Young people with all body shapes and weights can have eating disorders. Eating disorders are complex psychological conditions characterised by harmful attitudes and behaviours, such as restrictive eating, binge eating, and body dissatisfaction. Disordered eating behaviours can happen regardless of a person’s weight or what their body looks like.
Unfortunately, some eating disorder treatment programs use weight in their admissions criteria and may turn down young people who are not within a certain weight range. This means that many young people miss out on the treatment they deserve and need to recover. It can also mean that opportunities for early intervention (and easier recovery) are overlooked, delaying treatment until a later stage when young people may have already experienced serious long-term consequences.
This blog outlines some of the reasons why weight is not a reliable indicator of an eating disorder and eating disorder admissions should not be based on weight. It also offers information on ED treatment options that can support young people to lasting recovery.
How Common Are Weight-Based Admissions Criteria?
According to a 2016 survey by the BBC, around ⅓ of mental health trusts said they used BMI to decide who would qualify for outpatient services. Some services say that a lack of resources means that not everyone can receive treatment, and so they are forced to turn people down.
Some centres require young people to have a BMI below a certain level to be accepted for treatment. In some cases, community-based treatment centres also have a minimum threshold, below which they are instead referred to hospital treatment.
However, experts on eating disorders agree that BMI is an unreliable estimate of an eating disorder and that weight-based criteria can exclude young people in need of treatment and support. Some experts also emphasise the importance of a young person’s choice in their treatment and recovery, proposing that community-based treatment should never be withdrawn as an option and that hospitalisation should only be enforced in the most extreme situations.
Weight-Based Admissions: Encouraging Further Weight Loss
If a young person is denied treatment on the basis of their weight, it can encourage them to lose more weight. This can make disordered eating behaviours worse, causing them to engage in more restrictive behaviours and other harmful patterns.
Young people may feel like they are ‘not good enough’ at their eating disorder or need to ‘get better’ at it. These thoughts can drive disordered eating behaviours, body dissatisfaction, and other associated feelings.
Restrictive Eating Disorders: Delaying Treatment and Recovery
When someone has a restrictive eating disorder, they may lose weight over time. Weight-based admissions processes can prevent a young person from receiving treatment in the earlier stages of their illness, when they may be at a normal or higher weight.
Earlier treatment is associated with better outcomes: intervening sooner often means that symptoms are less complex and avoids long-term harm to someone’s mental and physical health. As an eating disorder progresses, a young person is more likely to develop other health conditions, such as depression or malnutrition, that cause additional harm.
Understanding Atypical Anorexia Nervosa: Restrictive Eating at Any Weight
Most types of eating disorders don’t include BMI in their diagnostic criteria. In fact, young people with bulimia nervosa typically have a BMI within the ‘normal’ range.
However, the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) still includes weight as a criterion (“significantly low weight”) for the diagnosis of anorexia nervosa. However, many young people meet the other criteria for anorexia while at a higher weight. These include restricting energy intake so that it interferes with physical health and experiencing an intense fear of weight gain. Experts point out that serious malnutrition can occur at any weight.
Young people who meet the other criteria for anorexia nervosa but not the weight criterion can still receive an eating disorder diagnosis. They may be diagnosed with atypical anorexia nervosa (AAN) under the Other Specified Feeding and EDs (OSFED) type. This might include individuals who severely restrict their diet but whose bodies resist weight loss or individuals who had a higher weight at the start of their eating disorder.
A recent review found that among the general population, atypical anorexia nervosa is more common than typical anorexia. However, in treatment settings, typical anorexia nervosa is more common. This suggests that diagnoses of AAN are often missed or overlooked.
Some experts argue that the weight criterion should be removed from the definition of anorexia nervosa so that these young people would receive the same diagnosis as those with typical anorexia. They think that when weight is not an important determinator of the severity of the condition or something that affects the character of restrictive disordered eating attitudes and behaviours, it may not make sense to have separate diagnoses. Removing the criterion may also help prevent young people with AAN from being overlooked or turned down for treatment.
Eating Disorder Treatment for Young People
Eating disorders are serious and complex mental health conditions that harm a young person’s mental and physical health and social life. However, eating disorders are treatable, and with the right support, most young people recover and reclaim their futures.
There are several different evidence-based treatment options available for young people. The most suitable treatment depends on the type of eating disorder and each individual’s personal characteristics, history, and circumstances.
Treatment approaches for eating disorders include:
Family-Based Therapy (FBT)
Family-based therapy is often the go-to treatment for children and adolescents with anorexia nervosa. Studies have shown it can also be effective for bulimia nervosa.
FBT empowers parents to support their children’s recovery by controlling their meals and exercise habits. As a young person recovers physically, they gradually regain their independence.
Therapy sessions help both parents and young people develop behaviours and habits that encourage eating disorder recovery. This might involve practising family meals or learning to avoid parental criticism.
It’s important to remember that FBT doesn’t work for everyone. Sometimes young people and their families are disheartened if FBT isn’t right for them – but there are several other options available.
Enhanced Cognitive Behaviour Therapy (CBT-e)
CBT-e is a transdiagnostic eating disorder treatment for anorexia nervosa, bulimia nervosa, binge eating disorder, and other/unspecified or specified feeding and eating disorders. It’s built on the assumption that different eating disorders share an underlying pathology – an over-evaluation of shape and weight.
In CBT-e sessions, therapists work with young people to develop positive and healthy eating patterns while addressing the thought patterns and behaviours that underpin disordered eating behaviours. The ‘broad’ version of CBT also focuses on underlying issues like perfectionism, interpersonal difficulties, and low self-esteem that may contribute to eating disorders.
While initially developed for adults, research shows that CBT-e is also effective for adolescents and has long-lasting effects.
Integrated Trauma Treatment
Experiences of trauma are common among young people receiving treatment for eating disorders. Trauma is a risk factor for eating disorders that can underpin disordered eating behaviours, affecting the way young people think, feel, and relate to the outside world.
Traditionally, ED treatment programs only addressed trauma in the later stages of treatment after a period of physical recovery. But unprocessed trauma can complicate the treatment process and make it more likely that disordered eating behaviours will restart at a later stage.
Integrated trauma treatment for eating disorders addresses experiences of trauma from the start of a recovery program. Research has shown that combining cognitive processing therapy with eating disorder treatment leads to lasting improvements in symptoms of both eating disorders and trauma.
The Wave Clinic: Specialists in Eating Disorders
The Wave Clinic offers specialist mental health treatment spaces for young people. Our residential and outpatient programs aim to make a difference in the lives of children, adolescents, and young adults. We offer the very best evidence-based modalities, delivered by a team with unequaled expertise and experience.
The Wave is a Global Centre of Excellence for the treatment of eating disorders. At our residential centre, every member of staff – including support staff and chefs – is trained in the core principles of eating disorders, creating an environment dedicated to eating disorder recovery. We provide intensive care beds for young people in the highest need, alongside a main house where young people live collectively through shared experiences and recovery goals.
If you’re interested in finding out more about our programs, get in touch today. We’re here to support you.
