Weight-Neutral Treatment for BED

Many studies and news stories have described the harm caused by teasing and bullying those with binge-eating disorder (BED) about being overweight. In a sad but and surprising twist, some patients report experiencing the same type of weight stigma from medical professionals in healthcare settings.

Dr. Meg G. Salvia from the Harvard T. H. Chan School of Public Health, Boston, and colleagues have described the results of their study of 21 women with BED (Lancet. 2023. 56). Their goal was to examine whether weight-neutral care might improve psychological and behavioral outcomes among women with BED.

All participants had been patients at a single specialty center that offered an intensive outpatient BED treatment program. Ninety percent of the women were non-Hispanic whites (mean age: 49 years) who had type 2 diabetes or prediabetes. The mean BMI ranged from 30.2 to 63.9 kg/m². The women had completed at least 2 weeks of a specialized BED treatment program, participated in an English-spoken interview, and did not have cognitive impairment or severe psychopathology that would interfere in the interview. The main outcome was the patients’ real-life experiences in general healthcare settings and in a weight-neutral eating disorders treatment program.

Perceived quality of care

The reports from the women were revealing. Many of the participants believed the weight stigma they experienced in healthcare settings lessened the quality of care they received. Even as they tried to lose weight, they felt embarrassment and a sense of failure, and felt blamed for their current weight and health. In contrast, in a weight-neutral treatment setting, they named helpful elements, including consistency in eating patterns, programs that emphasized varied, adequate, and nourishing foods, specific and sufficient education about BED, and comprehensive support by healthcare professionals. As a result, they had fewer binge-eating episodes, experienced less shame, and reported having increased resiliency after treatment.

The authors were particularly concerned about the extent to which weight stigma was found in healthcare settings. They noted that research points to evidence that such negative reactions by professionals adversely affect medical care and increase medical risk.

A misleading emphasis on weight loss

Nearly all the women reported that their healthcare providers emphasized the benefits of weight loss during visits and gave overly simplistic suggestions that did not take into account the underlying factors that had led to overweight. For example, the women reported that their doctors either discounted or did not acknowledge their past attempts to lose weight. Thus, the standard advice they received included statements such as ‘Well, you just need to lose weight,’ ‘cut the calories,’ or ‘exercise more.’ Others felt blamed or shamed in response to such comments and interactions where lack of weight loss was often interpreted as noncompliance.

Patients felt doctors were sternly telling them they must get in control and somehow have greater willpower to lose weight. Other healthcare professionals told patients that they were at fault for their BED and were “walking strokes” or “walking heart attacks.” One study participant reported that all was fine while she was doing well, but her doctor became very condescending when she slipped and regained weight—at this point the doctor told her she was wasting his time.

Having a high body weight also acted as a barrier to accessing care, according to some patients. Some described being turned away at the first examination with comments about their weight. The healthcare professional added that did not want to deal with any more overweight patients. Another physician told the patient that he couldn’t help her because she was too attached to food. Some patients did not help their case by avoiding mentioning that they had BED, fearing they couldn’t acknowledge to themselves that they had BED and that they couldn’t get help if they mentioned having BED episodes.

In the weight-neutral care setting, what skills helped physical and mental health?

Among the helpful experiences in the weight-neutral treatment setting, the women reported having improved physical health, such as reduced binge-eating, self-control around food choices, and less shame. One of the program components that participants enjoyed most was more about the consistency of their behavior than a need to change everything about their lifestyle. It wasn’t about counting calories but instead having balanced, healthy meals. Some participants were surprised but pleased that the program wasn’t about “losing weight.” The weight-neutral treatment approach gave them enhanced self-sufficiency, greater flexibility, and more freedom around food and decisions about eating.

Many participants reported that weight-neutral treatment helped them reduce their binge-eating behaviors during and after the treatment program. But, according to the authors, for longstanding BED, when the onset occurred in adolescence or young adulthood, it was unrealistic to expect that one treatment episode would extinguish binge-eating behavior. Some patients felt they had to return to or at least consider returning to the pursuit of losing weight. In their group of type 2 diabetics, the authors believed that a weight-centric approach can backfire, leading to decreased diabetic self-management and self-care, weight-cycling, weight regain, and worsening of physical and mental health.

This is valuable work. It emphasizes the risk of bad experiences in the medical system related to weight stigma. At the same time, it also describes that positive experiences can occur, perhaps particularly with a weight-neutral approach.