Eating disorders (EDs) and weight stigma present significant challenges within the healthcare landscape. This article explores the complex interplay between weight stigma, atypical anorexia nervosa (AAN), and emerging weight loss research, aiming to provide a comprehensive understanding of these critical issues.
Understanding Eating Disorders and Atypical Anorexia Nervosa
Eating disorders (EDs) are intricate biopsychosocial conditions that significantly challenge diagnosis, treatment, and the prevention of relapse. Atypical anorexia nervosa (AAN) is an eating disorder estimated to impact 0.2%−4.9% of women during their lifetime, with lifetime prevalence estimates double or triple that of typical anorexia nervosa (AN). Patient denial, minimization, and difficulty engaging in treatment contribute to illness persistence, leaving many frontline medical providers feeling "unsure" about diagnosing and treating EDs and desiring more training.
Both AAN and AN are characterized by severe caloric restriction, overvaluation of weight and shape, body image disturbance, and an intense fear of gaining weight. Individuals with AN and AAN experience disordered eating behaviors (e.g., food rituals, obsessive calorie counting, secretive eating) and dangerous compensatory behaviors (e.g., compulsive exercise, self-induced vomiting, laxative/diuretic abuse). The defining element differentiating AAN from AN is body mass index (BMI); patients whose BMIs are within or above the normal range are designated "AAN" while those considered underweight are designated "AN". However, the similarities between these two EDs has led some to recommend that these disorders be considered within the same diagnostic category. Though individuals with AAN do not present as emaciated, they experience life-threatening medical consequences at rates similar to AN, one of the deadliest psychiatric disorders.
The Pervasive Nature of Weight Stigma
Weight stigma refers to how higher weight (“fat”) people are systematically devalued in societies that idealize thinness. Fat people experience discrimination, fewer opportunities, and other forms of systemic mistreatment including microaggressions, marginalization, and violence. Weight discrimination occurs in employment, education, healthcare settings, and social relationships. Healthcare providers report strong negative attitudes towards heavier patients, inadvertently influencing provider perceptions, behaviors, and quality of care. Physicians (including pediatricians) are more likely to believe higher weight patients are unattractive, less intelligent, and less likely to respond to clinical recommendations; nurses reflect similar attitudes.
Debates persist regarding the long-term benefits of weight-centric health approaches. Obesity experts focus on obesity prevention via diet and weight management, whereas other experts question the benefits of weight-centric healthcare, as BMI is a poor predictor of cardiometabolic health in normal and high BMI populations. This debate is particularly pronounced in pediatric spheres. Since the advent of the "obesity epidemic," much emphasis has been placed on childhood obesity. For example, a 1978 review article described current best practices for childhood obesity management which included: caloric restriction, anorectic drugs, physical exercise, therapeutic starvation (e.g., overseen by hospital staff or summer camps), bypass surgery (in extreme cases), and behavioral therapy.
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The Impact of Weight Stigma on Eating Disorder Trajectories
Weight stigma in healthcare may be particularly risky in pediatric settings when children are forming foundational beliefs about their growing bodies. Focusing on weight management goals in pediatric care versus more inclusive health aims may inadvertently lead to harm. Dieting, disordered eating, and EDs appear to exist on a continuum of risk in ED development. Longitudinal evidence has shown that dieting in childhood and adolescence is associated with increased likelihood of later EDs. Because individuals with AAN present at higher weights compared to patients with AN, individuals with AAN are more likely to experience weight stigma, potentially complicating disease trajectories for AAN. For example, in a vignette study of a patient presenting with AN symptoms, mental health trainees were significantly more likely to diagnose patients who were underweight compared to those with normal or overweight BMIs. Similarly, heavier clients were recommended fewer therapy sessions compared to underweight clients.
Several qualitative studies have also highlighted the potential impact of stigma on patients with AAN. For example, in a study of Family Based Therapy (FBT), practitioners reported that their patients with AAN were more likely to have experienced higher weights as children (and weight-based teasing) compared to their patients with AN. These practitioners identified that ED treatment often sent "mixed messages" to patients with AAN, telling them they needed to gain weight for recovery, while also sending messages about weight management and weight loss. The authors concluded that when treating patients with AAN, providers should empathize with patients’ fear of weight gain, while being wary of colluding with the ED.
Patient Experiences with Weight Stigma in Healthcare
A study analyzed patients’ lived experiences with weight stigma in healthcare. Thirty-nine adult patients with AAN completed in-depth, semi-structured interviews regarding healthcare experiences. Guided by narrative inquiry approaches, transcripts were thematically coded. Across the illness trajectory (ED development, pre-treatment, treatment, post-treatment), patients reported that weight stigma in healthcare contributed to initiation and persistence of ED behaviors. Themes included "providers pathologizing patient weight," which patients reported triggered ED behaviors and relapse, "provider minimization and denial" of patients’ EDs, which contributed to delays in screening and care, and "overt forms of weight discrimination," leading to healthcare avoidance. Participants reported that weight stigma prolonged ED behaviors, delayed care, created suboptimal treatment environments, deterred help-seeking, and lowered healthcare utilization. This suggests that many providers (pediatricians, primary care providers, ED treatment specialists, other healthcare specialists) may inadvertently reinforce patients’ EDs.
Emerging Weight Loss Medications: Zepbound and Beyond
The landscape of weight loss medications is evolving, with new drugs offering promising results. Zepbound (tirzepatide) is a prescription weight loss medicine containing tirzepatide, the same active ingredient as the type 2 diabetes medicine Mounjaro. The FDA approved Zepbound in 2023 to help adult people with excess weight or obesity lose weight and keep it off, especially those who also have other health conditions affected by excess weight, such as high blood pressure, type 2 diabetes, and heart disease. Zepbound is usually injected once weekly, along with eating fewer calories and being more physically active. It comes in a ready-to-use pen for home injections.
Tirzepatide works by activating two proteins called glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) which belong to a group of hormones called incretins. Incretins are naturally produced by the intestine (gut) as soon as food enters your body and stimulate the production of insulin, a hormone that helps digest sugar. GLP-1 also helps control your appetite by working in your brain and slows down the movement of food through your stomach. This makes you feel full faster and stay full longer after eating. As a result, you may eat less and lose weight.
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In clinical trials, Zepbound helped people lose, on average, 52 pounds, nearly rivaling the weight loss results achieved with bariatric surgery, according to Dr. Christopher McGowan, a gastroenterologist who runs a weight loss clinic in Cary, North Carolina. In a phase 3 clinical trial, a 15-milligram dose of tirzepatide, the highest dose, led to an average weight loss of 22.5% body weight, or about 52 pounds. The participants in the study had obesity or were overweight with at least one weight-related condition. At lower doses, patients also lost weight: At a 10 mg dosage, the average weight loss was about 21.4%, or about 48 pounds; at 5 mg, patients achieved an average weight loss of around 16%, or about 35 pounds.
Eligibility, Cost, and Risks of Zepbound
The Food and Drug Administration approved Zepbound for use by adults with a body mass index, or BMI, of at least 30 or a BMI of 27 or more if a patient also has another weight-related condition, such as high blood pressure, heart disease or obstructive sleep apnea. The agency said the drug should be used along with a reduced calorie diet and exercise. People who are prescribed the medication should not take another GLP-1 agonists, like Ozempic or Wegovy. Zepbound is only approved for adults 18 and older.
Lilly has priced Zepbound at about $1,060 for a month’s supply, and while it’s less than Wegovy, which is priced at around $1,300, both drugs may be too expensive for many people who are eligible. Insurance companies often refuse to cover weight loss medications. Medicare, by law, does not cover them.
Zepbound, like other GLP-1 agonists, can cause uncomfortable side effects, including gastrointestinal problems. According to the FDA’s drug label, side effects include nausea, diarrhea, vomiting, constipation, and stomach pain. Other notable side effects include hair loss, belching or burping, and gastroesophageal reflux disease, or GERD. People who are pregnant should not take the medication. The FDA said patients should also be monitored for depression or suicidal thoughts, and should stop taking Zepbound if symptoms develop.
Mathematical Modeling of Weight Loss
Obesity interventions can result in weight loss, but accurate prediction of the bodyweight time course requires properly accounting for dynamic energy imbalances. A mathematical modelling approach to adult human metabolism simulates energy expenditure adaptations during weight loss. The bodyweight response to a change of energy intake is slow, with half times of about 1 year. Furthermore, adults with greater adiposity have a larger expected weight loss for the same change of energy intake, and to reach their steady-state weight will take longer than it would for those with less initial body fat. A small persistent average daily energy imbalance gap between intake and expenditure of about 30 kJ per day underlies the observed average weight gain. However, energy intake must have risen to keep pace with increased expenditure associated with increased weight.
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Implications for Clinical Interventions
The long timescale for weight loss in obese and overweight individuals has important implications for clinical weight-loss interventions. For example, implementation of a weight-loss programme in various stages so that a goal weight can be achieved in an abbreviated timeframe might be desirable. To assess the mechanisms and comparative effectiveness of various obesity treatments requires understanding their long-term effect on both energy intake and energy expenditure.