People diagnosed with Avoidant Restrictive Food Intake Disorder (ARFID) struggle with consuming adequate nutritional intake due to either 1) fear of aversive consequences (i.e choking), 2) low interest in food altogether, or 3) sensory sensitivity to food textures, smells, or appearance. Usually, people with ARFID do not report refraining from eating due to fears of weight gain or efforts to lose weight. In fact, many people with ARFID welcome weight gain and want to expand their food variety.
The Impact of Diet Culture
The current Diagnostic and Statistical Manual (DSM-5) excludes those whose eating is restrictive due to shape and weight concerns from receiving a diagnosis of ARFID. However, this does not mean that people with ARFID are immune to the societal messages around food and bodies. Sadly, we all live in a world that is very much driven by diet culture. Most of us, with or without eating disorders, can be impacted by diet culture. We are constantly bombarded by many sources, ranging from the media to doctors’ messages about the danger of fatness and categorizing foods as healthy or unhealthy.
Dieting is one of the leading causes of eating disorders. According to a study by the National Eating Disorder Association, 35 percent of people who diet progress into pathological dieters. Of this 35 percent, up to 25 percent will develop a full-blown eating disorder. People with ARFID could develop another eating disorder, such as bulimia nervosa or anorexia nervosa at some point in their life.
People with ARFID already face the challenge of limited food choices and heightened anxiety around eating. They can be very vulnerable to messages that their preferred foods “aren’t healthy” or “junk food.” This can lead to even more anxiety and shame around their food choices. People with ARFID thus have to battle their disorder as well as the concerns that diet culture imposes around food and body size.
Dieting encourages us to ignore our bodies’ needs. Diet culture emphasizes that our worth is based on the size of our bodies. In Christy Harrison’s book, Anti-Diet, she calls it “the life thief.” And that’s what it does- it steals the joy out of fun events or the everyday activity because it convinces us we need to carefully balance everything we put in our body. And if we go off the diet or “cheat” we are made to feel bad and unworthy causing a vicious cycle of yo-yo dieting.
People with ARFID with whom we have worked report confusion around some of these messages, which clearly come from diet culture, and affected their ability to eat their preferred foods:
“Water is the only hydrating beverage and I should only be consuming water.”
“I was only offered wheat bread which I didn’t like so I didn’t eat bread.”
“I must eat vegetables in order to be healthy.”
“Fried foods are bad so I should limit my chicken nuggets and french fries.”
Standing up to Diet Culture
If you have a loved one struggling with ARFID it is recommended to check your own relationship with food and body image. Explore your own internalized fat phobia. Great books include The Body is Not an Apology by Sonja Renee Taylor and What We Don’t Talk About When We Talk About Fat by Aubrey Gordon. If you are worried about the types of food you or your child is eating because it is “unhealthy” check in on what you are really worried about. Is it truly about the nutritional value of the food or is there a belief that these particular foods can lead to being in a larger body? If the fear is being in a larger body then you have work to do. Learn about Health at Every Size® and recognize that the size of our bodies does not correlate to how healthy or unhealthy we are.
Remember, it is better to be fed than to be dead. If all you or your child can eat is chicken nuggets or french fries or potato chips or white bread (or all 4), then that’s what needs to show up at each meal and snack. You or they should have permission to eat preferred foods at every meal and snack without shame. With therapy, the goal is to incorporate more food groups and decrease fear and anxiety around novel foods. Realistically people who struggle with ARFID might never have the most expansive palette and that’s okay. If protein has to come from a package or be fried then that’s where the protein has to come from. Insisting that one food is better than another can make a person with ARFID feel ashamed, embarrassed, or more anxious about their food choices and further limit their eating. We never want to limit the food choices of people with ARFID beyond those limitations that the disorder causes. Choosing to feed yourself foods our culture considers “less healthy” rather than not eating is the best and dare I say–-healthiest choice there is.
When it comes to expanding variety and trying new foods we always have to start with what feels safe for the person with ARFID. While the goal might be to eat blueberries the first step might be eating blueberry muffins or chocolate-covered blueberries. The goals of treatment are to make meals less intimidating and have the patient feel like they can master trying new things. We don’t want to increase shame by disparaging their food choices.
We need to create peace, joy, and relaxation around meals. Labeling food “good” or “bad” or “healthy” or “unhealthy” can increase anxiety and discomfort. Patients may second guess their food choices or end up becoming even more limited in what they eat. A fat-phobic mindset can be intimidating. Taking a Health at Every Size ® approach will be as important as it is in the treatment of anorexia and bulimia. It is the safest approach to navigating the world of diet culture.
Let’s push back on diet culture and spread the message that all bodies are good bodies regardless of their size. We need to make the world safe for people in fat bodies and for those in thin bodies who are fearful of becoming fat. Ultimately, diet culture is not only harmful to people with other eating disorders but is also harmful to those with ARFID.
Groups at EDTLA
We have groups for adults with ARFID as well as parents of teens with ARFID. For more information, check our Groups page.
Eating disorders are not only about body image. Nor have they only recently arisen in response to societal pressures to be thin. In fact, eating disorders date back to at least the 13th and 14th centuries, when it was documented that women were fasting to demonstrate religious devotion. However, today eating disorders do occur in the context of a society obsessed with thinness, afraid of fatness, and permeated with diet culture. This makes recovery more difficult.
How Diet Culture Impacts Eating Disorders
There are probably no other mental disorders whose behaviors the culture admires and values as greatly as the eating disorders. People frequently praise people with restrictive eating disorders for their self-control and success at dieting or commitment to exercise. Imagine being praised for the symptoms of other disorders, such as excessive worry or the inability to get out of bed due to depression. When it becomes “normal” for everyday discussions to revolve around diet suggestions or the shame of eating tasty food, recovery becomes even harder.
Research on Weight Stigma
The focus on eradicating “obesity” leads to discrimination and stigmatization of people living in larger bodies. In turn, this stigma encourages numerous negative psychological and health consequences. Studies have shown that weight stigma increases unhealthy eating behaviors— including binge eating—and decreases participation in physical activity. Weight stigma also has been shown to lead to depression, stress, low self-esteem, and negative body image. In fact, many of the negative health consequences commonly attributed to greater weight are now believed to be exacerbated by weight stigma itself.
Research on Weight Loss
Most individuals are unable to maintain weight loss long-term. Only 3% of dieters maintained weight loss at 5 years according to one study (Anderson et al, 2001). Mann and colleagues (2007) found that one-third to two-thirds of dieters regained more weight than they initially lost on their diets and concluded there was “little support for the notion that diets lead to lasting weight loss or health benefits.”
Diet failure can also lead to weight cycling: alternating periods of weight loss and weight gain. Weight cycling has been shown to lead to psychological and health problems. In addition, it can lead to reduced metabolic energy expenditure, which makes regain more likely.
What is Health at Every Size®?
Health at Every Size® (HAES) is an approach to health that shifts the focus from weight to health. It is a philosophy that has emerged primarily since the late 1990s. It is promoted by the Association for Size Diversity and Health (ASDAH), which owns the phrase as a registered trademark.
The primary goal of HAES® is to promote healthy behaviors for people of all sizes. HAES® is grounded in five principles:
Weight Inclusivity: acceptance that bodies naturally come in a variety of shapes and sizes, and no size of body is inherently better than any other size of body.
Health Enhancement: the focus on health rather than weight and attendance to additional disparities that contribute to health including economic, social, spiritual, emotional, and physical factors.
Respectful Care: acknowledgment of weight bias and weight-based discrimination, and the commitment to work towards its end. This involves the adoption of an intersectional lens to understand different identities such as race, body size, gender, sexual identity, etc.
Eating for Well-Being: flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure—not external eating guidelines focused on weight control.
Life-Enhancing Movement: encouragement of enjoyable physical activities for people in a range of bodies with a range of abilities, to the extent that they wish to participate.
What Research is there in support of HAES®?
Several studies support the use of HAES® interventions. Individuals who received HAES®-based interventions had improvements in physiological, behavioral, and psychological measures. Subjects exhibited statistically and clinically-relevant improvements in blood pressure and blood cholesterol levels. They displayed increased physical activity and decreased eating disorder symptoms. Subjects also had increased self-esteem and body image and decreased anxiety and depression. They exhibited increased fruit and vegetable intake. No studies found any negative consequences associated with the HAES® interventions. Subjects who receive HAES® interventions seem to stay in their programs longer. This is promising, considering that patients in weight loss programs often drop out.
How Can a HAES® Approach Help With Eating Disorder Recovery?
Weight recovery is a prerequisite for recovery from anorexia nervosa. Aside from the necessity of restoring suppressed weight for individuals with eating disorders who are weight suppressed, the treatment of eating disorders should not aim to address weight issues. Weight loss has not proven effective for patients with binge eating disorder. There is growing evidence that individuals who try to lose weight and maintain a suppressed weight—that is, a weight lower than a previous higher weight—are at increased risk for binge eating disorder and bulimia nervosa. Individuals with bulimia nervosa who maintain a suppressed weight are less likely to fully recover. A persistent focus on limiting weight gain or losing weight can drive and maintain eating disorder behaviors. Research shows that continued focus on weight loss as a goal can lead to food and body preoccupation, eating disorders, weight stigma, and reduced self-esteem.
Conventional thinking suggests that feeling bad about one’s body would motivate behavioral changes that promote weight loss; in fact, the opposite is true. Feeling bad about one’s body drives more destructive behaviors. By contrast, body acceptance can help promote healthier behaviors.
The HAES® approach shifts the focus from the resolution of weight issues to the resolution of body discontent. It encourages you to accept your body’s “set point”: the weight to which your body tends to return when you don’t fixate on weight loss and instead respond to your body’s natural cues for hunger and fullness; the weight you to which you return between diets; and the weight you maintain without a lot of effort. This is the weight your body “wants to be.”
While a HAES® approach acknowledges a correlation between higher weights and certain medical conditions, it questions whether this relationship is purely causal. The data suggest that behavior change may play a greater role in health improvement than weight loss itself. We know that weight loss rarely works, and when it does, people lose only a modest amount of weight and maintain even less of it. Is weight loss just an occasional and incidental result of the health improvements driven by these behaviors, rather than an important end in itself?
Each body is different. Humans naturally come in all varieties of shapes and sizes. It can be hard to remember this in a world where the dolls with which our children play are all white and svelte and the protagonists in television and movies are also in conventionally attractive bodies. The shape and size of our bodies are largely determined by genetics, just as is the color of our eyes and skin. A HAES® approach allows you to trust your body to maintain the body size and shape that is right for YOU.
The HAES® approach advocates for intuitive eating—listening to and acting on internal hunger and satiety cues and preferences. Those in recovery who have previously allowed proscriptive external diet rules to drive their food decisions may be especially helped by the HAES approach. HAES also recommends pleasurable movement—exercising for the goal of pleasure rather than weight loss. Decoupling exercise from weight loss is challenging for many patients with eating disorders.
We can work with people in person in Los Angeles and virtually throughout the state of California seeking HAES-informed treatment.
How Can I Learn About HAES?
There are many ways to learn more about HAES. Check out the following resources.
The Problem With Poodle Science by The Association for Size Diversity and Health is an animated video exposing the limitations of current research on weight and health
Health at Every Size: The Surprising Truth About Your Weight, by Linda Bacon, PhD addresses weight myths and gives the science behind HAES.
Body Respect: What Conventional Health Books Leave Out, Get Wrong, or Just Plain Fail to Understand about Weight, by Linda Bacon, PhD, and Lucy Aphramor, PhD, RD includes the latest science on diets and health and why diets fail. It teaches how to adopt a HAES approach.
There are also many blogs and social media groups and accounts focused on Health at Every Size. Try searching for #HAES.
Anderson, J. W., Konz, E. C., Frederich, R. C., & Wood, C. L. (2001). Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr, 74(5), 579-584.
Bacon, Linda, and Lucy Aphramor. 2011. “Weight Science: Evaluating the Evidence for a Paradigm Shift.” Nutrition Journal 10 (January): 9.
Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol, 62(3), 220-233.
Penney, Tarra L., and Sara F. L. Kirk. 2015. “The Health at Every Size Paradigm and Obesity: Missing Empirical Evidence May Help Push the Reframing Obesity Debate Forward.” American Journal of Public Health 105 (5): e38-42.
Puhl, Rebecca M., and Chelsea A. Heuer. 2010. “Obesity Stigma: Important Considerations for Public Health.” American Journal of Public Health 100 (6): 1019–28.
Tylka, Tracy L., Rachel A. Annunziato, Deb Burgard, Sigrún Daníelsdóttir, Ellen Shuman, Chad Davis, and Rachel M. Calogero. 2014. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” Research article. 2014.
As we have written elsewhere, we believe Family-Based Treatment (FBT) is a complete treatment for teens with eating disorders. Most teens will not need (or want) additional therapy. The one area where we think teens could use a little more support is in developing a strong anti-diet stance to stand up to weight stigma in our fat-phobic society. Teens who are in family-based treatment may also not have any interaction with peers who are also working towards recovery. Community in recovery can be a powerful support if teens are motivated and working together.
To fill these potential gaps in FBT we have developed a group to supplement FBT and help put a strong anti-diet finish on the treatment. This group is for teens of all genders in California, ages 13 to 18, who are in Phase 2 of FBT and are weight recovered and abstinent from eating disorder behaviors. Teens who are not in treatment with us, but who show similar signs of recovery will be assessed for readiness for our group.
The group is 6 weeks and is held on Tuesdays from 5:00 to 6:15. The group aims to help teens in recovery develop connections and build a strong anti-diet HAES (R) stance. The group explores how media messaging, diet culture, and weight stigma impact body image through a Health at Every Size (R) -informed approach. Teens will be able to share and connect through discussion, art, and advocacy, all while developing strategies to promote empowerment and body acceptance.
Feedback from participants has been positive. Teens have shared that it has been helpful to connect with other teens who have shared the same struggles and support each other in standing up to diet culture. They have also found the educational component helpful and take away strategies to continue to support their recovery.
The group is led by Lauren Barker, LMFT who has a lot of experience with this population. Space is limited. This group is offered several times a year. Next projected start date is September 13th.
Pricing: $270 for 6 weeks. Or in-network for teens with Anthem, Aetna, Anthem medi-Cal, and Beacon Partners health insurance
To register or for more information, email Hello@EDTLA.com and put “teen girl group” in the subject line.
Many parents experience guilt when their teen is diagnosed with an eating disorder. Nearly every parent can point to a time they themselves dieted, opted not to have a dessert they really wanted, expressed a preference toward thinness, or discouraged their child from keeping eating. You may have done things to try to keep your teen’s weight down and you likely did it with love and good intention—to protect your child from weight stigma and perceived subsequent health and social consequences.
It is common to wonder whether such actions contributed to the development of your teen’s eating disorder. Guilt is common for parents to experience when their child has any illness. In the case of eating disorders, many of the behaviors that are part of the disorder are reinforced by our culture’s preference for thinness and so blame is even more compelling.
What is Diet Culture?
Diet culture is a system of beliefs that values thinness and promotes it as a way to increase one’s worth. It creates rules about what type of eating is “healthy” and oppresses people who don’t meet the thin ideal.
Diet culture messages are everywhere, so it’s not your fault that you’ve absorbed them and subscribed to these beliefs without ever thinking twice about them. Diet culture is the soup in which we all swim. It’s the dominant paradigm. You likely have heard fear-mongering messages from other health professionals. You see it in the news.
Why is this system of beliefs so dominant? It’s promoted by a $70 billion diet industry. It’s entrenched in our fatphobic healthcare system. It’s reinforced by the media.
Parents often become the unwitting messengers of the dominant cultural message they hear from other health professionals. But this is an important turning point. Now that you are helping your teen with an eating disorder, it’s time to question what you think you know about health and weight and eating. You were not born hating your body. You developed these beliefs and you can unlearn them. It is never too late to start unlearning and unsubscribing to diet culture. We want you to join us in helping to break down the institutions that reinforce fatphobia and contribute to the development and maintenance of eating disorders and make your teen’s recovery harder. Your teen needs you fighting for their liberation.
We believe that parents are important allies for their teens with eating disorders. Even if you have disparaged your own body, dieted, cheered when your teen started eating healthier, or encouraged them to exercise in the early development of their eating disorder, we want you to know that you are not to blame for your teen’s eating disorder. Please show yourself compassion. Your teen needs you.
Learn about how health is much broader than weight. Read the resources on our website about Health at Every Size ® to expose yourself to messages that challenge the weight-normative paradigm.
Stop talking critically about any body, including your own body and especially fat bodies. Model body appreciation and respect for all bodies and for body diversity.
Accept that your teen likely needs to gain weight and examine your fears about what that means for them and for you. Read our article on recovery weights.
Encourage your teen to see fat not as something to be feared. We don’t want to reinforce what the eating disorder is afraid of. We need to make it safe for people to be fat.
Curate your social media feed. The mainstream media images we see are not diverse, and the images we do see of larger bodies are often portrayed in a particularly negative and stigmatizing way, adding fuel to the fire. One way to build your own acceptance of body diversity is to acclimate to seeing a broader range of bodies portrayed in a desirable way.
Refrain from categorizing foods as healthy or unhealthy, good or bad. Model eating a variety of foods including foods you may have previously demonized, including desserts. Model eating with enjoyment and the social connection that comes from sharing meals.
If you previously promoted leaner, restrictive or “healthy” eating and are worried about creating confusion or appearing hypocritical with a new message around more flexible eating and more calorically dense foods, you can unapologetically explain to your teen that, in light of their eating disorder and what you are now learning, that you are also working towards a broader understanding of health and nutrition and becoming a more flexible eater. Some of the more powerful situations I’ve encountered include when a parent shares their own process in rethinking their relationship with food and their body while simultaneously doing their own work alongside their teen in recovery.
Teach your teen to think more critically about health and media messages they observe.
It’s never too late to change your thinking about weight and food. Many parents of teens who’ve had eating disorders have become great advocates for size diversity. Please join us in the anti-diet movement.
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 (Swenne et al., 2017). 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 (more on growth curves below). 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 and family medicine doctors 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.
Please be aware that some non-ED specialist pediatricians/health professionals 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.
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.” For further guidance on parenting kids in larger bodies we recommend this guide to parenting fat kids.
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.
This quote has generated a lot of reaction. In this podcast, Shira—who lives in a larger body when she is not using eating disorder behaviors—details how she has suffered from fatphobia in the world and in treatment centers. She shares that she has been significantly harmed by both well-meaning treatment providers and highly-regarded treatment centers.
This blog addresses two questions:
How is fatphobia affecting therapy and patients?
When is someone well enough to treat?
Shira is my friend and colleague. I regard her above quote to be a challenge to all treatment providers who have not faced their own fatphobia, including those who seemed afraid of Shira’s weight gain, tried to reassure her she was not gaining weight or would not gain weight, tried to help her keep her weight down, and limited her portions. These actions have harmed her by making her afraid to eat enough to sustain her healthy body weight and making her unable to fully recover after a 19-year history of an eating disorder.
Weight Stigma in Treatment
One incident Shira experienced in treatment was relayed to her friend, Sam Dylan Finch who described it in a blog post:
“The dietitian said, ‘You three get two scoops of ice cream.’ She then looked at me and said, ‘You’ll get a kiddie scoop.’”
Some of you won’t understand the gravity of that comment. To be clear, a dietitian told a patient with anorexia nervosa to eat less food than her peers, because she is a patient in a larger body.
The message here being, of course, that Shira needed to eat a child-sized portion of ice cream, because she wasn’t thin enough to “safely” consume more than that.
This plays directly into the eating disorder’s conviction that she needed to tightly control her food intake and her body. Her peers could eat a “normal” amount of ice cream. But she couldn’t and was singled out, because something was “wrong” with her body.
“This was the message I received my entire damn life,” Shira told me. “That I couldn’t eat like everyone else.”
— Sam Dylan Finch
The mixed messages of “eat ice cream” but “only a tiny serving” have further strengthened Shira’s eating disorder. The message treatment providers delivered over and over again was that her body needed to be controlled in order to avoid fatness. She yearned to be able to eat freely.
Shira also acknowledges that there were times in the past when she thought she was fully recovered. She only discovered years later after a relapse that what she thought was fully recovered was only partially recovered. How is this possible? Because we live in a culture where it is considered desirable and virtuous to maintain a low weight, deny ourselves tasty foods, limit the amount we eat, and exercise intensely. No other mental illness is so unfortunately reinforced by our cultural ideals.
And in terms of who is well enough to treat people with eating disorders, is recovery from one’s own eating disorder the only criterion that matters? How would we ever be able to vet that? How do we define recovery anyway?
I agree with Shira that there are many providers in the field who have not faced their own fatphobia. Focusing exclusively on providers who have had an eating disorder and whether or not they are recovered ignores a large portion of the provider community who do not have diagnosable eating disorders but may still be casualties of diet culture, wrestling with internalized weight stigma. These providers may be doing much more harm, but their impact has unfortunately received limited attention.
Providers With History of an Eating Disorder
Research indicates that a significant number of eating disorder treatment professionals have personally experienced an eating disorder. A study by De Vos and colleagues (2015) found that 24 to 47 percent of eating disorder clinicians reported a personal eating disorder history. An unpublished 2013 Academy for Eating Disorders online survey indicated that out of 482 respondents from professional eating disorder organizations, 262 (55%) reported a personal history of an eating disorder and half of those reported working directly with eating disorder patients. If we added subclinical eating disorders and disordered eating I have no doubt the rates would be higher.
Some have suggested over the years that providers with histories of eating disorders should never work in the field. This would be a mistake. Many professionals with their own personal histories (disclosed or not) have made major contributions to the field and to our understanding of eating disorders. Carolyn Costin, MEd, LMFT, CEDS and Mark Warren, MD, MPH, FAED are two public examples of prominent recovered professionals. In the broader field of psychology, one need only look at Marsha Linehan, Ph.D., who developed the leading evidence-based treatment for borderline personality disorder and other conditions based on her own experience of recovery from a severe mental illness to see that blanket restriction like this make no sense. In various surveys, patients have consistently reported it is helpful to work with providers who have had an eating disorder.
But even more complicated is the fact that we do not have a solid definition of recovery. In eating disorder research studies, recovery is often defined by three components:
Physical—BMI higher than 18.5 or another universal marker like expected goal weight;
Behavioral—absence of binge eating, vomiting, laxative use, or fasting; and
Cognitive—EDE-Q subscales about shape and weight concerns within 1 standard deviation of age-matched peers.
With dieting widespread (a 2018 study reported 36 percent of Americans were dieting), how many providers with disordered eating and their own extreme weight control behaviors go under the radar? How many providers may be engaging in their own intermittent fasting, keto diets, counting calories, or excessive exercise? I would agree with Shira that we should be equally if not more afraid of these providers.
Who is Fit to Treat Eating Disorder Patients?
If the field can’t decide who is recovered, who is to decide who is fit to treat eating disorder patients? Are therapists who acknowledge they have clinical eating disorders worse than fatphobic dieter providers who deny their own food issues and go on to shame patients, recommend any kind of dietary restriction, and limit the weight gain necessary for full recovery? How do we decide when someone is well enough to treat others?
The following quote from Carolyn Costin M.A., M.E.d., LMFT, FAED, CEDS and Alli Spotts-De Lazzer M.A., LMFT, LPCC, CEDS in their article for Gurze (2016), “To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder,” highlights an important point:
“Even if the field reaches its consensus on a definition of recovered—and then holds it up as the criteria for being able to be work with eating disorder patients—how would we verify a recovered status? Could standardized measuring and monitoring happen? When substance abuse facilities hire individuals who identify as recovering alcoholics or drug addicts, drug testing can verify if the person is considered clean and sober or ‘using.’ There is no similar test to determine if a person is ‘using’ his or her eating disorder symptoms. Some have suggested that therapists with personal eating disorder histories be subjected to clinical eating disorder assessments and ultrasound checks for ovarian size to determine if they are at a healthy weight (Wright & O’Toole, 2005). Without even discussing the actual merit of these as determining factors, would these tests be administered to all therapists who wish to work with eating disorders or just those who say they once had an eating disorder? And couldn’t those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?”
Costin and Spotts-De Lazzer go on to state, “It seems interesting and confusing that there could be so much proposed attention on therapists who have recovered from an eating disorder but not for therapists who have histories of depression, anxiety, post-traumatic stress disorder, or another diagnosis in their past.”
Perhaps we should be focusing on assessing providers for awareness of weight bias instead.
Further, if we shame Shira for being a provider with an eating disorder, how do we make it safe for other providers to acknowledge their own struggles and receive help if they have a lapse or relapse? Shira has reported that a significant number of providers have shared with her that they have struggled or are currently struggling. This says a lot.
So back to the question—how do we decide when someone is well enough to treat others?
I don’t have the answer to this question. The field has been unable to even define recovery.
Am I more afraid of fatphobic dieting therapists who may not be aware of their potential for harm than therapists who believe in and espouse Health At Every Size ® while acknowledging their own mental illnesses? Ultimately, yes, I am.
I think we need to look inward and address the rampant weight bias in the field. With dieting so widespread we have a lot of work to do. I believe everyone deserves treatment to full recovery and safety in their bodies. We need to address structural issues that limit access to care and safety. We need to make it safe for providers to receive help for eating disorders. I think it behooves every professional working with eating disorder patients to look at their own weight bias and work to practice from a weigh-inclusive approach. Only this way can we reduce the harm done to people like Shira.
Costin, C. & Spotts-De Lazzer (2016). To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder. Gurze Salucore, Eating Disorders Resource Catalogue.
Stych, A (2018). Percentage of Dieters More Than Doubles. Bizwomen: The Business Journals.
One of the cardinal rules of dieting is “Eat only when you’re hungry.” I often find that the fear of eating when not hungry is one of the most difficult bits of dogma to overcome. People with eating disorders and good dieters everywhere have been taught that this is all that stands in the way between us and complete loss of control and utter disaster in our lives. Many don’t even see it as an actual choice or symptom of the eating disorder.
Successful recovery from an eating disorder or disordered eating or chronic dieting requires overcoming and challenging this rule.
Just off the top of my head, I can think of a lot of reasons to eat when not hungry. Here are a few related to disordered eating:
You have overridden your hunger cues for years from cycles of dieting, bingeing and purging. You don’t recognize normal hunger cues or satiety. Your treatment team has told you to eat regularly—three meals and two to three snacks per day. You feel like it is too much food and you’re not hungry. Should you follow their meal plan? Yes! Eating regularly is a crucial step in recovering from any eating disorder and it helps to regulate your hormones and circadian rhythms so you can regain your hunger and satiety cues and become a more intuitive eater.
You are in recovery from a restrictive eating disorder and rarely feel hunger. You are told you need to eat more, but you don’t believe it. Isn’t it better to delay eating until later in the day? Should you really eat breakfast and lunch at the times scheduled by your dietitian? Yes, absolutely! Regular meals are critical to getting all of your body functions to work properly again. One of the reasons you may not be feeling adequate hunger could be delayed gastric emptying, which occurs when someone is undereating and food remains in the stomach far longer than it should. One of the consequences is low appetite. The solution: eat regularly as prescribed, even if you’re not hungry.
I can think of many more situations that apply to all of us, not just those with eating disorders:
You normally eat dinner at 7 pm and your circadian rhythm is conditioned to get hungry then. But your sister has scheduled a family dinner at 5:30 to accommodate her children so they won’t be cranky at the table. Should you eat at 5:30 before you are hungry? Absolutely! Adjusting our schedules allows us to have meaningful social interactions that typically revolve around eating.
You have a meeting that is scheduled from 12 to 3 pm. You’re not hungry at 11 am; breakfast was only at 8:30. You have the option to have a proper lunch at 11:30. Should you? Of course! Be practical—it’s better to eat before your meeting. Then you’ll be properly fueled and will be better able to concentrate during the meeting. Our brains don’t function as well when they’re low on glucose. Planning ahead and adjusting mealtimes accordingly is an important act of self-care.
You are traveling to another country. You arrive at your destination and it’s dinnertime. Your circadian rhythms are all thrown off. You feel like you’ve been eating constantly. Should you eat? Yes! Acclimation to a new time zone is ushered along by institution of regular eating at the times appropriate to the destination. You will adjust faster if you get your body in synch.
You just had a rough breakup. You’re eating meals, but sad. Your friends show up and want to take you out for ice cream to cheer you up. You’re not hungry. Should you go and eat ice cream with your friends? Absolutely! Food is not solely about nutrition – it’s also about bonding and comfort, and you should let the ice cream and your friends soothe your broken heart.
You’re stressed and preparing for a presentation tomorrow. You’ve eaten adequately throughout the day and are not truly hungry. But you know that crunching on some popcorn will soothe your nerves. This is an old behavior that you’ve overused in the past. Contrary to popular belief, emotional eating is not itself a problem. Food is our earliest comfort and humans are designed to find food to be rewarding. If it were not, we would have died out as a species. There is no shame in using food as comfort—what can be problematic is if there are no other tools in your emotional toolkit. If eating is your only coping skill then I encourage you to learn some other strategies for managing negative emotions to give you a broader range of alternatives.
So, not eating when you’re not hungry is a rule that should be confronted. How can you start to challenge this rule and, if you have one, the eating disorder that uses it as an excuse?
You must face it head-on with new behaviors, deliberately defying it. If you have been instructed to follow a meal plan: follow it. If you have been told you are undereating: practice eating one thing per day when you are not hungry. The next time you have something in your schedule that interferes with a normal meal time: eat beforehand. Accept invitations to eat at times to which you are unaccustomed. Eat something spontaneously when it shows up, even if you are not hungry.
By practicing these behaviors, you will become less fearful of eating when not hungry. You will learn that this, too, is a normal part of being a human. You will be more relaxed around food and you will see that nothing horrible happens if you eat when you’re not hungry. You do not have to continue to be a victim of diet culture.
Food for us comes from our relatives, whether they have wings or fins or roots. That is how we consider food. Food has a culture. It has a history. It has a story. It has relationships. –– Winona Laduke
Food is about more than sustenance. It is about pleasure and joy and connection. Food is one of the ways we connect with our cultural traditions and our ancestors. This is one of the reasons I am so passionate about my work to help people with eating disorders. When someone has an eating disorder and they are fearful of eating or of eating certain foods, they miss out on the pleasures of food and they miss out on the opportunities to connect with others through food. They also miss out on their own connection with their relatives and their cultural heritage.
In my own family, my 103-year-old Nana has always been known for her piano playing and her delicious poundcake. While her prized Steinway piano now stands in my home, I did not inherit her piano-playing her abilities. I did, however, learn her poundcake recipe.
From the time I was a young girl, I have memories of “Nana’s poundcake.” Simple to make with only 5 ingredients, buttery and yummy. During visits to Kansas City, I looked forward to making it with her. And when she visited us in New York we would make it together. And, occasionally my mom and I would make it without Nana. My kids have had the experience of making poundcake with my Nana, their great grandmother. And they have made it with me. After she eventually passes, we will retain this connection to my Nana and my kids will hopefully continue to make and share her recipe with future generations.
Photos of my daughters making poundcake with Nana back in 2012 at her apartment (she was 96)
I am glad to have this connection to Nana and to be able to fully enjoy making and eating poundcake with all its rich butter and sugar. What joy and connection I would be missing out on if I were afraid of eating it. To be able to make it and eat it with enjoyment enriches my life and allows me to have a shared experience through four generations of my family. I will always have joyful memories of baking and eating poundcake with the different generations in my family.
Bonus Feature — Nana’s Poundcake Recipe
1/2 pound salted butter (2 sticks) – softened
1 3/4 cup sugar
2 cups sifted flour
2 T vanilla
Cream butter and sugar
Add eggs one at a time while beating constantly
Add flour and flavoring
Pour into well-greased loaf pan (or bundt pan)
Bake at 350° for 90 minutes
Photos from a poundcake I made with my daughter in 2019.
“Body positivity can’t be just about thin, straight, cisgendered, white women who became comfortable with an additional ten pounds on their frame.” —Stacey Rosenfeld, Ph.D., Shape magazine (July, 2018).
Eating disorders are about so much more than body image, but the current diet culture, idealization of the thin ideal, and “war on obesity” make it much harder for people with eating disorders to recover. We are barraged on a daily basis by media images of people who represent only a small portion of the population.
As Dr. Muhlheim discussed in a previous post about fat photography, the mainstream media images we see are not diverse, and the images we do see of larger bodies are often portrayed in a particularly negative and stigmatizing way, adding fuel to the fire.
Thus, an important exercise for people of all sizes in recovery is to curate their social media feed by removing accounts that perpetuate the thin ideal and expand the range of body sizes and types to which one is exposed. Adding diversity to your social media feed isn’t only important for people in recovery, it can be just as important for partners as Sarah Thompson wrote about here. It would even be useful for parents and family members of those recovering.
The term used to describe the absence of representation in media was coined by George Gerbner in 1972. This phenomenon is “symbolic annihilation.” Gerbner was a Hungarian Jewish immigrant and communications professor who researched the influence of television trends on viewers’ perceptions of the world. According to Coleman and Yochim, Gerbner explained that “representation in the fictional world signifies social existence; absence means symbolic annihilation.” Representations, or lack thereof, lead to assumptions about how the world works and who holds power.
Gerbner did not assign symbolic annihilation to any particular group, so it has since been applied to many different identities. We can apply the concept to non-dominant systemic identities, such as larger bodied people, people of color, trans and gender-expansive people, disabled people, etc. If we don’t see bodies like our own represented, we may come to believe “my body doesn’t matter”. Often, this can turn into “I don’t matter”. This means that for people whose bodies are marginalized in any way, it is essential to see images of people that look like them.
We have developed a roundup of Instagram accounts to help you on the journey. While it is not comprehensive, it is a starting point. What follows are some Instagram accounts that show body-positive images that celebrate diverse bodies in ways that mainstream media does not.
At the time of this posting, these accounts are free of body shaming, fat shaming, food shaming, and disordered eating. Some are people in recovery from eating disorders. If we missed one of your favorite accounts that consistently publishes photos of bodies at the margins, please email us and let us know!
People of color
Gender diverse people
People with disabilities
Other body positive accounts to follow
Coleman and Yochim. The Symbolic Annihilation of Race: A Review of the “Blackness” Literature. Perspectives. Spring 2008. http://www.rcgd.isr.umich.edu/prba/perspectives/spring%202008/Means%20Coleman-Yochim.pdf
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.
A blog post by The Militant Baker with some photos
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.
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.