Eating disorders and weight stigma

Not all eating disorders develop from wanting to lose weight/dieting, but dieting is a significant risk factor for developing an eating disorder. Weight stigma affects everyone, just in different ways and to different extents. Even if a person doesn’t have an eating disorder based on trying to lose weight, their access to treatment is based on a system embedded in biases and assumptions based on body size and heavily reliant on BMI (body mass index).

The BMI scale

NHS eating disorder treatment in the UK has limited funding and resources, and many people report being told they’re “not thin enough” for help (see Hope Virgo’s campaign “Dump the Scales”). The BMI chart is relied upon, despite the NICE guidelines stating not to use BMI to diagnose an eating disorder or to make treatment decisions. It seems that healthcare professionals are pushed into a place of using BMI to decide who gets treatment (in restrictive eating disorders, mainly anorexia) because there’s only enough space for the sickest people to get help. What that means is they’re waiting for someone’s eating disorder to get worse, sometimes to the point of serious medical complications, before they can get help. This is reactionary and generally just unhelpful, to say the least.

The BMI scale was made in the 1830s by a mathematician and astronomer who based it on mainly European men – it was for general statistics, not a measure of individual health. So I think we can safely say that it isn’t the best thing to be basing any kind of decisions/treatment on. When you add weight bias and eating disorder stereotypes (of people with anorexia being thin, white, young, female etc) this only makes the situation a whole lot worse.

Weight bias

Many of us have grown up in a world that says thin equals beautiful, happy and successful. Health professions, GPs, therapists etc – as well as policymakers and people in charge – have grown up with this too. Diet culture is the norm, thin is good and fat is bad, and “health” is a moral value. It’s quite a challenge to start unpicking these ideals, especially when they are ingrained from childhood, which for myself and many of my clients, was very much the case.

We all have biases, even I as a person in a larger body had biases and assumptions about fat people. I thought, from a very young age, that fat was the worst thing you could be. This impacted my self-esteem, my eating, my body image and my identity, and took many years of learning and therapy to start changing that and healing.

Counselling training often involves having a lot of personal counselling and doing a lot of reflection, which is so important for being able to work with our own biases, assumptions and prejudices. Medical professionals may not have experienced the same in their training so this can lead to medical weight stigma. I have experienced this myself and heard hundreds of accounts of people harmed by assumptions and judgements made by medical practitioners.

GP’s only have a couple of hours of training on eating disorders, so there’s a risk eating disorders may be overlooked and missed. A common example of this is when a person who is not thin presents with eating problems. An unexamined view, holding weight biases, may assume the person can’t have a restrictive eating disorder because they are not thin. Or if the person is in a larger body it may be assumed they have binge eating disorder. This is absolutely not the case as anyone of any size can have any kind of eating distress. A body size is not an indicator of an eating disorder, this is why it’s imperative for professionals to have done this personal reflective work.

Eating disorders are deeply entwined with cultural and social ideas so we can all play a part in helping prevent them. This “othering” of eating disorders, seeing them as the opposite of ob*sity (they’re not) and disconnecting them from the normalised diet culture and fatphobic society we live in is not helping. Disordered eating is so normal in our society, many people likely wouldn’t necessarily recognise themselves as having difficulties with food.

Bullying and shame

For people who have body image or eating issues due to trying to lose weight, many will have experienced bullying or abuse about their size or appearance. They may have encountered teachers, health professionals and other authority figures using shaming approaches to encourage weight loss. When kids were mean to me at school I could try to shrug it off, but when adults and health professionals told me I had to lose weight, I had to do what I was told. It led to me trying to diet from a young age, trying to restrict my food, hating my body and blaming myself for being too fat.

People can often be well-meaning with their comments about dieting or weight loss. Maybe they’re just saying what they think is expected of them, making a joke or genuinely trying to help people feel better about themselves. However, this just reinforces diet culture and the idea that “thin is good”. Attempting to change our bodies to make ourselves feel better or happier is only a surface-level, short-term solution. Instead of changing our bodies, it’s about changing the way we think about our bodies. That’s why body image and eating problems should all be part of a broader mental health conversation.

Fatphobia

The root of many eating disorders, by definition, is a fear of fatness (otherwise known as fatphobia). We are told we have an “obesity epidemic” whilst we in fact have a huge mental health crisis going on. Many attempts to help the “obesity crisis” so far have been based on shaming and stigmatizing approaches (mainly involving blaming individuals and making people feel bad about themselves) and it’s causing more harm than good. The focus needs to be on mental health and relationships with food. I firmly believe that eating disorders are a much bigger issue than we see on the surface.

There are so many people who face barriers to help due to:

• Not recognising they have an eating disorder.
• Thinking they’re “too fat” to have an eating disorder.
• Not being able to access treatment due to stigma, shame, cultural or religious beliefs, family pressures etc.
• Not being able to access services due to rigid treatment plans and not enough adaptability and inclusion for neurodivergent people.
• Not being able to access treatment because they’re “not thin enough”.
• Not being able to access treatment because healthcare professionals prescribe weight loss instead of recognising an eating disorder.
• Lack of services that can support people with eating disorders with disabilities, autism, diabetes, or any other aspects which co-exist and often exacerbate the eating disorder.

The list could go on. If we really knew the full scale of eating disorders, disordered eating and difficult relationships with food, we’d see the real epidemic.

What can we do

If you feel you’re struggling with any kind of body image or food-related problem, know that you can ask for help, even if you don’t think it’s serious or you don’t think it’s an eating disorder. Any kind of anxiety or distress around food/body is important and you are deserving of help. For people in larger bodies especially – no body shape or size is more deserving of help, so go and take what you deserve!

For professionals, it’d be helpful if you’d spend some time considering your own relationship with your body and your views of others. Learn about weight stigma and eating disorders, and consider your own experiences growing up and the narratives you heard about thinness, fatness and eating. Think about the rules you had around food (e.g. at the dinner table) and the way larger people have been treated at school, in workplaces and in everyday life.

To everyone: consider shaking up your social media feeds – unfollow anyone who promotes dieting or thin ideals and follow diverse people instead. We need to hear more from people who are not the standard “norm” (mainly thin and white) to widen our views of the world and perceptions. We must challenge the norms, the ideals and the stereotypes.

Thanks for reading. Here are some resources which might be helpful:

• First Steps ED – eating disorder charity
• NEDDE – eating disorder training for professionals