By Jamie Marchetti, MS, RDN, LD, MA, PPC, NCC
October 28, 2020
For patients who present with what are typically considered weight-related disease states (diabetes, heart disease, or lower extremity joint pain), it is nearly second nature to recommend that clients “eat less and move more.” Conventional thinking and practice support this, and if this generalized directive doesn’t lead to weight loss and improvement of disease symptoms, the next steps typically include encouraging the patient to track their food and physical activity to report back to the physician. While this is a logical process within the framework of convention, there are a few reasons why it could become problematic.
The first reason relates to the assumptions that (1) people cannot be healthy at a higher weight, and (2) that “failure” to lose weight indicates that the patient must not be eating and moving their body “correctly” or “enough.” The next reason, however, and the focus of this article, is that the traditional promotions of weight loss as well food and physical activity tracking have implications for mental health and eating disorder risk.
The “Other” Anorexia
The Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5) lists three criteria for Anorexia Nervosa:1
- “Restriction of energy intake relative to requirements…”
- “Intense fear of gaining weight or becoming fat…”
- “Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation…”
For the standard Anorexia Nervosa diagnosis, each of these criteria is couched in the patient having an unusually low body weight. There is another diagnosis, however, called Atypical Anorexia Nervosa, which is a subset of the “Other Specified Feeding or Eating Disorder” diagnosis; it states, “All of the criteria for Anorexia Nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.”1 It is clear then that even patients who follow prescriptions for “healthy dieting,” such having reducing their food intake, increasing physical activity, and meticulously tracking both of these in order to induce weight loss, can develop eating disorders without being underweight.
The Dangers of Compulsiveness
Behaviors that are generally accepted as “healthy” can also easily become obsessive and result in patients developing eating disorders as well. In addition to Anorexia Nervosa or Atypical Anorexia Nervosa risk, patients may have episodes of binge eating or purging in response to intake restriction, which could lead to Bulimia Nervosa or Binge Eating Disorder. Patients can also develop exercise compulsions that get in the way of other areas of their lives.
These very unclear boundaries of what is “healthy” versus what is “disordered” ought to make providers wary of prescribing restrictive dieting, strict exercise regimens, and meticulous tracking of both. A 2019 article in Obesity Reviews presented the results of a meta-analysis that showed that treatment of child and adolescent obesity that included a dietary component frequently spiraled into eating disorders for the patients.2 It stands to reason that this would also be the case for adults.
A Healthier Approach
So, what is the alternative? I recommend working with clients from a Health-At-Every-Size perspective, which includes providing bodies with nourishing food and movement with the understanding that these alone are beneficial to health, independently of changes in body size.3
Removing the fixation on weight change means that the patient is trusted to make behavior changes that improve their own quality of life and health without the pressure to “prove” the changes through weight loss. Additionally, when clients feel that behavior changes enhance their quality of life rather than make them feel restricted, they are likely to continue beneficial behaviors habitually, continuing to reap health benefits and include them in their lives in ways that are less likely to become compulsive or disordered.4
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. Washington, DC: American Psychiatric Publishing, 2013.
- Jebeile H, Gow ML, Baur LA, Garnett SP, Paxton SJ, Lister NB. Treatment of obesity, with a dietary component, and eating disorder risk in children and adolescents: A systematic review with meta‐analysis. Obesity Reviews. 2019;20(9):1287–1298
- Robison J. Health at Every Size: Toward a New Paradigm of Weight and Health. Med Gen Med. 2005;7(3):13.
- Provencher V, Begin C, Tremblay A, Mongeau L, Corneau L, Dodin S, Boivin S, Lemieux S. Health-At-Every-Size and Eating Behaviors: 1-Year Follow-Up Results of a Size Acceptance Intervention. J Am Diet Assoc. 2009;109(11):1854-1861.
Jamie M. Marchetti, MS, RDN, LD, is a Health At Every Size ® dietitian. She is also a freelance writer and a MA Mental Health Counseling candidate who plans to combine her skill sets to provide nutrition and body acceptance therapy through her private practice, Wonderfully Well.
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.