Dr. Katherine Hill is a board-certified pediatrician who completed her undergraduate, MD degree, and pediatric residency at Stanford. Prior to Equip, she was a Clinical Assistant Professor of Adolescent Medicine at Stanford, caring for adolescents with eating disorders in the inpatient and outpatient settings. A former collegiate swimmer, her research has focused on eating disorders in athletes.  

Francisco* (not a real patient) is a 17-year-old larger bodied male who recently learned he was “overweight” at a recent visit with his primary care doctor. His doctor, with good intentions, recommends that he start “eating better and exercising”. For his health, Francisco cuts out sugar and processed food, starts exercising 30 minutes a day, and begins losing weight. Soon, Francisco’s friends and parents are complimenting him on his weight loss. So Francisco decides to cut out dairy, gluten, and meat, and increases his exercise to 2 hours a day. Within two months, he has lost 50 pounds and is down to a “normal” weight. But he feels terrible. He has no energy, is dizzy when he stands up, and his mental health is suffering. All he seems to be able to think about is food, weight, or exercise, but he keeps hearing, “Wow, you look great!” from all the people who love him, including his doctor. Francisco’s weight loss stalls, so he resorts to purging after meals. In a gym class at school, he passes out and has to go to the emergency room. He is found to have a heart rate in the 30s (about half of what a normal heart rate is), and dangerously low levels of potassium in his blood. He is admitted to the hospital, and told that if he doesn’t gain weight, he might die. When he shares with his best friend that he is hospitalized with malnutrition and an eating disorder, his best friend asks, “How can you have an eating disorder? Don’t you have to be a thin white girl to have an eating disorder?” 

Understandably, Francisco is very confused and has many questions. Didn’t I do what my doctor suggested? How can my best friend be thinner than me and not have to be hospitalized? Why do my doctors just want to make me gain weight again when I was told my body wasn’t “right” before? And how can I have an eating disorder if I’m not a thin white girl?

Unfortunately, though this is a fictional patient, Francisco’s scenario is all too common. What started with good intentions at the recommendation of a physician, ended in a near-death situation. Francisco will need an experienced and compassionate team of providers, like the ones we offer here at Equip, to help his body and mind stabilize and recover from his eating disorder.

In honor of Weight Stigma Awareness Week and people like Francisco, I wanted to focus on a very common misconception about eating disorders -- that one must be thin to have an eating disorder. Unfortunately, this myth runs rampant, even amongst the medical community. The truth is, you can’t tell by looking at someone if they have an eating disorder. 

Eating disorders are more likely to be missed in larger bodied individuals. The longer a diagnosis is missed and treatment is delayed, the more likely they are to end up sicker and higher risk when they do finally present to care. Regardless of the starting weight, if patients lose too much weight too quickly, then they can have serious medical and psychological consequences (1). 

Compared to their thinner counterparts, larger-bodied individuals frequently lose huge amounts of weight before presenting to care. And studies show that the bigger the difference between starting and ending weight after weight loss, the more severe the eating disorder symptoms tend to be (2). Like with Fransisco, too-rapid weight loss not only leads to dangerous physical changes affecting virtually every organ system, but also is associated with worsening of disordered eating behaviors and obsessive thoughts surrounding food, exercise, and weight. A malnourished body and brain tend to behave this way no matter what the individual’s body size

In the past, a patient had to be low weight to receive a diagnosis of anorexia nervosa. Thankfully, that is no longer the case, as the latest medical research and clinical experience show that people of all sizes can suffer the exact same deleterious consequences of eating disorders. 

Another related myth is that all eating disorders lead to weight loss. In fact, binge eating disorder, which is not associated with weight loss, is the most common eating disorder in the US. During tough times like these, it is also important to recognize that lower income individuals facing food insecurity may be at increased risk of disordered eating behaviors, yet much less likely to have access to quality treatment (3). 

Eating disorders, it turns out, aren’t limited to thin, rich, white, straight teen females. People struggling with eating disorders come in virtually every shape, size, body type, socioeconomic status, ethnicity, gender, age, and sexuality. At Equip, we aim to increase access to evidence-based eating disorder treatment to all individuals, no matter which categories they fall into. And we owe it to patients like Francisco to raise awareness that (repeat after me) you can’t tell by looking at someone if they have an eating disorder.

Sources:

  1. Garber, Andrea, Cheng, Jing, Accurso, Erin, Adams, Sally, Buckelew, Sara, Kapphahn, Cynthia, Kreiter, Anna, Le Grange, Daniel, Machen, Vanessa, Moscicki, Anna-Barbara, Saffran, Kristina, Sy, Allyson, Wilson, Leslie, Golden, Neville. Weight Loss and Illness Severity in Adolescents With Atypical Anorexia Nervosa. Pediatrics. Dec 2019, 144 (6) e20192339; DOI: 10.1542/peds.2019-2339
  2. Berner, Laura, Tronieri, Jena, Witt, Ashley, Lowe, Michael. (2013). The Relation of Weight Suppression and Body Mass Index to Symptomatology and Treatment Response in Anorexia Nervosa. Journal of abnormal psychology. 122. 694-708. 10.1037/a0033930. 
  3. Becker, Carolyn, Middlemass, Keesha, Taylor, Brigitte, Johnson, Clara, & Gomez, Francesca. (2017). Food insecurity and eating disorder pathology. The International journal of eating disorders. 50. 10.1002/eat.22735.