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gretchen692

Can Someone Really Recover from an Eating Disorder?

Updated: Oct 23



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I’m a dietitian who almost exclusively works with people in eating disorder recovery. It’s been pretty much my entire career, and I can’t imagine myself doing anything else - except maybe following my dream of running a fat positive camp (for people to just be people at camp but with body acceptance as the core tenet?? And ensuring that all activities are made for anyone who wants to participate?? Is that not the dream??).

Okay, back to business - the thing about working in the eating disorder world is that there are a lot of rumors. And I don’t know who started the rumor that there is no such thing as full recovery from an eating disorder, but I’d like to give them a swift kick to the face. What a dangerous and annoying thing to tell people who are seeking support and hope. Just in case you don’t want to read this whole thing: yes. I do believe that recovery is possible.

Let’s get into it. The thing about medicine/nutrition/treatment is that we haven’t always known as much as we know now and, even now, we don’t know everything. When we look back on eating disorder treatment of the 80’s, 90’s, 2000’s, and even into today there are a couple issues that I think contribute to this myth of not being able to recover feeling true for a lot of people. The biggest, most glaring issue is that we were using BMI to determine whether someone was “healthy” or not. There are about a trillion reasons that this wasn’t the right way to monitor recovery or illness, but two reasons stand out.
Let’s start with people who start as “clinically underweight”1 as a symptom of their disordered eating. Many eating disorder providers of ages past (and, honestly, present) were setting an arbitrary goal weight for their clients that resulted in a BMI of at least 18.5 - the minimum BMI that is considered “normal”2. The problem with this is that very few people naturally maintain a BMI of 18.5. Their natural, healthy body weight would actually be significantly higher than this if they had never developed an eating disorder. We see that the people who do not weight restore to their natural, healthy body weight, the weight that is maintained in the absence of disordered eating, have higher rates of relapse than those who fully weight restore3. We see significant mental and physical shifts as a person returns to their body’s appropriate weight - decrease in fixation on food and body, increased flexibility in thinking, return of appropriate hunger and fullness cues, and improvement in GI function among other things. When we don’t allow people to fully weight restore, we may never see some of these changes that can help to sustain recovery. We have, thankfully, seen a significant shift in the eating disorder treatment world to do better at setting goal weight ranges using patients’ previous highest weights or weight history and using growth charts in patients under 20 years old to determine their body’s unique growth goals. Unfortunately, there are still providers today utilizing BMI as the primary method of determining illness or stopping treatment. What I have typically seen is that those patients end up seeking care again after relapsing and do not start to see the cognitive shifts associated with long-term recovery until their body weight is stable.

The physical symptoms listed above are important, but when we, as providers, buy into the idea that higher weight = bad we are also doing a disservice to the mental recovery of a patient. Diet culture is rampant and all around us, so if you got through childhood and young adulthood without developing a fear of your body growing bigger, I would love to talk to you about how you were shielded from this message. (seriously will you email me please?). With that, fatphobia exists for most people, including (maybe especially?) healthcare providers. And if you come into a clinic with an eating disorder that includes a fear of weight gain… and your provider says something along the lines of “don’t worry - I’ll make sure you don’t get fat”… that the provider is colluding with the disordered thinking. Unfortunately, this sentence is incredibly common even today in eating disorder treatment. Providers might think they are being comforting and “safe” when they assure a patient not to worry about their body growing, but what they are really doing is telling a patient that their fears of weight gain are valid. And how in the world are you supposed to recover from your disordered beliefs if your own provider is telling you that they agree with them?

What about those with an eating disorder who do not meet the criteria for being clinically underweight (most people who have an eating disorder)? Well, as you might be able to imagine, if we’ve spent most of our years treating eating disorders based on weight being the primary indicator of severity, we have really not been treating many of the eating disorders that exist. And we’ve been actually encouraging disordered behaviors in people with bigger bodies. AND we’ve waited until people get so sick and so medically unstable from their behaviors that they finally are clinically underweight before we take the behaviors seriously. Unfortunately, we have evidence showing that early intervention is an important factor in reducing length of time in treatment and risk of relapse. And many people who meet the criteria for disordered eating either don’t seek help or are told that they don’t have an eating disorder because they aren’t “clinically underweight”. I’ve even had people tell me that when they reported their disordered symptoms to a doctor they were encouraged to keep going since their weight was trending down.
There are some other things that we have seen impact rates of relapse - decreasing caloric intake too quickly when someone is still hypermetabolic, living in a world where thinness is glorified, trauma, and just generally not being ready to give up the safety and comfort of an eating disorder. While all of these are important considerations, I do believe that weight bias is a central piece of why recovering from an eating disorder is so incredibly difficult to maintain.

Where are we now? The eating disorder treatment world has made some progress. Health at Every Size (R) is part of the infrastructure of many treatment facilities and many outpatient providers are using these principles to provide appropriate care for all of their patients. But not everyone is up to date on the most supportive treatment methods - so let’s talk about what to look for in a provider if you are seeking help for disordered eating.
  1. No matter your size, look for a provider who promotes body acceptance, fat acceptance, and/or HAES (Health at Every Size (R)) on their website. A provider can’t help you to accept yourself if they agree that you are better off in a malnourished, underweight body. The flip side of this is to fire any provider who makes you feel like your body is wrong or that you need to maintain some disordered patterns to keep your body small.
  2. Find providers who you trust. Eating disorder recovery is so incredibly vulnerable and scary. If you don’t really like talking to your dietitian or therapist, you aren’t going to get into the stuff you need to. It’s okay to test out different providers - do the discovery calls, see if you gel, and be honest about what is supportive and not supportive with your providers.
  3. Utilize your provider’s professional network. I am a part of eating disorder groups across the country and 9/10 times can find a referral for a client who is going to be up to date on current eating disorder treatment practices. It’s a pain to find a new therapist/RD/doctor/psychiatrist. Use your people to find your options.
  4. It’s okay to seek help even if you don’t think you “meet the criteria to be diagnosed with an eating disorder”. For one, many of us don’t actually know the criteria for things like OSFED or Atypical4 Anorexia and could actually meet the criteria for an eating disorder without feeling like we “look” the part. Second, if you are struggling you deserve care. All that matters is that you get to feel good about your relationship with food and your body.

1 For simplicities sake, I’m considering being under a BMI of 18.5 as the criteria for “clinically underweight” although I don’t use that as a primary indicator that someone is underweight in my practice. I use growth charts, weight history, and recent weight change to evaluate an individual’s individual needs.
2 quotes to always indicate that the BMI standards for weight are not useful or helpful and I do not agree with the terminology the system uses.
3 Seen here, here - lower BMI’s associated with higher risk of relapse.
4 atypical anorexia is anorexia… with some fatphobia thrown in.

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