“Maybe I Really Am Too Fat to Have an Eating Disorder”: A Mixed Methods Study of Weight Stigma and Healthcare Experiences in a Diverse Sample of Patients with Atypical Anorexia
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Within mental disorders, anorexia nervosa (AN) has the second highest mortality rate, second only to opiate addiction; additionally, AN patients experience impairments in multiple spheres including psychological, social, physical, employment, and overall quality of life. “Atypical anorexia” (AAN) is an eating disorder (ED) describing those who meet all criteria for AN except being underweight. Further, by having larger bodies, AAN individuals are more likely to experience weight stigma. Currently, no literature has systematically reviewed published findings on AAN, and the extent to which AAN individuals experience physical consequences commensurate with AN, and the extent to which their healthcare experiences are impacted by their higher weight status are unknown. The present study used multiple methodologies to explore the AAN experience, focusing on how weight and weight stigma affect access to ED treatment and healthcare. Methods: Study 1 utilized a systematic review of 42 articles to determine the weight history and medical complications of AAN compared to AN. Study 2 utilized in-depth semi-structured arts-based qualitative interviews with 38 AAN patients to describe their experiences of weight stigma in healthcare. Study 3 utilized correlations to deter-mine associations between weight-related variables, treatment delay, and level of care received. Results: The review revealed that AAN patients experienced life-threatening medical complications (electrolyte imbalance, bradycardia, hypothermia, orthostasis) at commensurate rates to AN patients, despite AAN weights being higher. However, AAN experienced lower rates of amenorrhea and bone density loss compared to AN. Qualitative findings demonstrated that across the illness trajectory (risk development, pre-treatment, treatment, relapse prevention), patients reported that provider weight stigma contributed to initiation and persistence of ED behaviors, complicating illness trajectories. Quantitative results corroborated the impact of weight-related variables on treatment receipt and delay. Participants experienced a mean weight loss of 28.4% (SD = 10.0) of their premorbid weight and a treatment delay of 11.6 years (SD = 11.7) from the time patients believed they had an ED until receiving treatment. In correlation analysis, lower minimum BMI was associated with less treatment delay, and higher maximum BMI was associated with lower levels of care received. Discussion: These findings demonstrate that 1) AAN is a serious illness with similar medical comorbidities as AN, 2) higher weight patients were counseled to lose weight despite the presence of ED cognitions and behaviors that created health risks, 3) healthcare providers generally failed to recognize AAN in normal and higher weight patients, and 4) consequences of provider weight stigma included longer periods of living with undiagnosed, untreated EDs and instances of providers triggering (or re-triggering) ED behaviors, leading to increased health risk. These findings suggest several needed steps. First, transitioning to a spectrum model for AN diagnosis (wherein weight is one severity indicator, but not the predominant focus) may facilitate faster diagnosis and treatment. Second, training is needed for transdisciplinary healthcare providers to increase recognition and screening of EDs in normal and higher weight patients. Third, conversations are needed between obesity and ED professionals to ensure that universal health promotion efforts do not cause unintended harm. Addressing weight stigma in these ways could enhance treatment receipt, quality of care, and healthcare engagement for ED patients, particularly those at higher weights.