The guideline from Australia includes suggestions for psychological approaches for adults and younger patients.

An Australian research group tasked with producing a clinical guideline for people with eating disorders who have higher weights has produced a number of suggestions and guidelines (J Eat Disord. 2022.10:121). The group, which offered 21 recommendations, also worked with individuals with lived experiences of higher weights and weight bullying.

Although anorexia nervosa (AN) receives the most attention, the most common eating disorders are binge eating disorder (BED), other specified feeding or eating disorders (OSFED), and bulimia nervosa (BN). All can occur in people with a wide range of body types, including those with higher weights.

Dr. Angelique F. Ralph, of the National Eating Disorders Collaboration, Sydney, Australia, and the School of Psychiatry at La Trobe University, Wodonga, Australia, and her colleagues noted that people with higher weights often report misdiagnosis, dismissal by health professionals, and being sidelined or excluded from eating disorder treatment services. This population is also often absent from eating disorders research–with the exception of those with BED. Moreover, the researchers added that people who are at a higher weight are at greater risk of adverse experiences such as bullying and weight‑related victimization from peers, friends, parents and teachers than from their peers at lower weights.

Psychological approaches

The researchers recommend using standard cognitive behavioral therapy (CBT) for an eating disorder or therapist-guided self-help as first-line treatment for adults with BN or BED. Other psychological treatments with evidence-based approaches, such as interpersonal therapy (IPT) and dialectical behavior therapy (DBT), should be considered as second-line therapy in adults with BN or BED. The group also recommended therapies using non-dieting principles and interventions to reduce disordered eating.

Therapist-guided self-help should be considered as first-line treatment in adults with BN or BED. For children and adolescents with BN or BED, the group recommends using family-based treatment first. Then, adolescent-based therapy (AFT) and CBT are second-line options for these younger patients. The authors also recommended that clinicians working with BN and BED patients with weight issues consider using psychotropic medications, and to monitor these patients for any nonprescribed use of medications. Also, physical activity should focus on positive physical and mental benefits and away from use for weight or changing shape.

Special approaches for males with BN and BED

The report also singled out male BN and BED patients. Compared to women, men more often have higher weights, and more often have experienced weight-related bullying. Weight gain also happens later among males.

Another challenge for men is that health professionals are also less likely to offer them treatment. Compared with women, men are more likely to have a history of higher weight prior to the onset of their eating disorder, accompanied by weight-related bullying (Int J Eat Disord. 2019. 52:497). Added to the weight stigma associated with having a “female” disorder, or an eating disorder, may keep men from seeking help.

While men have every eating disorder diagnosis, some differences in eating disorder psychopathology have been noted across genders. Men are less likely to report loss of control of overeating, despite having similar rates of objective binge eating as women, and they are more likely to engage in compulsive exercise to for emotion (see a related article elsewhere in this issue).

Using appropriate language

An important aspect in addressing weight stigma among men and women is using language that avoids stigmatizing terms. For this reason, the Guideline uses the phrases ‘people with higher weight’ and ‘living in a larger body.’ There is not one universally preferred term for people living in larger bodies, and health professionals should discuss preferred terms with each individual.

For all people with eating disorders, especially children and adolescents, information on eating, purging, and compensatory behaviors may need to be gathered from multiple sources, including family and support persons. Eating psychopathology can impair perceptions of frequency of disordered behaviors or amount of food intake, so verification with other sources can be useful for establishing clinical status. However, for people with higher weights, it is important not to assume that the person is being untruthful or evasive. Instead, the Australian group recommends that clinicians be respectful and sensitive when gathering information, even with the knowledge that a person may minimize their symptoms for fear of losing important coping mechanisms or access to interventions.

The way clinicians approach questioning about eating habits and compensatory behaviors is critical to establishing a non-stigmatizing and supportive therapeutic alliance. This includes respectfully seeking permission to obtain further information from family members or others.