"Recover-But Not Too Much": Experiences of Weight-Centric Care and Weight Stigma in Higher Levels of Care for Eating Disorders

Abstract

Objective: Patients with atypical anorexia (atypical AN) often require higher levels of care (HLOC). Paradoxically, elements of HLOC may negatively impact atypical AN patients via weight-centric care and weight stigma. We examined patients with a history of atypical AN in HLOC and investigated their perceptions of weight stigma and related impacts.

Method: Data originated from a longitudinal study of patients with a history of atypical AN and involved a sub-sample of all patients who attended HLOC. Seventeen adults (M_age = 32.4, SD = 8.8; 88% cisgender women, one trans man, one nonbinary person; 29% People of Color, 41% heterosexual, 35% low income) completed in-depth, semi-structured interviews. De-identified, validated transcripts were coded using Dedoose, following thematic analysis guided by narrative inquiry.

Results: Five themes emerged: (1) Difficulty with admission: patients reported difficulties obtaining diagnoses, accessing insurance approvals, and uncooperative providers, (2) Insufficient nutritional care: participants reported inadequate meal plans and weight restoration, (3) Unhelpful treatment interventions, milieu, and norms: patients reported activities centering thin clients and fatphobia in milieus, (4) Influence of providers' bodies, behaviors, and beliefs: patients reported an overrepresentation of thin providers, modeling of disordered eating, and minimizing patients' EDs, and (5) Systemic issues: patients reported lack of provider education, undertreatment, and cyclic readmissions.

Discussion: Results suggest that systemic (e.g., insurance, policies) and interpersonal (e.g., providers, peers) weight stigma may negatively impact patient care. Patients may benefit from advocacy with insurance companies, legislative protections, strengthened nutritional rehabilitation and weight restoration, weight-inclusive therapies, and interventions that address weight stigma in HLOC milieus.

Keywords: atypical anorexia; higher levels of care; iatrogenic harm; intensive outpatient; partial hospitalization; residential treatment; weight bias; weight stigma; weight‐based teasing; weight‐inclusive care.