can lead to conflict and disappointment.

You can let family members know that you have given up dieting. Do not expect them to do the same. You can offer them information about HAES by sharing some articles or favorite blogs or podcasts but do not expect they will read them. Be happy if they do, and offer to discuss these ideas if they want to. Be satisfied if they accept the recommendations. Practice empathy for their perspective; they are a victim of diet culture just as you once were.

Focus on setting a healthy boundary. You can ask them not to comment on your body or comment on your eating in your presence. This request is not hard for them to meet. You can also ask that they try to refrain from diet talk in front of you. Over time, you can remind them and train them.

I know from experience. I have been at this with my family and friends for years. I have a close family member who continues to be diet-focused but for the most part, knows they cannot discuss this in front of me. Recently, they told me (several times) about how a friend had lost so much weight and how great it was. I told them I was not interested in hearing about their friend’s weight loss. They told me, “Oh, I forgot who I was talking to.”

That’s how you train family members.

Read more: To the Family Member Who Worries I Am Not Helping Your Loved One’s “Weight Problem”

A Better Resolution For Exercise

joyful movement [image description: woman in a flowy skirt jumping in front of trees and grass]
Representation Matters

by Kristen Wright, LMFT

Did you make a New Year’s Resolution to start a new fitness routine? Those “thirty days of push-ups or sit-ups” or “do 15 of this and 12 of that a day to your ideal body in no time,” might sound appealing. But you may have already discovered it’s just another commitment that has left you feeling depleted and disheartened. What if this didn’t have to be a failure but the start of a new experience?

No, you are not lazy, inadequate, or hopeless. There! I said it and I firmly believe it. It is very easy to slip into a cycle of unhelpful thoughts. If you were talking to your friend that way, would your friend listen to you? Of course not! Saying “Get off that couch, you lazy cow” is no way to get it done. I used to think beating myself up would help me work out, and I had no excuse for not exercising. I now know that is not the solution.

Here are some strategies that may be helpful.

Rethink Exercise as Simply Movement

Exercise is often viewed as something unpleasant or punishing or even penance for eating. It shouldn’t be! Movement is much broader. It may be a dance class, a walk on the beach with your partner, a hike with a friend, or shooting hoops with your child. It could be jumping around to good music or playing on the ground with our pets or kids. It might even be just walking back and forth or stretching. Workouts come in many forms and all movement counts. Movement should be fun and have some freedom.

We need to reject the idea that a workout has to be 30 minutes to an hour, requires sweat, requires a shower, and must involve so many sets of different things. What if movement didn’t have to be so structured? If you are still trying to understand why workouts are difficult, it may be because in the past you only exercised when you also dieted. I find that many people with a history of repeated dieting have a very negative association to working out. Reframing it as movement helps with removing that association.

Welcome Those Rest Days

Balance is important. Sometimes rest is more important than exercise. Learn to listen to your body and all its needs. You may have had a bad day at work or you may be dehydrated. Everyone needs days off. When taking care of bodies, we have to take care of our mental health. And sometimes the workouts won’t happen. But instead of thinking of “I missed a day, and everything is ruined,” think instead, “Today I took care of my body by resting.”

Stop the Inner Critic

Become aware of your negative thoughts: “I can’t do this; I am lazy; I am a failure. I am too out of shape.” All of these jumbled thoughts weigh us down. We just can’t expect to operate under these conditions. You should talk to your body as you would talk to a friend. And when you do start being kinder to your body, pay attention to the peace and freedom that will follow. Remember: don’t push yourself to the point of negative self-talk. If the negative inner critic pops up, it is time to evaluate the workout and listen to your body.

Challenge Your Perfectionism

Not all workouts will be better than or even equivalent to the last. Watch and challenge that urge to make each bout of exercise more intense or more successful than the previous one. Try to remove performance measures from your exercise. You do not need metrics to measure the success of your movement. Try focusing instead on how your body feels. As well, after having a great week of workouts you might find that the next workout is barely anything. Don’t despair. Your body might be reacting to fatigue, stress, or just screaming for a break. Remember movement is still movement.

Recognize You are not Obligated to Move

In the words of Christy Harrison, MPH, RD, CDN: “Health isn’t a moral obligation, and you don’t owe *anyone* the pursuit of health. Too much of the wellness world is caught up in healthism, and equating our worth to how much we pursue health goals. But the truth is that your value as a person and as a member of society doesn’t lie in whether or not you value your health.” Now how can this apply to you? Your worth as a person does not correlate to your fitness achievements. You are not a moral failure if you don’t exercise. You are not required to exercise!

In Conclusion

You are the only one who can know what your body needs. Different bodies appreciate different activities. Just because your favorite fitness guru on Instagram says that “this” or “that” will get you in shape, does not mean it is something you must do. You are the leader and guru of your own body. So, let your body tell you what it enjoys. Find the movement that makes your body say “Ahah! That felt good, let’s do this again.” It took me many different workout classes and videotapes to find out what I liked. I had to invest and become the explorer and expert of my own body. Be your body’s best friend and explore what your body likes to do. Please don’t give up on a movement style your body enjoys because it doesn’t look like it is making a difference. Rather spend time enjoying how the movement makes you feel. Do you feel better afterward?

AT EDTLA we can help you improve your relationship with food and exercise.

Fat Positive Photography

Fat Positive Photography [image description: woman doing yoga on a beach in front of the sunset]
Representation Matters
I’ve recently returned from the Association for Size Diversity and Health (ASDAH) Conference and I’m reflecting on all I’ve learned. I’ve wanted to share and further explore Substantia Jones’ keynote, “Fat Visibility Through Photography: the Who, the How, and the Hell Yeah.”

Jones is a photographer, a “Fat Acceptance Photo-Activist,” and the proprietor of the Adipositivity Project.  She started Adipositivity in 2007 to “promote the acceptance of benign human size variation and encourage discussion of body politics” by publishing images of women, men, and couples in larger bodies. Substantia is passionate about the fact that fat people don’t see a balanced representation of themselves in the media—as she says, “Humans need visibility. Positive and neutral visibility is being denied to fat people.”

So many of the media images we see of larger-bodied people portray them in negative and stereotyped ways: unkempt, unhappy, eating fast food, and often headless—as if they are ashamed to show their faces. At the same time, the range of body types provided by media images does not really represent most bodies. The media typically culls the thinnest or fittest sliver of the population, and then proceeds to photoshop the images of these bodies.  According to the Body Project, “Only 5% of women have the body type (tall, genetically thin, broad-shouldered, narrow-hipped, long-legged and usually small-breasted) seen in almost all advertising. (When the models have large breasts, they’ve almost always had breast implants.)”

In September 2009, Glamour included a photo of Lizzie Miller, a model who is a size 12-14. The photo showed Lizzie nude and looking joyful while displaying a roll of belly fat. The response was overwhelming—American women were thrilled to see a woman who looked more like them and was happy to boot.

While this was groundbreaking, the average American woman is a size 16. So where are the images of the upper half of the weight spectrum? It should be noted that it is not only larger bodies that are marginalized; other bodies are often not portrayed in mainstream media. These include bodies that are darker-skinned, disabled, aging, and gender diverse.

It is important that people in larger bodies see images of people that look like them. It is also important for all people to broaden their aperture on what people should look like. This includes viewing images of fat people who are happy, sexy, desired, and beautiful and engaging in all the activities that make up a fulfilled life.

Those working in the field of body acceptance confirm the therapeutic value of seeing attractive images of larger-bodied people. Unfortunately, these images can still be hard to find. One must look outside of the mainstream media. With that in mind, I thought it would be useful to provide resources for beautiful, artful photos of people living in larger bodies.

During her keynote, Substantia shared photos from several of her favorite fat-positive photographers, including those that inspired her. Below I list some of the photographers she shared and where to find their photos and information about them.

  • The photography of Patricia Schwarz can be found in Women of Substance – Portrait and Nude Studies of Large Women, published in Japan in 1996 by The Kiyosato Museum of Photographic Arts. Little has been published about her aside from this article, which states that Schwarz, who belonged to the fat liberation community in the 1980s, specialized in full-color photography of fat women. The book features women posing in domestic, natural and urban settings in various stages of clothing and nudity.
  • Laura Aguilar is known for her photographs of people from various marginalized communities (including fat, lesbian, and Latina). She is particularly known for portraying her own nude body as a sculptural element in desert landscapes.
  • Leonard Nimoy (yes, that one) published The Full Body Project, a collection of black-and-white nude photos of members of a burlesque troupe called the Fat-Bottom Revue. According to Nimoy, the purpose of the book was to challenge the harmful beauty ideals promoted by Hollywood.
  • Catherine Oakson was described in an obituary as a creator of “artistic self-portraits—some playful, some sensuous—and messages of body positivity.” Unfortunately, since her death, her photographs are extremely hard to find. Her website, “Cat’s House of Fun,” is only available via web archives (web.archive.org). Search for the website, http://catay.com and look at screen grabs prior to 2017
  • Shoog McDaniel, an artist and photographer living in Florida, was also present at the ASDAH conference, and their art was used in the conference program. Shoog was featured in this article in Teen Vogue which described them as “the photographer pushing the boundaries of queer, fat-positive photography.” Shoog states “the work that I do is about telling the stories of people who are marginalized and not usually put on the forefront, and whose lives are beautiful and important.”

Although Substantia’s presentation did not touch upon it, it’s worth mentioning Representation Matters, the world’s first website providing high-resolution, royalty-free, stock images of diverse bodies for commercial use. (The image in this post is from Representation Matters.) They specifically include larger bodies portrayed in a positive light. These photos are available for purchase.

Unfortunately, diet culture and thin privilege are alive and well, and those in larger bodies remain marginalized and excluded from most mainstream media. I hope you’ll check out these resources and come to appreciate the vast diversity of the human body. I purchased some photography books to share at my office. Together we need to work to challenge the notion that there is a best way to have a body and learn to celebrate the beauty of all bodies.

On a closely related topic, I’m thrilled to see that Meredith Noble has a great list of body positive artists to follow.

Source

Baker, Cindy. 2013. “Aesthetic Priorities and Sociopolitical Concerns: The Fat Female Body in the Photography of Patricia Schwarz and Jennette Williams A Review of Patricia Schwarz: Women of Substance, by Patricia Schwarz, and The Bathers: Photography by Jennette Williams, by Jennette Williams.” Fat Studies 2 (1): 99–102. https://doi.org/10.1080/21604851.2012.709447.

Ten Facts About Weight Stigma – Guest post by Liliana Almeida, Ph.D.

 

  1. Weight Stigm [Image description: larger black woman holding towel that says "wide load"]
    Photo featuring plus-size model by Michael Poley of Poley Creative for AllGo, publisher of free stock photos featuring plus-size people.
    Weight stigma is a bias or discrimination relating directly to weight. Despite the fact that more than half of U.S. citizens are larger-bodied, our society holds a strong negative bias against fatness.
  2. The media reinforces weight stigma. The media, such as news media, displays persons in larger bodies in stigmatizing ways by depicting them sitting and eating unhealthy foods, wearing ill-fitting clothes, headless, or with their abdomens showing.
  3. Weight stigma is based on the belief that weight is under one’s personal control. This belief suggests that larger persons are undisciplined and inactive. However, when weight is attributed to uncontrollable factors such as diabetes or hypertension, people’s attitudes change. 
  4. Weight stigma exists in romantic relationships. Romantically, people in larger bodies are less preferred.  They are less preferred in comparison to those who are in wheelchairs, mentally ill, or those who have sexually transmitted diseases.
  5. Weight stigma starts as early as preschool.  Children ages 3-5 negatively characterize larger children as mean, ugly, stupid and sloppy. As children get older they start believing their larger peers are lazy, less popular, and less happy. College students report that their peers in larger bodies are lazy, self-indulgent, and less attractive, with low self-esteem and deserving less attractive partners.
  6. Teachers have a weight bias towards heavier students. They believe their larger students lack self-control and are less likely to succeed.
  7. Health professionals are also biased. Health professionals treating individuals with eating disorders report believing that larger patients do not comply with treatment recommendations and perceive poor treatment outcomes. Those strongly biased believe larger body sizes are the result of overeating and lack of motivation.
  8. Individuals in larger bodies have internalized stigma. The most common anti-fat bias among larger individuals is the belief that they are lazier and less motivated than thinner individuals. The failed attempts of individuals in larger bodies to lose weight may cause them to begin to internalize society’s beliefs that they are lazy and lack willpower.
  9. Weight stigma increases binge eating. Weight stigma causes psychological distress such as depression, anxiety, and low self-esteem. It is also associated with poor body image and increased fear of fat.
  10. Weight stigma experiences are as common as other forms of discrimination. In women, it is as common as racial discrimination. In some cases, it is more common than gender and age discrimination. 

References 

Ashmore, J.A., Friedman, K.E., Reichmann, S.K., &Musante, G.J. (2008). Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eating Behaviors, 9, 203-209.

Chen, Eunice & Brown, Molly. (2005). Obesity Stigma in Sexual Relationships.  Obesity Research, 13, 1393-1397.

Cramer, P., & Steinwart, T. (1998). Thin is good, fat is bad: How early does it begin? Journal of Applied Developmental Psychology, 19, 429-451.

Friedman, K., Reichmann, S., Costanzo, P., Zelli, A., Ashmore, J., & Musante, G. (2005). Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obesity Research, 13, 907–916.

Latner, J., Wilson, T., Jackson, M., & Stunkard, A. (2010). Greater history of weight-related stigmatizing experience is associated with greater weight loss in obesity treatment. Journal of Health Psychology, 14, 190-199.

Puhl, R., Andreyeva, T., & Brownell, K. (2008). Perceptions Of Weight Discrimination:Prevalence And Comparison To Race And Gender Discrimination In America. International Journal of Obesity, 992-1000.

Puhl, R., & Latner, J. D. (2007). Stigma, obesity, and the health of the nation’s children. Psychological Bulletin, 133, 557-580.

Puhl, R., Latner, J., King, K., & Luedicke, J. (2013). Weight bias among professionals treating eating disorders: attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders, 1-11.

Puhl, R., Lee Peterson, J., DePierre, J., & Luedicke, J. (2013). Headless, hungry, and unhealthy: A video content analysis of obese persons portrayed in online news. Journal of Health Communication, 1-17.

Stice, E., Presnell, K., & Spangler, D. (2002). Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psychology, 21, 131-138.

Tiggemann, M., & Wilson-Barrett, E. (1998). Children’s figure rating: relationship to self-esteem and negative stereotyping. International Journal of Eating Disorders, 23, 83-88.

Wang, S. S., Brownell, K. D., &Wadden, T. A. (2004). The influence of the stigma of obesity on overweight individuals. International Journal of Obesity, 28, 1333-1337.