QUESTIONS AND ANSWERS: Higher-Weight Patients with Eating Disorders

Q. Recently, I have seen several clients with bulimia nervosa and binge eating disorder, who are in larger bodies. I am trying to find specifically tailored approaches for such patients. Do you have any suggestions? (TS, Charlottesville, SC)

A. Eating disorders affect people in bodies of all sizes, but little research has been done in this area. Too often, those living in larger bodies are overlooked and thus not treated appropriately, according to results of a recent study and guidelines from the National Eating Disorders Collaboration (J Eat Disord. 2022. 10:21). This group outlined numerous barriers to care of such patients, and these guidelines may be helpful for you.

The group, based in Australia, has developed 21 clinical guidelines to help clinicians in this understudied area.

Those with eating disorders living in larger bodies report being misdiagnosed and dismissed by healthcare professionals, and encounter delays in treatment or are excluded from treatment services. Much of this is due to weight stigma, according to Dr. Angelique F. Ralph of the National Eating Disorders Collaboration, in Sydney, Australia, and her colleagues. The group reports that too often these patients have a lifetime of weight-related trauma, such as bullying in high school or weight-related emotional abuse. Experiences with stigma and discrimination may lead these individuals to be reluctant to speak about their weight or eating, for fear of being shamed further and/or not being believed, and because of prior negative experiences related to their weight.

A few recommendations include: (1) psychological first-line treatment for BN for patients with higher weights; (2) supporting physical activity for positive physical and mental health and intrinsic quality of life, as opposed to exercising solely for weight loss or changing shape; (3) family interventions; and (4) addressing poor nutritional status and diet quality. Further, it is important during treatment to address the impact of the patient’s experience with bullying, and the trauma of ongoing weight stigma and marginalization. Among the group’s recommendations is “promoting the need for research into weight-neutral approaches and other treatment approaches in this field.”


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