The Role of Body Size in the Treatment of Restrictive Eating Disorders

An important new clinical question is how to diagnose and treat people with restrictive eating behaviors, psychological focus on weight loss and obsessive thoughts about food and weight in people who are not extremely underweight.

This week’s New York Times article discusses a new consideration in the diagnosis among providers and the possible acceptance of a more inclusive diagnosis. The unfortunate and inaccurate diagnosis of “atypical Anorexia Nervosa,” as the article suggests, will only feel dismissive and shameful to all people who are trying to fully grasp the severity and significance of their illness, no matter their body size.

The central issue is the lack of creativity and limited diagnostic categories for people with eating disorders. Over many years, I have seen people exhibit the same food restriction with extreme variability in weight. People in large, medium, small and emaciated bodies can all have very similar symptoms.

Each person is genetically programmed to respond to starvation and malnutrition in different ways. These metabolic changes induced by anorexia are the body’s attempt to survive a severe, prolonged famine. The resulting body size reflects how that body can survive such an assault.

However, it is naive to assume that everyone with restrictive eating behaviors but in different size bodies will experience their eating disorder the same way and respond the same treatment.

Because anorexia has a strong cultural association, people assume anorexia only applies to someone who does not eat and has an emaciated body. Because of the increased pressure for thinness and almost universal belief that dieting or undereating is virtuous and supposedly healthy, almost everyone risks inducing an eating disorder. Chronically underfeeding one’s body is the number one risk factor for an eating disorder, no matter the reason for restricting food.

But people who restrict in larger bodies will be misdiagnosed and often judged for their body size no matter how little they eat. And those in emaciated bodies often receive attention and even praise for the result of their eating disorder. The psychological ramifications of body size is very significant to an eating disorder and to the path of treatment and recovery.

Moreover, the physiological adaptations that lead to larger or smaller bodies when restricting are very different. Our metabolism can respond in many ways to adapt to the lack of food, and the overall course of treatment needs to be tailored to each person’s biological response to the illness.

No one can predict how a body will respond to severe restriction. The focus of diagnosis and treatment needs to be on behavioral, psychological and medical symptoms and include the effects of body size and weight as a part of the treatment. Discounting body size as a factor in eating disorder treatment is ignorant and misguided.