"I Just Wanted the Same Treatment As Everybody Else": Patients Experiences of Weight Stigma in Higher Levels of Care for Eating Disorders

Background and Purpose: Eating disorders (EDs) often require multiple interventions, including nutritional rehabilitation, psychotherapy, and at times, medical stabilization. Higher levels of care (HLOC) become essential when patients need medical stabilization or support in interrupting deeply engrained behaviors. Paradoxically, HLOC can have negative consequences, including decreases in patient autonomy and exposure to disordered peers; additionally, patients with marginalized identities may feel further ostracized. This study examined the experiences of patients with atypical anorexia (AAN) in HLOC. Patients with AAN present with the same behavioral, cognitive, and medical symptoms as patients with anorexia nervosa, except their weight is not considered “underweight.” Due to their higher weight status, patients with AAN have reported experiencing weight stigma during treatment.

This qualitative study explored AAN patients’ lived experiences with higher levels of care. Research questions included: 1) How do patients with AAN experience treatment in HLOC settings? 3) How do patients with AAN perceive weight stigma to impact their illness journey?

Methods: Seventeen adult patients (Mean age= 32.4, SD=8.8; 88% cisgender women, 1 trans man, 1 nonbinary; 29% People of Color, 41% heterosexual, 35% low income) with AAN were recruited from ED treatment centers, provider referral, and social media. Participants completed in-depth, semi-structured, arts-based interviews regarding treatment experiences in HLOC for EDs. Interviews were audio-recorded, transcribed, de-identified, and validated. Interview transcripts and participant artwork were coded (Huberman, Saldana, & Miles, 2014) using Dedoose software, using a thematic analysis approach (Braun & Clark, 2006), guided by principles of narrative inquiry approaches to qualitative analysis.

Results: We identified six themes regarding AAN patients’ experiences of HLOC: 1) Difficulty with admission, 2) Inadequate nutritional care, 3) Unhelpful treatment interventions, milieu, and norms, 4) Non-affirming providers, 5) Providers encouraging disordered behaviors, and 6) Systemic issues of weight bias. Regarding admission, patients reported experiencing difficulties with insurance approvals, receiving inaccurate diagnoses, and encountering resistance from outpatient providers when seeking admission to HLOC. Regarding nutritional care, participants reported low meal plans, being denied nutritional supplementation, and experiencing limited weight restoration. Regarding interventions, patients reported activities centering thin clients (e.g., clothing challenges that did not have options for plus-sized patients), activities that involved cultural appropriation, and patients encountering fatphobia in milieus (in peers and providers). Regarding providers, patients reported providers minimizing their EDs and encouraging disordered behaviors. Finally, regarding systemic issues, patients reported difficulty affording treatment and insurance coverage ending prematurely, resulting in cyclic readmissions.

Conclusion and Implications: These results suggest that weight stigma at the systemic (e.g., insurance and treatment center policies) and interpersonal levels (e.g., provider and peer interactions) may be negatively impacting AAN patients in HLOC. In addition to systemic change, patients with AAN may benefit from increased provider advocacy with insurance companies, strengthened nutritional rehabilitation and weight restoration guidelines for care, weight-inclusive healthcare practices, and interventions that address weight stigma in HLOC milieus.