Messaging From Eating Disorder Professionals Misses the Mark

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I get emails regularly from individuals facing serious health problems, and they often begin with the same phrase: “I know that dieting and intentional weight loss doesn’t work, but…” Then, there’s the client who sheepishly tries to hide her use of GLP1 even though she has blood sugar levels running in the 200s. She cries in my office, feeling as if she’s “betrayed the sisterhood” of the Health At Every Size (HAES) movement. Many of these patients are middle-aged now; they gave up dieting more than a decade ago and now find themselves heavier, sicker, and more hopeless than ever before.

As an eating disorder specialist who primarily works with binge eating disorder, I recognize that anti-weight loss messaging has been strongly reinforced in our industry. Unraveling the thin ideal and letting go of restrictive diets are part of the healing process from disordered eating. But for some, the eating pendulum swings and never seems to right itself to center. These individuals begin to gain more and more weight but never want to go back to the prison of weight loss obsession. I get it. I’m a proponent of mindful eating and weight neutrality.

Some providers prescribe intuitive eating and an “all foods fit” approach. And yet, for some patients, this prescription is difficult to manage. Thanks to a daily dosing of processed foods and treats, trying to stay within the limits of hunger and fullness can be problematic. This balance is especially challenging when they are prone to inattention, sensitive nervous systems, and metabolic disorder—a disorder that begins to work harder and harder against you as your body can no longer process the foods that come with an “all foods fit” lifestyle.

Unfortunately, the messaging has been wrong. Weight and body mass index (BMI) continue to muddy the issue. It’s a great distractor. Weight is just one symptom of the problem, and the problem is a metabolic one. Not everyone with a high BMI is metabolically unhealthy, and not everyone who is metabolically unhealthy has a high BMI.

So what’s all this talk about metabolism? I remember when I was younger, we used to say, I must have a slow metabolism or a hormonal problem. Nope, my thyroid is good. Fifty years ago, the health of our mitochondria and circulating insulin was not on our radar. And yet today, we are beginning to understand that most of our chronic mental and physical health issues today stem from the health of the powerhouse of our cells.

Ilona Maher, a rugby star participating in the Olympics, has faced criticism regarding her high BMI. I mean, really? She is an amazing athlete. Her skeletal muscle is off the charts! Years ago, an exercise physiologist from Arizona State University named Glenn Gaesser wrote the book, Big Fat Lies: The Truth About Your Weight and Your Health. The primary messaging was that lean muscle mass has more to do with our longevity than our body fat, so why are we so focused on fat?

The message that stuck was that fat is OK, but we didn’t catch the propelling message regarding skeletal muscle. Skeletal muscle contains the mitochondrial powerhouses that determine how we convert food into energy. In Forever Strong: A New, Science-Based Strategy for Aging Well, author Gabrielle Lyon tries to shift the fat-focused paradigm as well and promotes muscle-centric medicine.

Metabolism is how we utilize the food we eat. On the surface, the antiquated “calories in and calories out” equation may have few differences between individuals. Yet, when we look through a lens of how our bodies utilize fuel, there are vastly different pathways from one individual to another. For instance, donuts in one person are utilized for muscular fuel and deposited as fat in another individual. It has to do with their metabolic health, not the size of their bodies. Unfortunately, our society judges someone of size eating donuts but doesn’t think twice about someone who is thin and eats the same thing.

Let’s take a deeper look at what's really going on. Fat is not an equal-opportunity organ. People who have great subcutaneous fat storage are subject to societal scrutiny through the lens of the thin ideal, yet they have little health consequences in having large hips and thighs. Others who store their fat viscerally in their torso aren’t so lucky. This fat storage interrupts their organ function, creating overall inflammation that can have grave health consequences.

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If this were a thyroid or other hormonal crisis, there would be early intervention. Insulin malfunction, though, sometimes starts decades before one “technically” becomes ill and qualifies for a diabetes diagnosis and medical intervention.

When it comes to metabolic health, the type of fuel and exercise matters. Diet has become a dirty little four-letter word. It’s often used interchangeably with “diet culture,” which is a pervasive belief that appearance-driven weight loss is the normative value. The anti-diet movement has spread a message that any intentional weight loss or restrictive dieting is damaging. A drive for thinness is part of the pathology of an eating disorder, so how does someone reconcile this dichotomous dilemma facing so many people with disordered eating histories who are now dealing with a health crisis?

Abstinence isn’t the answer, but harm-reduction models can work. It is not fat-phobic to restrict or modify your diet to improve your blood sugar metabolism. We can remain weight-neutral and be mindful of building a more metabolically efficient body using a model of science and compassion. Our clients need not feel shame if their metabolic pathways become more efficient or if they lose visceral fat stores as a result of lifestyle changes or novel medications. After all, the GLP1 medications meant to heal metabolic disorder were hijacked by Big Pharma with high dosing side effects to attract a weight-centric following. This type of rapid weight loss has done cyclical harm by tearing down the skeletal muscle and ruining the metabolic pathway it was intended to heal, making users dependent on the drug for a lifetime.

The answer is in dialectics: It’s both. Eating disorder professionals must be open to considering a place for those needing interventions that include altering what and how clients eat, allowing for body composition changes that aren’t weight-centric. It’s also important to understand our clients will need compassionate guidance on how to negotiate food insecurity and responses to diet trauma as they find their way in a harm-reduction model aimed at healing the metabolic injury.