Doctors Are Prescribing Eating Disorders

Doctors are prescribing eating disorders to fat patients — not by accident, not in spite of the guidelines, but because of them. In this episode, I bring the clinical evidence to back up what the fat community has known for years: that severe dieting causes eating disorders, that eating disorders look nothing like the stereotype, and that fat people with eating disorders are being failed at every stage — dismissed, gaslit, and denied treatment. If you've been told to lose weight by a healthcare professional, you have the right to ask them why they're willing to put you at risk. This is the data. These are the receipts. 

A selection of studies to start you off:

1. Peebles, Rebecka et al. “Are diagnostic criteria for eating disorders markers of medical severity?.” Pediatrics vol. 125,5 (2010): e1193-201. doi:10.1542/peds.2008-1777
2. Sawyer, Susan M et al. “Physical and Psychological Morbidity in Adolescents With Atypical Anorexia Nervosa.” Pediatrics vol. 137,4 (2016): e20154080. doi:10.1542/peds.2015-4080
3. Moskowitz, L., & Weiselberg, E. (2017). "Anorexia nervosa/atypical anorexia nervosa." Current Problems in Pediatric and Adolescent Health Care, 47(4), 70-84.

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Transcript

Hello, and welcome to Episode 12 of Season 6 of the Fat Doctor Podcast.

I'm going to start this episode with a trigger warning. This episode is going to be dealing with eating disorders in depth. If that's something you are navigating personally, or something that's likely to cause you distress in any way, please take care of yourself first.

If you have lived experience of an eating disorder, none of what's coming today is going to be news to you. People in the fat community — and I'm really only speaking about eating disorders in fat people — people in the fat community with lived experience of eating disorders have been talking about this for years. I'm not bringing anything new to the table, I'm not an expert, I don't have personal lived experience, and I want to put that out there right from the start. You've been saying it, I've been listening. I'm just bringing the clinical evidence today to back up what you already know. I'm bringing the facts. The data. The receipts. The lived experience belongs to you, belongs to the community, and if that's you, then you already know all of this.

I'm going to start with a report that came out in 2021 from the UK Parliament's Women and Equalities Committee. It's called "Changing the Perfect Picture," and we talked about it a lot when it came out, though it's kind of fallen out of fashion now. The report found that a large majority of adults and children have negative body image. No shit. They listed a whole range of reasons: unrealistic media portrayal, appearance-based bullying, racism and colourism, societal pressure to be image-focused. And they said that negative body image resulted in low self-esteem, anxiety, depression, and of course, eating disorders.

The committee's response was actually quite radical. Around the same time, calorie labelling on menus was being rolled out across the UK — nowadays, if you go to a restaurant, the calorie count for every meal is on the menu. But the committee called for that scheme to be scrapped, even before it really took off. They refused to support the government's weight loss and so-called obesity policies, because they found out that no one had ever actually reviewed whether these policies work. They said: until you have evidence that they work, we want you to scrap them. Pretty bold. Of course, the government predictably ignored them, and we haven't done anything about it since.

We've known for a long time that dieting causes eating disorders. Project EAT, a large study in Minnesota, looked at adolescents using what they called "unhealthful weight control behaviours" and found they were at significantly higher risk of disordered eating five years later. Kids who diet in their teens are much more likely to have eating disorders after that. There was another study in Australia that found dieting was the single most important predictor of new eating disorders. Say it again: dieting was the single most important predictor of new eating disorders. Severe dieters were up to 18 times more likely to develop an eating disorder than non-dieters. I'll say that again. 18 times. 18 times. It's not a little risk, it's not a theoretical risk, it's not a small risk. 18 times.

So what counts as severe dieting? Fasting. Skipping meals. Very low calorie intake. Rigid food rules. Avoiding entire food groups. Using extreme weight control methods — including medications. Do these sound familiar? How many of you have been doing that for years, maybe longer? How many of you were taught to do that from a very young age? How many of you went to Weight Watchers as a kid? How many of you went to fat camp? How many of you had parents who severely restricted how much food you could have, or didn't let you eat foods your siblings were allowed? How many of you were counting calories, skipping meals regularly, following rigid food rules that were forced on you from a young age? How many of you were told to avoid entire food groups? And how many of you were doing what you could to be thin as teenagers? 18 times more likely to develop an eating disorder.

All of this — these unhealthful weight control behaviours, this severe dieting — is the very same thing that NICE, the National Institute for Health and Care Excellence, literally recommends for people who are fat. It's baked into the guidelines. In summary: doctors are prescribing eating disorders to their fat patients. They are prescribing disordered eating, which leads to eating disorders, and they are doing so legitimately, using the guidelines from our governing body, the source of all of our recommendations.

Here's the thing that the rest of the world doesn't understand — though you probably do. Eating disorders don't look how you think. We have these stupid misconceptions. The most common one: eating disorders only affect underweight young women. This is wrong. This is wrong because everyone else was excluded — from the literature, from the teaching and training, from social media and the media. Black people were excluded from the conversation. Fat people were excluded. Transgender people were excluded. Men were excluded. Everyone else has just been excluded. It doesn't mean it doesn't happen — it just means we're not paying attention to it.

And fat people are actually excluded from the definition itself. Both the DSM and the ICD-10 require you to be underweight in order to receive a diagnosis of anorexia nervosa. The ICD-11 has changed things a little — not enough — but a little. Everyone, and especially fat people, are excluded from this conversation. And that's not okay.

When you actually look at the evidence, eating disorders are more prevalent in people with higher body weights than in people with "normal" weight. And of course the next assumption is: fat people binge eat, thin people restrict. Again, that is a stereotype soaked in weight stigma and couldn't be further from the truth. First, I would argue that binge eating disorder is itself a restrictive disorder — people tend to binge because they've been restricting. We talked about that in the last episode. A lot of people who are labelled as binge eaters are also restricting at the same time.

But even if you just look at the restrictive eating disorders — at the data on people with anorexia nervosa and bulimia — the number of higher-weight adolescents with restrictive eating disorders increased massively between the 1990s and 2015. According to one study, restrictive eating disorders like anorexia in higher-weight adolescents increased 11.5-fold between 1995 and 2015. And is it any wonder? Everyone from the 80s and 90s was going on diets, and diets predispose you to eating disorders. So it's no surprise that fat people who are dieting constantly are developing eating disorders in significant numbers. And these are just the ones who have been diagnosed — forget the ones being ignored.

One study looked at all the adolescents admitted to a specialist eating disorder unit between 2007 and 2011 and found that over a third of those with restrictive eating disorders were higher weight. And these were the ones who managed to get into the unit, which — as you probably know — is really hard to do.

Despite all of this, an anorexia diagnosis is reserved for those who are underweight. Anyone else gets a so-called "atypical anorexia" diagnosis — a name designed to separate the "real" ones from the ones in fat bodies. It's a diagnosis plus weight stigma. And this is how it's done across the world. It's so wrong. So unbelievably wrong.

I want to make it very clear that just because you're a fat person with an eating disorder doesn't mean your prognosis is better than a thin person's. Quite the contrary.

What we call disordered eating in a thin person, we call a healthy lifestyle change in a fat person. What we call concerning behaviour in a thin person is compliance in a fat person. If you're thin and losing weight unexplained, that's a red flag — we immediately ask: is it intentional? Is it unintentional? Is there a disease process? We do all the tests. But if you're a fat person losing weight, and we measure you and see you're several kilograms lighter than last year, we celebrate it. At no point do we think: maybe this is a sign that something bad is happening. A red flag if you're thin. A green flag if you're fat.

Eating disorders are only taken seriously at lower BMI. That's the only way to access treatment, the only way to access support. I have met many higher-weight people with eating disorders who, even when admitted, were repeatedly accused of lying. "You can't possibly be eating only that much food. Look at you. You're not losing weight fast enough." Doctors and nurses — people who are supposed to be experts in the field — accuse them of lying, because their bodies aren't responding the way they assume they should. But that's bullshit. We've got the evidence. Clinicians in the eating disorder field are still operating on very outdated stereotypes. They are not operating on evidence.

Higher-weight patients with eating disorders have typically been ill for longer before receiving a diagnosis and treatment. And remember: fat does not protect you. When it comes to prognosis, the biggest factors are how long you've had an eating disorder without intervention, how much weight you've lost over your lifetime, and how much weight you've lost recently. These are much better predictors of physical complications than what your weight was on admission. If you're a fat person with an eating disorder, you will probably have been ill for longer before diagnosis, and you will probably have lost significantly more weight over that period.

We have studies showing that patients with atypical anorexia experience equal or greater medical instability than those with so-called typical anorexia — bradycardia, low blood pressure, electrolyte disturbances. This is backed up by facts. The heavier you are, the longer it takes to get a diagnosis, and the more likely your doctor is to celebrate the very thing that is making you sick. If you are lucky enough to get a diagnosis, chances are you won't qualify for treatment. And if you get so sick that you need to be admitted, by that point you will have been sicker for longer, lost more weight, and your prognosis will be poorer. Once again, fat people are being punished for being fat. Fat people are receiving poorer healthcare. Fat people's lives are being put at risk. Because of weight stigma. That's it.

When someone has a long history of restricting and weight cycling, the body adapts — it becomes more metabolically efficient. There's a big red flag, like a post-it note on the recipe book of your DNA, that says: you can't trust the food supply. And as a result, you are much better at holding on to your fat stores. When you starve yourself, if you've been doing it repeatedly, you're far less likely to lose large quantities of weight. That means weight is not a reliable indicator of nutritional status or energy intake, especially in someone with a history of disordered eating. So when a doctor says, "look at you, you can't possibly be starving yourself" — that is not true. Weight is not a reliable indicator of that. Because of adaptive thermogenesis, if you are a chronic weight cycler — if you've been weight cycling for decades — your weight is not an indicator of anything.

These are real, lived consequences. Fat patients are being discharged from eating disorder services because their weight loss is too slow, too inconsistent. And instead of clinicians recognising adaptive thermogenesis — which is well-established, which we know about — they conclude that you're lying and send you home. And that's not just gaslighting, though it is that, and that alone is a serious problem. When you're gaslit in this way, you begin to doubt yourself. You disconnect from your own body. You know what's happening, but they're telling you you're lying, so you start to wonder if they're right. And don't forget — when you're not eating enough food, your brain isn't functioning at full capacity anyway. Your nervous system is dysregulated, your thinking is very black and white, very tunnel-visioned. So when you finally reach out for help and the clinician looks at you and says "no, you're lying" — even though you're not, even though there's plenty of evidence showing otherwise — that can really mess with your thinking. Beyond that, it is actively putting people in harm's way. These are the actual harms. These are the fucking receipts, right here.

Weight is not a reliable indicator of nutritional status. It is a fundamental clinical error to assume that it is. The belief that true restriction produces predictable weight loss ignores everything to the contrary, and denies treatment to the patients who need it the most.

I'm putting this episode out there. I haven't talked about eating disorders very often — like I said, it's not really my place. I just wanted to bring the facts, the data, the receipts. I'll link all the studies in the show notes for those of you who want access to them.

If you're struggling to get people to take you seriously, if you're suffering and your doctor isn't listening, I'm here. I can offer consultations where I can advocate for you with your own doctors, help you write letters, help you fight for your care. But even if you just need someone to listen and say "I'm here, I get it, I believe you" — I'm here for that too. And more importantly, there are brilliant people out there who have been talking about this for decades, who really know what they're talking about, who can be trusted. There is a small group of fat eating disorder specialists — people who have both the lived experience and the clinical expertise. A lot of eating disorder specialists, unfortunately, look a certain way, and even if they've had their own experience with an eating disorder, that can be off-putting if you're a fat person seeking support. I cannot stress the importance of reaching out for help. I want to offer signposting and advocacy, but more than that, I want to encourage you to find the people who understand what you're going through and can support you. Find community, is what I'm trying to say.

If you're a healthcare professional listening to this — especially if you work in eating disorders, or if you're a generalist like me who comes across people with eating disorders — this is a real problem. I am showing you, with evidence, how much harm we as clinicians are causing our patients. Fat patients with eating disorders wait longer for diagnosis, they lose more weight over a longer period of time before anyone intervenes, they often can't find a service that will accept them at their BMI, and that results in a worse prognosis. Eating disorders have the highest mortality rates of all mental health conditions. Out of every diagnosed condition in the DSM, eating disorders have the highest mortality rates. And fat people are, once again, being harmed by you and by me. That worse prognosis is not because of anything they did. It's because we failed them. The system failed them. Everyone is failing them. That is not okay. We have a responsibility to look out for our patients, to protect them, to act in their best interests, to not cause harm.

When you prescribe dieting to your fat patients, you are prescribing disordered eating, and you are putting them at risk of an eating disorder. And you're sitting there worrying about theoretical potential cardiovascular risk — are you not worried about eating disorders? Are you weighing up both risks? Are you discussing eating disorder risk with your patients? Are you even thinking about it? Probably not. Stop prescribing eating disorders to fat patients in the name of health.

And if you're a person who doesn't have an eating disorder but is being told to go on a diet, you have the right to question. When a healthcare professional tells you to diet, or start a GLP-1, or whatever it might be, you can say: "Sorry, can I just ask — why are you willing to put me at risk of an eating disorder?" Just ask them. Why do you think it's okay to put me at risk of an eating disorder? And if they say, "what risk?" — you can say: studies have shown that severe dieting methods make someone 18 times more likely to develop an eating disorder.

And especially — especially — if you're the parent of a fat child. I remember being in an appointment with a paediatrician who brought up my son's weight. And I lost it. I said, no. No, no, no, no, no. Not at this age. You don't get to do that. You don't get to put my son at risk. I lost it, then and there, and I wrote a complaint letter. I will not let a paediatrician put my child at risk of an eating disorder by telling them they're too fat. And for what it's worth, it's all nonsense anyway, as we'll discover later in this season and in my book — children should just be allowed to eat what they want.

If you have a child who is being fat-shamed by a nurse or a doctor, you can stop them and say: "Excuse me — can I just ask why you think it's okay to put my child at risk of an eating disorder? They are up to 18 times more likely to develop one if they start dieting at this age." Just say it.

Alright, that's me done. Thank you very much for listening. I knew this was going to be a challenging episode, and I wasn't sure whether to record it, but I'm glad I did. When we talk about the harms of dieting, we talk about weight cycling, we talk about the Minnesota Semi-Starvation Experiment — but we don't talk about eating disorders enough. Especially eating disorders in fat people. So thank you for listening, and I'll see you next week.