Internet Editor’s Note: Laurie Veillette and colleagues published an article titled “What’s weight got to do with it? Mental health trainees’ perceptions of a client with anorexia nervosa symptoms” in Frontiers in Psychology. The article is open access and is available here.
Weight stigma, or unfavorable attitudes and beliefs about people of a higher body-weight, is ubiquitous in society, as well as mental health settings (Puhl & Heuer, 2009). Stigma associated with high body-weight shares many similarities with stigma related to disordered eating behaviors, such as the perception that both are indicative of a flawed disposition or temperament (Goffman, 1963; Puhl & Suh, 2015). In mental health settings, stigma can have a profound impact on case conceptualization, treatment expectations, the personal impressions of mental health providers, and general clinical care (Phelan et al., 2015; Puhl & Heuer, 2010). This is concerning given research findings that indicate that people of a higher body-weight are more at risk of developing eating disorders than people of normal and low body-weights (Darby, Hay, Mond, Rodgers, & Owen, 2007; Lebow, Sim, & Kransdorf, 2015; Neumark-Sztainer, Paxton, Hannan, Haines, & Story, 2006; Sim, Lebow, & Billings, 2013). As a result, symptoms of disordered eating behaviors exhibited or reported by people of a high body-weight may be misdiagnosed or misinterpreted by mental health providers which, in turn, can significantly disrupt the quality and type of care provided (Lebow et al., 2015; Phelan et al., 2015; Puhl & Heuer, 2010; Sim et al., 2013).
This is depicted by Harrop (2018), who describes her experiences in an inpatient eating disorder treatment setting:
Though I presented with the same behavioral, emotional, and cognitive symptoms of severe anorexia during two separate inpatient hospitalizations, I experienced radically different treatment from providers when I presented as an emaciated, typical anorexia patient and when I presented as a starving, fat-identified, atypical anorexia patient years later (p. 2).
Weight Bias Influences Perceptions of Clients with Eating Disorders
Our study examined the impact of client body mass index (BMI) on the diagnostic impressions and perceptions of mental health trainees. Participants read a clinical vignette in which a hypothetical female client presented with symptoms of anorexia nervosa, and was described as “underweight,” “normal weight,” or “overweight” based on BMI. As expected, client body-weight impacted diagnosis, treatment recommendations, and stereotypical perceptions of the client. Participants were less likely to assign a diagnosis of anorexia nervosa or atypical anorexia nervosa to the higher-weight client. Furthermore, participants recommended fewer treatment sessions and assigned more weight-based stereotypical traits when the client was described as “overweight.”
Our study lends support to existing literature that demonstrates the prevalence of weight stigma in mental health care, treatment, and the perceptions of mental health professionals. It is the first of its kind to demonstrate the effect of client body weight on conceptualization and treatment of restrictive eating disorders. The findings reveal how weight bias, and the emphasis placed on weight for eating disorder diagnosis, can serve as a barrier to appropriate psychological care for a serious mental health disorder. Furthermore, these findings support initiatives aimed at providing training on weight stigma and eating disorders to mental health trainees and professionals.
Based upon our findings and the work of additional researchers and clinicians that demonstrate the impact of weight bias in treatment for eating disorders and psychological care more generally, we recommend that mental health professionals:
- Avoid BMI as a criterion for eating disorder diagnosis or recovery. Weight status is not an accurate indicator of an eating disorder. Anorexia nervosa may present in bodies of all shapes and sizes, as may bulimia nervosa, binge eating disorder, and other eating disorders (Burgard, 2017).
- Gain understanding of diverse presentations of a range of eating disorders, including atypical presentations, and the presentation of eating disorders in bodies of different sizes. It is well understood that anorexia nervosa is a serious mental disorder because of health complications and mortality risk. Research demonstrates, however, that atypical eating disorder presentations have similar, elevated mortality risks as those found with anorexia nervosa and bulimia nervosa (Crow et al., 2009). Atypical anorexia nervosa presentations because of higher weight status also exhibit similar, serious profiles as typical anorexia nervosa presentations regarding life-threatening complications due to malnutrition (Peebles et al., 2010; Whitelaw et al., 2014).
- Consider the potential impact of client body size on clinical and diagnostic impressions, assessment, and perceptions of pathology. For example, Harrop (2018) describes how she was put on a restricted calorie diet during inpatient treatment for atypical anorexia, while her thinner peers were following high calorie meal plans. This differential treatment due to weight stigma had a number of negative consequences, including further entrenchment of weight bias internalization, encouragement of weight-based bullying from peers and staff, and delayed and disrupted eating disorder treatment.
- Reflect on and acknowledge beliefs and attitudes toward people of a higher body-weight, and challenge sizeist or prejudiced assumptions. This can be done through honest self-reflection and the use of tools like the Implicit Association Test (Project Implicit, 2011), Anti-fat Attitudes Questionnaire (Crandall, 1994; Quinn & Crocker, 1999), Attitudes toward Obese Patients scale (Puhl, Luedicke, & Grilo, 2014), and Fat Phobia Scale (Bacon, Scheltema, & Robinson, 2001).
- Educate themselves on critical weight science. Contrary to popular thought, research demonstrates that BMI is a weak predictor of mortality, dieting is not effective for long-term weight loss, and individual behavioral efforts to lose weight are more harmful than helpful for the vast majority of people (Bacon & Aphramor, 2011).
- Adopt a weight-inclusive approach to psychological care that recognizes the fundamental right to be fat (Calogero, Tylka, Mensinger, Meadows, & Daníelsdóttir, 2018). This approach recognizes that body diversity is natural, that weight bias is a social justice issue, that weight and health are not the same, and that psychological care should do no harm and should benefit people regardless of their weight.
Cite This Article
Veillette, L. A. S., Serrano, J. M., & Brochu, P. M. (July, 2019). 6 recommendations to reduce weight stigma and discrimination in eating disorder treatment. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/6-recommendations-to-reduce-weight-stigma-and-discrimination-in-eating-disorder-treatment
Bacon, J. G., Scheltema, K. E., & Robinson, B. E. (2001). Fat Phobia Scale revisited: The short form. International Journal of Obesity, 25, 252-257. doi:10.1038/sj.ijo.0801537
Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10(9). doi:10.1186/1475-2891-10-9
Burgard, D. (2017, November 1). The obsession with thinness is keeping us trapped in a senseless loop. Life. Unrestricted. Audio podcast retrieved from https://www.lifeunrestricted.org/lu066/
Calogero, R. M., Tylka, R. L., Mensinger, J. L., Meadows, A., & Daníelsdóttir, S. (2018). Recognizing the fundamental right to be fat: A weight-inclusive approach to size acceptance and healing from sizeism. Women & Therapy. doi:10.1080/02703149.2018.1524067
Crandall, C.S. (1994). Prejudice against fat people: Ideology and self-interest. Journal of Personality and Social Psychology, 66, 882-894. doi:10.1037/0022-35220.127.116.112
Crow, S. J., Peterson, C. B., Swanson, S. A., Raymond, N. C., Specker, S., Eckert, E. D., & Mitchell, J. E. (2009). Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry, 166, 1342-1346. doi:10.1176/appi.ajp.2009.09020247
Darby, A., Hay, P., Mond, J., Rodgers, B., & Owen, C. (2007). Disordered eating behaviours and cognitions in young women with obesity: Relationship with psychological status. International Journal of Obesity, 31(5), 8766-8882. doi:10.1038/sj.ijo.0803501
Goffman, E. (1963). Stigma: Notes on a spoiled identity. Englewood Cliffs, NJ: Prentice Hall.
Harrop, E. N. (2018). Typical-atypical interactions: One patient’s experience of weight bias in an inpatient eating disorder treatment setting. Women & Therapy. doi:10.1080/02703149.2018.1524068
Lebow, J., Sim, L. A., & Kransdorf, L. N. (2015). Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders. Journal of Adolescent Health, 56(1), 19-24. doi:10.1016/j.jadohealth.2014.06.005
Neumark-Sztainer, D., Paxton, S. J., Hannan, P. J., Haines, J., & Story, M. (2006). Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health, 39(2), 244-251. doi:10.1016/j.jadohealth.2005.12.001
Peebles, R., Hardy, K. K., Wilson, J. L., and Lock, J. D. (2010). Are diagnostic criteria for eating disorders markers of medical severity? Pediatrics 125, e1193–e1201. doi:10.1542/peds.2008-17777
Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for clients with obesity. Obesity Reviews, 16, 319–326. doi:10.1111/obr.12266
Project Implicit (2011). Preliminary information. Retrieved from https://implicit.harvard.edu/implicit/takeatest.html
Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: A review and update. Obesity, 17(5), 941-964. doi:10.1038/oby.2008.636
Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: Important considerations for public health. American Journal of Public Health, 100(6), 1019-1028. doi:10.2105/AJPH.2009.159491
Puhl, R. M., Luedicke, J., & Grilo, C. M. (2014). Obesity bias in training: Attitudes, beliefs, and observations among advanced trainees in professional health disciplines. Obesity, 22(4), 1008-1015. doi:10.1002/oby.20637
Puhl, R. M., & Suh, Y. (2015). Stigma and eating and weight disorders. Current Psychiatry Reports, 17, 10. doi:10.1007/s11920-015-0552-6
Quinn, D. M., & Crocker, J. (1999). When ideology hurts: Effects of belief in the Protestant ethic and feeling overweight on the psychological well-being of women. Journal of Personality and Social Psychology, 77(2), 402-414. doi:10.1037/0022-3518.104.22.1682
Sim, L. A., Lebow, J., & Billings, M. (2013). Eating disorders in adolescents with a history of obesity. Pediatrics, 132(4), 1026-1030. doi:10.1542/peds.2012-3940
Whitelaw, M., Gilbertson, H., Lee, K., and Sawyer, S. M. (2014). Restrictive eating disorders among adolescent inpatients. Pediatrics, 134, e758–e764. doi:10.1542/peds.2014-0070